The Sleep Magazine
8TH EDITION
Understanding Sleep Disorders
A TMJ PATIENT WITH AN UNEXPECTED OUTCOME DR. DAN TACHE
P. 8
MY DENTAL SLEEP MEDICINE STORY DR. JERRY HU
P.4
HOW DENTAL SLEEP MEDICINE REWARDED ME DR. JOHN COMISI
P.18
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SLEEP BREATHING DISORDERS The Fastest Growing Dental Specialty
STNETNOC FO ELBAT
4
MY DENTAL SLEEP MEDICINE STORY
7
WHY DENTISTS HAVE A RESPONSIBILITY TO SCREEN FOR SLEEP APNEA
9
A TMJ PATIENT WITH AN UNEXPECTED OUTCOME
14
SLEEP APNEA AND THE RISK TO PREGNANT WOMEN
16
WHY THE FUTURE IS OURS TO MOLD
19
HOW DENTAL SLEEP MEDICINE REWARDED ME
21
THE POWER OF MEDICAL BILLING
22
CE QUIZ
Finding new sleep apnea patients made easy. 1-800-SNORING Change the way you practice dentistry for the health of your patients!
DISCLAIMER Dental Sleep Medicine, and all of the expert opinion herein, represents many years of dental sleep medicine practice. It is presented as a forum for the advancement of dental sleep medicine. The articles within this publication are the opinions/statements of the medical professionals featured. Sleep Group Solutions is a private medical equipment and education company producing and distributing medical equipment and services. SGS provides practitioners with appealing diagnostic and treatment alternatives and in no way offers medical advice in the sleep disorder industry.
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Forward
By: Charles Kravitz, DDS
This edition of The Sleep Magazine offers you insights to the solutions available to patients who are afflicted by sleep apnea. With so much help available we ask why so many victims are untreated. It is estimated that 22 million Americans suffer from sleep apnea, with 80 percent of the cases of moderate and severe obstructive sleep apnea (OSA) undiagnosed. If we accept the reports that a minimum of 80% of Sleep Apnea is undiagnosed, then only 20% is actually addressed in any fashion. The undiagnosed may fit into these categories: 1. Patients have no idea that such a thing as Sleep Apnea exists. Hard to believe it but there are such people. 2. They know about, but have no idea that they suffer from, Sleep Apnea . "Isn't snoring normal?" "Doesn't everyone wake up 4-6 times a night?" (Snoring is the tip of the iceberg: a warning sign.) 3. They know they have the symptoms of Sleep Apnea but are in denial. I know a smart lawyer who insists sleep apnea does not exist. He tells me that I am "just as bad as [his] wife" who listens to him snore and gasp for breath every night. He's in denial . 4. They know they have problems but refuse to do anything about it. Some have heard horror stories about CPAP machines and simply do not want to take action. They need to learn about the oral appliance therapy (OAT). 5. Misdiagnosed Sleep Apnea. There is a lack of knowledge of sleep apnea among many health professionals. OSA is often confused with ADHA and other diseases. Also, many physicians are alerted only by the stereotypical signs. Men, women, children, obese and slim- all can be OSA victims. It is very difficult to get some of these OSA victims to want to be screened and diagnosed by just telling them that they have a life-threatening disease. It is necessary for them to "see" it for themselves and for them to adopt a top-down approach - of their own volition. The best way to do this is to educate them in the most simple, effective, non-intimidating and costeffective way - we can show them films of OSA victims, including their own, having sleep events. We must find a way to get them diagnosed and filmed and then show them their results. This is a massive education deficit issue. All dentists must be trained to effectively screen their patients and to treat them for OSA. Courses are given every weekend in several cities and CE units are awarded through AGD/PACE. Find these courses at SleepGS.com.
Sources American Sleep Apnea Association http://www.sleepapnea.org/i-am-a-health-care-professional.html Indy Star, Lauran Neergaard, http://www.indystar.com/articles/9/186972-5719-052.html Detroit Free Press, Bill Dow, http://www.freep.com/news/health/sleep2e_20041102.htm
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President's Letter
Welcome
to our magazine
SGS President and Founder Rani Ben-David
Sleep Group Solutions is again demonstrating its leadership in Dental Sleep Medicine. Our team of esteemed lecturers is highly acclaimed in the field of dental sleep medicine. They present seminars throughout the nation, training dentists to screen and treat patients who are afflicted by obstructive sleep apnea. They make presentations to dental associations, societies and study clubs. They are responsible for introducing this life-saving service -DSM to hundreds of dentists every month. On top of this they find time to practice dental sleep medicine in their busy successful offices. They “practice what they preach “ In this issue of The Sleep Magazine you will hear from these experts: *Dr. Jerry Hu relates how his journey into DSM began with his own untreated OSA. *Dr. Barry Freydberg finds it difficult to understand why every dentist is not demanding education to treat their sleep breathing dysfunctional patients. *Dr. Dan Tache’ describes a heartwarming case history of a young woman who for 20 years was misdiagnosed by the physician community and whose life was turned around by the successful treatment of obstructive sleep apnea. *Racheal Verret, the SGS Social Media Coordinator, offers a valuable understanding of the dangerous relationship between OSA and pregnancy. *Dr. John Carollo reveals where dentists can get DSM knowledge and accreditation. *Dr. John Comisi tells how a revelation opened his eyes and brought him great rewards. *Dr. Charles Kravitz answers the mysteries of medical billing for dentists. We have included a quiz that you may take to test your knowledge of DSM and also to receive a free continuing education unit as well as deep discounts on SGS training seminars. As always, we are happy to hear from you. If you have any questions or something you want to tell us about please call us at (855) 475-3374 Wishing you success in saving lives, Rani Ben-David President and Founder Sleep Group Solutions
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MY DENTAL SLEEP MEDICINE STORY Even worse, I created the classic bedroom
AUTHOR:
horrors by being a "freight train" at night, causing my wife to also have fragmented sleep.
DR. JERRY HU DDS DABDSM DACSDD
Being tired and sleepy day-to-day, my health and OSA started to rob me of my joy in my work, and I knew at that point, something had to change. I first tried a CPAP, but my
Dr. Hu is a Diplomate with The American Board of Dental Sleep Medicine, The American Sleep and Breathing Academy, and The Academy of Clinical Sleep Disorders Disciplines. Dr. Jerry Hu describes
compliance was nothing but shameful. As an Alaskan, I also enjoy the outdoors, and for me, CPAP and camping just don't mix. It didn't take very long for me to try my own oral appliance therapy.
how his experience with dental sleep medicine has changed his approach to dentistry.
Thanks to being compliant with my oral appliance for several years, I attained a black belt in Karate, dropped several pant sizes, and
M
y journey into dental sleep medicine
went from being able to never do any chin ups to doing over 10 at each rep cycle during my workouts.
began with my own untreated OSA. Prior to that, I had attained many accreditations,
It was after this experience with utilizing dental
awards, and published journals in cosmetic and
sleep medicine on myself that I knew my
implant dentistry. I was thriving in my practice,
calling in life is not just "changing lives," but
changing lives and smiles one patient at a time.
saving them! I still do cosmetic and implant
Something was missing!
dentistry, but my deepest passion in dentistry is sleep medicine.
At that time, I was over a hundred pounds heavier than I am now, and my overall health
Without a doubt the most important finding
was on a spiral down to death. My hypertension
I’ve attained with all of the equipment and
became uncontrolled with the need of adding
credentials is that the airway trumps everything!
multiple prescription meds; I snored, had acid
It is my humble opinion that Airway Centric
reflux, fragmented sleep... the list goes on and
Dentistry should be the number one goal in ALL
on.
dental practices! THE SLEEP MAGAZINEPAGE 4
When I look at my own airway on multiple CT scans and multiple Pharyngometer readings, just for curiosity, I can visually see the difference from pre to post oral appliance therapy and weight loss. It was a huge difference, not just in the circumference (axial slice) of my airway at the smallest point, but also on the pharyngometer, my modified Mueller's Collapse is now the same as normal breathing. My airway no longer collapses! This shows me that healing of inflamed pharyngeal tissues, nitric oxide with nasal breathing, and oral appliance therapy do help tackle comorbidities connected to inflammation, endothelial dysfunction, and overall cardiovascular health. I also had seen morphologic changes in my condyles from being all the time in a retrognathic/retruded position to being, at least at night, to a more downward and forward position. Seeing that gave me an "Ah Hah" moment. All the smile makeovers, implant dentistry, fixed dentures (all on 4, 5, or 6 etc) and all restorative work must be connected to airway. I cannot agree more with the recent ADA Oct 2017 Scope of Practice Recommendation that states that ALL dentists should screen for OSA and that dentists are the only ones who are qualified to make an oral appliance for OSA. Tooth loss, severe parafunctional forces, and damages that come from sleep bruxism and airway issues will definitely affect my smile makeovers, implants, and restorative work. Thus, when I teach for Sleep Group Solutions, I preach that the airway trumps everything. All the effort, artistry, planning, wax ups, TMJ/TMD considerations, orthotics, neuromuscular rehab cases, all of them, must respect airway!
I teach that if the body displays and/or results in red flags from tooth loss to acid erosion, and there is inflammation, anatomical problems (narrow arches, etc), they are not just going to magically go away with a smile makeover or implant. Moreover, placing a flat plane splint, as a recent Prosthodontic journal/publication shows, might even worsen the airway! As I was lead to information and real data that I can analyze and collect, I learned that precision dentistry/ precision medicine is of most importance. I found that there really is a "sweet spot" position, that for me is a true therapeutic position for the patient. This position would be sensitive to the TMJs, muscles, and physiology of each unique individual I treat. For children, I also treat airway problems using craniofacial epigenetic and pneumopedic concepts, and because I also have the equipment to do so, as I concentrically expand their arches, I use my pharyngometer and neuromuscular equipment to see their progress. The board-certified Sleep Physicians I work with are also impressed about how everything is connected and affirm that our body has its own unique physiology and position. When that is respected, then there are far fewer side effects and potential doubts from naysayers to use when considering OAT for OSA.
THE SLEEP MAGAZINE PAGE 5
With the advancements in digital dentistry and digital workflow from design to final fabrication, dentists can be assured that if they capture a "sweet spot" or "therapeutic position" that respects the individual's physiology, etc. that it is now possible to precisely transfer that position to the appliance’s start position! In Alaska, we have many shift workers who come in to see me. We all hear in the news from train derailment to FAA pilots landing in the wrong airport, various disasters caused by possible untreated OSA connection. It is estimated that there are over 1 billion people worldwide with untreated OSA. It’s a pandemic, and I see people working with heavy machinery in the oil fields, (platforms, North Slope) to Alaska State Troopers and Wildlife workers-- all shift workers, and their OSA affects not just the people and animals, but the environment and future of this great state. When I was lecturing in Austin, Texas years back, I showed the results showed several lifesaving and life changing dental sleep medicine cases I had the privilege of doing on Alaskan shift workers. The audience was amazed at the life changing metamorphosis of these patients after seeing the dramatic "before and after" photos I provided. The weight loss, smiles, and renewed energy, seen on the photos of the patients, make it all worthwhile.
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THE SLEEP MAGAZINEPAGE 6
WHY DENTISTS HAVE A RESPONSIBILITY TO SCREEN FOR SLEEP APNEA AUTHOR: DR. BARRY FREYDBERG, DDS, DASBA Arizona dentist and Diplomate with the American Sleep and Breathing Academy, Dr. Barry Freydberg discusses why dentists are primed to be the first line of defense for sleep apnea suffers.
W
hat if I told you that, as dentists, there is a way for you to add 10-15 years of life to your patients? I’ve been a practicing dentist for decades and I can personally tell you that there are few things that give me more professional satisfaction than treating obstructive sleep apnea (OSA) and the conditions that result from it, then seeing that person’s life turn for the better almost instantly. The true danger of sleep apnea is in how the various health complications that it causes (heart disease, diabetes builds up slowly over time with the patient usually unaware of the underlying cause. Their doctors may be treating the symptoms rather than the condition.
The problem, quite simply, is that the majority of medical care providers do not screen for OSA when their patients come to them with symptoms of chronic fatigue or high blood pressure and other systemic conditions. Essentially, examining patients for this issue became our job as dentists. If we don’t do it, patients would lose a decade of life from treatable causes.
"We can observe symptoms such as high palates, retrognathic mandibles, signs of bruxism and acid erosion, TMJ pain, large tonsils, large uvulas, red tonsillar pillars, dozing off in the chairs, thick necks (>17’’ for men, >16’’for women)."
THE SLEEP MAGAZINE PAGE 7
DENTAL SLEEP MEDICINE SEMINARS DETAILED PROGRAMS: You are going to experience a one-of-a-kind program that has been tested, adjusted and fine-tuned based on the experience and success of thousands of your peers. Our goal is for you to be clinically elite with your treatment of this deadly condition while experiencing rock solid case acceptance and medical insurance reimbursement.
16 CEU COURSE AGENDA SEMINAR DAY 1 SEMINAR DAY 2
Open Your Eyes
The untapped dental sleep gold mine in your practice A call to action: what you've been missing for way too long Opportunity in your community
Know Your Enemy
This isn't your grandfather's snoring Deadly Sleep Apnea The alphabet soup of apnea - definitions & vocabulary Co-morbidities: sleep apnea red flags
Advanced Airway Anatomy Nose to Neck - Where is the problem? Airway trumps all
OSA Screening: Upgrade Your Examination IQ Signs, Symptoms & Clinical Consequences What to look for and scripts for patients interaction What to say / what not to say Initial documentation & sleep questionnaires - how to best use them
The Sleep Consult Appointment
The Dental Sleep Medicine Cookbook Cont. How to read a home sleep test and PSG Download and review studies done on attendees the night before OSA Positive! Now What? Multidisciplinary team building - networking with MD colleagues
DSM Marketing Pearls Inexpensive things you can do and say right now to start off strong Sleep Apnea Phone calls do's and don'ts Golden ticket for primary care referrals
Non-Dental Treatment Options CPAP, Upper Airway Surgery, Weight Loss, Positional Therapy and more Creating the mutually beneficial sleep MD relationship Combination therapy - when is it an option?
Your Ticket for DSM Success! Appliance Records
An objective way to predict oral appliance success and ideal bite position No more guessing Airway Imaging with bite repositioning jigs Initial Patient Exam Appliance selection based on airway assessment and Airway evaluation - how and why to measure nasal and oral patient indications airway with Eccovision Pharyngometer/Rhinometer Lifetime Treatment: long term implications Live patient exam demonstration & hands-on testing of attendees How to mitigate dental side effects Appliance delivery & adjustments Home Sleep Testing Short & long term follow up plan Home testing vs. Polysomnogram Lab testing Billing Medical Insurance & Medicare No Barriers: how to use home testing for a faster path to A Simple "hands-off" approach to getting paid and not appliance therapy overwhelming your staff Set up and dispense tests to volunteer attendees for Medical codes, fee structures and how to bill to overnight sleep studies maximize collection and reimbursement How to get a YES! Medicare - the good, bad & ugly A Clinical case presentation that works & how to take How to be a Medicare DME supplier down barriers and set yourself up for success
Why a dedicated appointment? Goals of testing Patient education: raise your patients' sleep health knowledge
THE SLEEP MAGAZINE PAGE 8
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THE SLEEP MAGAZINE PAGE 9
A TMJ patient with an unexpected outcome AUTHOR: DR. DAN TACHE, DMD, DABDSM DASBA Diplomate with The American Board of Dental Sleep Medicine and American Sleep and Breathing Academy, Dr. Dan Tache discusses the significance of investigating OSA in a, particularly severe case.
M
y purpose in presenting this case is to
Such is the case with EJ whose case I will
illustrate the real value in becoming educated
display shortly. First, some background
in Dental Sleep Medicine and instituting a
information. Most of our patients who may be
screening program for ALL of your patients who
afflicted with Sleep-Related Breathing Disorders
are admitted into your practice. I wish to share
(SRBD) such as Upper Airway Resistance
how tremendously gratifying identifying and
Syndrome or Obstructive Sleep Apnea (OSA) are
participating in the care of such patients who
aware that they do not sleep well or light
suffer from Sleep-Related Breathing Disorders
sleepers, but totally unaware that some or many
(SRBD) and who may not even realize it at the
troublesome symptoms associated with their
time they enter your professional life.
poor sleep such as teeth grinding, gingival recession, fatigue, fibromyalgia, Irritable Bowel Syndrome, cardiac arrhythmias, hypertension, diabetes, headaches and TMD pain to mention a few, may all be related to their problems with sleep. Table 1 is an exhaustive list of signs & symptoms of risk factors for SRBD. The photos in Figure 1 graphically displays the clinical presentation of those risk factors listed in Table 1. As you will soon notice from even a cursory review of the following photos, we see many patients who potentially present with risk factors for SRBD.
THE SLEEP MAGAZINE PAGE 10
The benefit of being a dentist is that we’re primary care providers working right next to the airway, and therefore are in the best position to see any airway obstruction and recommend patients for sleep test. We can observe symptoms such as high palates, retrognathic mandibles, signs of bruxism and acid erosion, TMJ pain, large tonsils, large uvulas, red tonsillar pillars, dozing off in the chairs, and thick necks (>17" for men, >16 for women). There are also many indicators of obstructive sleep apnea that lay in a patient’s medical history that a dentist can assess, such as having high blood pressure, acid reflux, can’t lose weight, snoring, or on sedatives/sleeping pills. Obvious signs of obstruction in the mouth and airway can be used to complete the puzzle of medical history that a patient may have neglected for years, totally unaware of the underlying cause. Dentists are also in a unique position to help patients that have failed other forms of treatment for sleep disorders. The American Dental Association agrees, with their policy statement on the role of dentistry in the treatment of sleep related breathing disorders as follows: “Dentists are encouraged to screen patients for sleep related breathing disorders (SRBD) as part of a comprehensive medical and dental history to recognize symptoms such as daytime sleepiness, choking, snoring or witnessed apneas.”
Table 1 Clinical Risk Factors for SRDB (Bailey, 2010)
Risk Factors for SRBD
Clinical Observation Potential Relationship TONGUE Coated Enlarged Scalloped at lateral borders Obstructs view of oropharynx
Risk for gastroesophageal reflux disease or mouth breathing Increased tongue activity; possible OSA Increased risk for sleep apnea Mallampati score of III and IV: increased risk for OSA
Clinical Observation Potential Relationship TEETH AND PERIODONTAL STRUCTURES Gingival Inflammation Gingival bleeding when probed Gingival recession Dry mouth (xerostomia) Tooth wear Abfraction
AIRWAY Long sloping soft palate Enlarged/swollen/elongated uvula
At risk for OSA/snoring At risk for OSA
NOSE / NASAL AIRWAY Small nostrils (nares) Alar rim collapse with forced inspiration
Difficulty nose breathing At risk for OSA/sleep-breathing disorder
Mouthbreather; poor oral hygiene At risk for periodontal disease Mouth-breather; may be medication related Maybe at risk for clenching May have sleep bruxism Increased parafunction/clenching
EXTRAORAL Chapped lips or cracking at the corners of the mouth. Poor lip seal; difficulty maintaining a lip seal Mandibular retrognathia Long face (doliocephalic) Enlarged masseter muscle
Inability to nose breathe Chronic mouth breather Risk for OSA/snoring Chronic mouth breathing habit Clenching/sleep bruxism
POSTURE OF THE HEAD/NECK Forward head posture Loss of lordotic curve Posterior rotation of the head
Airway compromise and restriction Chronic mouth breather Tendency to mouth breathe
IMPORTANT: Remember, suspecting a problem is not a diagnosis, only a suspicion. Currently, the diagnosis of OSA is not within the scope of the practice of dentistry. A formal diagnosis is reserved for a board-certified sleep medicine specialist to determine.
THE SLEEP MAGAZINE PAGE 11
This particular case will forever impact my life due to the outcome being so unexpected, and how it wound up impacting this young woman’s life forever. “EJ” is a 34-year-old female patient who was referred to our TMJ/OFP clinic by her primary care physician for TMJ pain. During her initial interview, in her HPI, EJ expanded her Chief Complaints (CC)and reported the following: 1) “grinding teeth at night” 2) awakens with jaw pain in the am 3) teeth pain 4) awakens sweaty throughout the night 5) nocturia x3-4/night. These were her CCs. Meet EJ: Below, is a review of the history we collected, my clinical findings, differential diagnosis, recommended treatment and the outcome from the treatment which we provided for EJ.
Figure #1: Meet EJ, age 10
Figure #2: EJ today at age 34
The Clinical Exam: Temporomandibular Joint Evaluation
Figure #3: Evaluating for TMJD
Her very first seizure occurred in 4th grade while standing in line at a water fountain. Teachers stated lost consciousness completely for “a couple of minutes” EJ was seen by a neurologist who prescribed Dilantin to prevent future seizures Sadly, the seizures became more and more frequently despite being on the Dilantin Additionally, it was notable that all of the subsequent events would occur while she was asleep EJ was given alternative drugs as they became available and by the by time that she presented at my office, she was taking 4-5 drugs anti-epileptic drugs (AEDs) concurrently was taken, she was regularly taking 3 or more drugs/day Her condition was reclassified from epilepsy to Epilepsy EJ was referred to our office for help complaints of “jaw pain” and “teeth pain” She experienced these symptoms daily upon awakening and she would “grind (her) teeth during the day so symptoms were worse by end of the day She reported that her seizure frequency had no abated at all, in fact, following neurosurgery performed 20 years earlier, to remove an intracranial “lesion” the seizures only increased in frequency and now the seizures were occurring both day and night However, the majority of seizures, still occurred at night while she was sleeping EJ also reported to me that next to her jaw and tooth pain that she had a terrible problem with sleeping She often awakened during the night to “go to the bathroom” She often awakened feeling sweaty and sometimes, her heart would be racing and on those occasions, it felt like she could not catch her breath When she reported this to her neurologist, the explanation that she was given was that “people who have seizures often report bad sleep” EJ just resigned herself to the likelihood that poor sleep would continue until her seizures abated She would take Lorazepam daily to help her fall asleep more easily but she would still awaken every night Maximum opening (MO) was moderately limited @ 35mm Lateral movement was normal @ 10mm Auscultation and palpation of the TM joints revealed what appeared to be normal function despite the somewhat limited maximum opening No evidence of TMJ disc displacement The fact that EJ’s TMJ pain occurs most often upon awakening would imply that she has sleep bruxism (SB) People who have SB do often report poor quality of sleep In the absence of a TMJ disorder, SB is now the primary diagnosis Nonetheless, TMJ imaging will be ordered to make certain that nothing is left to question.
THE SLEEP MAGAZINE PAGE 12
(These CBCT Images were read by a board certified dental radiologist with BeamReaders - Kennewick, WA 99336; P: 916.771.3605) The findings in the right and left TMJs are suggestive of normal osseous morphology and condylar position. The right condylar process and mandibular ramus is slightly shorter than the left resulting in mandibular asymmetry. SUMMARY: normal TM joints and apparent normal function.
She related that she has had sleep problems i.e. awakening sweaty and frequent bathroom breaks for a long time but only within the past 3 months has she been having pain as well. She does not report any history of head, neck, or facial trauma, nor did she have complaint of jaw joint noises or locking, i.e. typical TMJ complaints. EJ then began to chronicle her very extensive past medical history which initially did not seem to necessarily correlate with her current CCs but as we learned more, we would learn that it was quite the opposite. She told us that she had been having medical problems dating back for “more than 20 years” beginning at only 10 years old, which was when she experienced her first “seizure”. Each year, 120,000 children experience a first or newly diagnosed seizure. EJ seizures did in fact recur and quite frequently and was referred to a neurologist who officially diagnosed EJs condition as epilepsy and prescribed anantiepileptic drugs (AEDs), which are typically quite effective in controlling seizures. It’s notable that by the time I met EJ, she was taking as many as five (5) drugs concurrently and she still had sporadic seizures. Her condition had proven to be quite disabling, as she had not been able to be gainfully employed for over 20 years. EJ was provided with the EMA and she was very compliant with my treatment plan to wear the lower tray during the day and the DUAL appliance (both attached) while sleeping. I was very happy to hear, after only a week or so, that her symptoms were declining very rapidly. It was not many weeks into treatment when her aunt who was also her guardian, began to accompany EJ for her monthly follow-up progress evaluations. She wanted to express her happiness with just how much better EJ was doing symptomatically, reiterating how much her pain had declined and how much less she was waking up at night because she was no longer having to urinate “all night long” any longer. Treatment progressed well, and I kept EJ in on this plan for approximately one year. After that year, we reduced the use of her EMA to nighttime only and EJ continued to do so very well. She was noticeably more animated and happy each time she returned for a follow up visit. The results of the cursory case study might suggest the bi-directional nature of epilepsy and sleep fragmentation in contrast to the bulk of scientific literature that views reduced sleep quality as a co-morbidity of the epilepsy. I feel that this perspective may warrant further studies of a more controlled, prospective nature. I will lastly state that my education in Dental Sleep Medicine has proven to be perhaps, the most important aspect of my professional life and that we, as licensed practicing dentists, may have been able to help another person in such a profound and fundamental way is very humbling and gratifying and furthermore, we should begin to appreciate the need to effect real change in both Dental and Medical School curricula so that more professional training is devoted to the teaching of sleep medicine. THE SLEEP MAGAZINE PAGE 13
SLEEP APNEA AND THE RISK TO PREGNANT WOMEN Obstructive sleep apnea can cause a laundry list of unnecessary risk to pregnant women.
By: Rachael Verret
O
bstructive sleep apnea (OSA) is estimated to occur about twice as often in men than in women. However, it is found that pregnancy does increase the risk and instance of sleep-disordered breathing.
The daytime sleepiness brought upon by the OSA in addition to the natural fatigue that comes with pregnancy can be extremely dangerous for the mother in certain situations that require clear cognitive functioning.
Experts suggest that the condition can arise as the result of changing hormones and physiology in pregnancy (e.g.- Certain hormones are found to lead to the congestion of the upper airway. Natural weight gain can lead to snoring and an obstructed airway). If left untreated, they can and do lead to preventable health issues for both mother and baby, before and after birth.
As for physical comorbidities: preeclampsia, pregestational diabetes, and preterm delivery are all seen in an increased volume in mothers with OSA. Of course, this can all be extremely dangerous for the mother and child, leading to complicated births and babies that may have compromised immune systems and birth weights.
Some facts: -Women with OSA are found to be twice as likely to need a hysterectomy. -Around 65% of pregnant women with OSA were required to have a C-section. -Pregnancy is already linked to high blood pressure and cardiovascular disease. -Proper treatment of the condition can ensure the health of the mother. -Studies show that ICU admission is higher in pregnant women with OSA than those without.
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Sleep Apnea and Polycystic Ovary Syndrome (PCOS) Polycystic Ovary Syndrome (PCOS) is a common hormonal disorder that causes enlarged ovaries and cyst that can cause and exacerbate certain health issues during pregnancy. With these particular comorbidities, the issues associated with PCOS such as fatigue, weight gain, and high cholesterol levels can worsen and compound itself with the added OSA. An increase of androgens and testosterone in the endocrine system (caused by pregnancy) are found to disrupt sleep receptors in the brain that control breathing. CONCLUSIONS: Having a serious sleep disorder like OSA on top of all of the other stresses that pregnancy brings is a scary challenge to overcome. However, given the proper medical guidance, your patents can certainly gain a renewed sense of control and peace over their health issues. The previously mentioned complications can be prevented by receiving a proper diagnosis and treatment recommended by a primary health provider, after which the health of both baby and mother will improve. You may wish to ask your pregnant patients about bedtime congestion, fatigue, and sudden or worsened snoring.
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WHY THE FUTURE IS OURS TO MOLD AUTHOR: DR. JOHN CAROLLO, DMD, DASBA Diplomate with the American Sleep and Breathing Acadamy and team dentist for the NFL team The New York Jets, Dr. John Carollo discusses why Dental Sleep Medicine is primed to innovate the dental industry.
D
ental Sleep Medicine, (DSM), is the fastest growing area in dentistry. Back in the early 1990’s, implant dentistry was the exciting new area to study, and everyone was taking continuing education and learning about both surgery and restorative therapy for dental implants. Fast forward to 2018 and Dental Sleep Medicine Education is the hot area in dental continuing education. It is not uncommon to see the cover of dental journals featuring DSM. The March 2017 journal; “Inside Dentistry’s cover; was: “Don’t Sleep on a Golden Opportunity, Collaborating with Physicians to Treat Sleep-Disorder Breathing”1. My physicians who are board certified in Sleep Medicine; only like to work with dentists who are knowledgeable and have advanced training in DSM. In DSM, there are two academies; one is the American Sleep and Breathing Academy (ASBA), and the other is the American Academy of Dental Sleep Medicine, (AADSM). The U.S. Bureau of Labor Statistics has data on the number of dentists in the United States and the bureau estimates that the number of dentists is expected to grow by 29,300 by the year 2026.
The Center for Disease Control and Prevention, (CDC) also has statistics on the number of dentists. The CDC’s Data states that there were 172,603 dentists in 2006 and 195,722 in 2015. That is a 13.4% increase in the number of dentists during this nine-year period. In comparison, according to the AADSM, their membership in 2003 was approximately 300 members and in 2013 their membership was around 3,000member dentists. This is a 900% increase in member dentists in the AADSM doing dental sleep medicine, and it is the author’s opinion that most of this increase is getter higher in the last three years! Without a doubt, the time to learn about Dental Sleep Medicine, (DSM), is NOW! In 2015, The American Academy of Sleep Medicine and the AADSM issued new joint clinical practice guidelines for oral appliance therapy.
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"Coming from a variety of dental backgrounds we all have all made the treatment of snoring and sleep apnea a large part of our practices and are eager to share this information with our attendees." As a dentist for over 36 years, I have had many patients appreciate the dentistry that I have done, especially dental implant and esthetic dentistry. (figures 1 and 2). While all patients are grateful for their dental therapy, dental sleep patients are especially receptive to treatment. There are many reasons for this.
Figure 1: Before and After of a Full Mouth Dental Implant Patient of Dr. Carollo’s
Patients with Obstructive Sleep Apnea, (OSA), feel tired most of the time. We sleep about a third of each day, and that third affects the two thirds we are awake. We all know how we feel if we get a bad night’s sleep, so imagine OSA patients that feel this EVERY DAY! Treating an OSA patient can also make them live longer and have a healthier life. Less chance of diabetes, dementia, stroke, hypertension and even death to name a few comorbidities.
After taking a Sleep Group Solutions course and implementing the proper protocol for DSM, along with the acoustic technology from SGS, my practice is now 40-45% dental sleep medicine. Acoustic Pharyngometry has made the difference in my achieving better efficacy with my oral appliances. My goal as a dentist and dental peer is to spread the word about OSA and train other dentists to treat this condition in their offices. Many offices that get started in DSM find value in how it helps both their patients and community. Dental sleep medicine practices can learn more via the upcoming Sleep Group Solutions Study Club.
Figure 2: Before and After of a Congenitally Missing lateral Incisors; Restored with Dental Implants by Dr. Carollo
The first ten chapters will have our expert SGS instructors as chapter presidents and leaders. Most of the SGS instructors are Diplomats’ in the ASBA and/or the AADSM. In addition, we will have guest instructors, present on the most current topics and literature in Dental Sleep Medicine. Topics like Oral Appliance Titration, Medical Billing for DSM, Improving Case Acceptance, and many other topics will make this the elite Dental Sleep Medicine Study Club in the country. I am proud to be the National President of the SGS Dental Sleep Medicine Study Clubs, as well as the NY/NJ Chapter President. You can learn more by contacting Sleep Group Solutions. Whether you are just getting started in Dental Sleep Medicine, and/or are looking to advance yourself in this area, there is a program suited just for you. Come join the fastest growing area in dentistry. It will change your practice for the better, and you’ll be helping your patients who have this deadly sleep disorder.
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HOW DENTAL SLEEP MEDICINE REWARDED ME AUTHOR: DR. JOHN COMISI DDS, MAGD Professor at the Medical University of South Carolina College of Dentistry and prolific speaker, Dr. Comisi talks about how dental sleep medicine has enriched his practice.
I
have been a general dentist for almost 35 years and love all that it entails. Which dedicated philosopher can we credit for originating the phrase, “If you love what you do you won’t ‘work’ a day in your life.”? Each day is a different love affaire for me in dentistry with new challenges and opportunities. But there was one arena that always seemed a bit daunting to me: the management of my patients with sleep breathing disorders. My patients or their significant others would explain to me what they were experiencing, typically telling me there was snoring involved and that their bed partner could not tolerate the noise they were making every night. When I would go on camp outs with my son’s Boy Scout troop there was always one or two other adults making a “racket” all night long with their snoring so that no one in camp could get any good sleep. I did some reading on the subject and began to consider creating “snoring” devices to help these patients. I tried all kinds of potential solutions. Some seemed to work, others did not. In fact some of them probably were causing more problems than solutions. You see, I always understood that the noise made from snoring was caused by the tongue blocking the back of the throat and that, like CPR, if we moved the lower jaw as far forward as possible, we’d open the airway and stop the noise. Well, I couldn’t be more wrong. All it was doing was causing jaw problems and causing patients’ lower teeth to feel like they were being pushed out of the mouth. I tried to convince myself that I could find a solution by perhaps splinting the teeth, using a soft guard to cushion the teeth, other things to solve the problem. Nothing worked. I was failing my patients and myself. My wife Karen constantly urged me to take further training on this subject, but I always put it off because I had other priorities. Then she scheduled a course for me without me knowing it and we were suddenly off to Atlanta, GA to take a weekend educational program. I begrudgingly went, figuring it wouldn’t be of much help. But as the weekend progressed, my eyes opened. I was looking at the subject so wrong! I was trying to stop my patients from snoring, but I really needed to help them breathe!
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In South Carolina, where I now live and teach, the state motto is: “While I breathe, I hope”. At this course, I realized I needed to work in concert with my patients’ primary care physicians and the pulmonologists in my area to help my patients. This is not a single entity solution. First, the patient must be diagnosed with some form of sleep breathing disorder, then with that diagnosis, and the proper training and technology, I could finally really help my patients. This team approach made the day to day practice of sleep medicine so much more interesting and satisfying. I, along with my medical colleagues were making a difference for our patients with my creation of effective oral appliances that actually could open the airway and take patients with even severe obstructive sleep apnea to the point of almost normal, unobstructed fully restful and beneficial sleep. The first time one of my patients came in wearing his newly created oral appliance and told me that for the first time in 20 years he dreamt, it was a HUGE day for me. His eyes were wide open with excitement and joy. He told me it was amazing to have a really restful sleep for the first time in so very long. As the weeks progressed with our follow-ups, he continued to tell us his energy level was increasing and he felt better than he had in a very long time. About three months after the delivery of his oral appliance he had a follow-up hospital sleep study and the results were exciting for the patient and his physician. Through the technology we use (EccoVision Pharyngometry and Rhinometry) we improved him from severe obstructive sleep apnea to a diagnosis of very mild to nonexistent apnea. Since that first case, there have been many others who have benefited from our care and countless more to come. My greatest rewards are from the gratitude my patients show me for improving their quality of life. Saving lives and having income benefits cannot be matched anywhere else in dentistry. I urge you to consider looking further into bringing Sleep Medicine into your day to day work. I believe it will make a difference in your practice life, and the lives of so many people who are already part of your practice and are unaware of this life-threatening condition. You can make a difference in their lives and they will see you as their hero. Take the next step.
ABOUT SLEEP GROUP SOLUTIONS
LEADERS IN DENTAL SLEEP MEDICINE
Sleep Group Solutions is a privately held dental & medical sleep medicine education, instrumentation, and in-office training company. Based in Hollywood, Florida, and established in 2005, SGS focuses primarily on dental treatment of snoring and sleep apnea. Today, Sleep Group Solutions stands alone as the only provider of a complete suite of solutions. Starting with continuing education courses and in-office training, screening, diagnostic and treatment instrumentation. With over 50 Million people in North America suffering with sleep apnea and less than 0.5% of the dentists currently trained and equipped to offer assistance, we can expect to see continued growth of this field over the next decade. By offering every piece of the education, screening, diagnosis and treatment puzzle, SGS provides a unique position to capitalize on this tremendous growth.
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THE POWER OF MEDICAL BILLING BY: CHARLES KRAVITZ, DDS
B
illing for dental sleep services is the stick that stirs the DSM health cocktail. It should be enough that a patient with Obstructive Sleep Apnea is anxious to pursue treatment for this life-threatening disease, but learning that the services are in large part covered by medical ("insurance") benefits should make this treatment irresistible. Making treatment available for most people Medical codes, which heretofore were seldom used by dentists, are now providing the missing link to make payment for life-saving medical services become simpler and quicker for dental professionals. A dentist or a dental auxiliary has two options for benefiting by using medical codes. They can learn the codes, the system and the protocol for medical billing and then process all the billing themselves. Another option is to utilize the services of a professional billing company. If outsourcing is your option This company will set up a method of receiving a dental treatment plan from the dental office and then process the invoice to the benefits (insurance) company. The billing company will be paid a commission for each case by the dental practice. If the dental practice chooses the option to process the claims themselves they will obviously save any commission paid out to a billing company. If they want to process the claims themselves they would need to learn the system completely so as not to lose out on any possible services that can be billed and to be able to do the process quickly, completely and correctly. It takes a lot of time to become proficient in the medical billing process. The owners of any dental practice would make that decision on which option to choose. In any case, once the medical billing process is in place, a dental practice will be able to achieve great rewards from a successful dental sleep medicine service.
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CONTINUING EDUCATION QUIZ 1) What is the percentage of pregnant women with sleep apnea that are required to eventually have a C section?
7) OSA is estimated to occur how much more often in men than in women?
a) 50% b) 20% c) 65% d) 70%
a) Three times as often b) Twice as often c) Eight times as often d) Six times as often.
2) What is an example of two signs of obstructive sleep apnea that dentists are in a position to observe during a checkup?
8) What does the 2017 ADA Scope of Practice Recommendation state according to Hu’s article?
a) Headaches/Snoring b) Snoring/Large Uvula c) Incontinence/headaches d) TMJ Pain/Large Uvula
a) Dentists should screen for OSA and are the only ones qualified to make an oral appliance. b) They should not screen for OSA but are qualified to make an oral appliance c) They should neither screen for OSA or make oral appliances d) None of the above.
3) How many people worldwide are estimated to have untreated sleep apnea, according to Dr. Hu’s article? 9) What is the American Dental Association’s policy statement on the role of dentistry in the treatment of sleep-related breathing disorders?
a) 1 billion b) 2 million c) 100 million d) 250 million
4) According to the CDC, what was the percentage increase of dentist from 2006-2015? a) 13.4% b) 14.7% c) 14.19% d) 13%
5) How many meetings will Sleep Group Solutions Study Club have a year? a) 7 b) 6 c) 5 d) 4
a) Dentists should treat sleep apnea with a decade of working experience. b) Dentists are encouraged to screen patients for sleep-related breathing disorders (SRBD) as part of a comprehensive medical and dental history to recognize symptoms such as daytime sleepiness, choking, snoring or witnessed apneas. c) Dentists are encouraged to screen patients for sleep apnea as part of a comprehensive medical and dental history to recognize symptoms such as daytime sleepiness, choking, snoring or witnessed apneas. d) Dentists are encouraged to screen patients for sleep disorders as part of a comprehensive medical and dental history to recognize symptoms such as daytime sleepiness, choking, snoring or witnessed apneas
10. Which of the following is NOT a sign of sleep apnea that dentists can observe in the chair?
6) According to the Bureau of Labor Statistics, to what number are dentists in the US expected to grow by 2026?
a) High Palates b) Large Tonsils c) Thick Necks d) Snoring
a) 29, 000 b) 30, 000 c) 29, 300 d) 19, 000
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