Your Role in Dental Sleep Medicine P5
2014
So, usually the patients are motivated to wear it to stop the snoring, and they realize how much better they feel, too. So, there are different types, and those include a tongue retaining device that’s the grandfather, the place where we started, the non-custom boil and bite that you see on the internet or the infomercials. This is PureSleep® that you can buy online, buy one get one free right now for $59.95, but you can see you boil it, bite into it, and you can actually adjust it a little bit.
Non-adjustable but custom-made. This was made for a patient who was a friend of a dentist. He said he tried it to make him something to help him. It’s basically a couple of mouth guards together. This is the Tap-3, it is now, as of December 26th, approved by Medicare to use. This is good for patients that are going to need a lot of dental work because you can use a material that’s white, and when you heat it up, it turns clear. You can place it in the patient’s mouth and re-align it.
This is the Medicare-approved Herbst. Most of the appliances, at one point, were actually approved by Medicare, and as of November 1st, the Herbst was pretty much the only appliance that was. Someone decided that the hinge was needed and that the rubber band’s elastic hooks were needed as well. So, you advance it by turning the screw over here, and then you can advance the mandible forward. Again, just like when you to CDR training, when you need to get into the airway, you move the mandible forward. So, that’s how we’re treating our patients.
Moses is a common appliance that’s used. A lot of dentists like it because it is comfortable. Because of its anterior opening, the tongue actually postures forward, and they think that’s actually better airway opening because you’re unconsciously pulling that tongue forward at night. There’s no way to hook them together, but this is a fixed retainer on the top that glides into the appliance on the bottom. By turning the screw, you can pull the mandible forward more.
What I think is interesting by the Narval is that it is created by ResMed. ResMed is the world’s largest CPAP manufacturer and dealer, and so many DME suppliers are actually against oral appliances. They say they don’t work, that anyone who turns in their CPAP are making a big mistake, but now that ResMed makes an appliance, and they’ve told the DME suppliers that, they go, “Hm, wait a second. Maybe there is a place for oral appliances.” It’s a flexible material, and it’s actually really strong, and you can change the lengths of these hooks to pull the mandible forward, too. It’s [56:44] milled.
Now, a real common one is the Somnodent. This is probably the one I use the most because it’s comfortable for the patients. I use the flexible material, and then, I add elastic hooks that the patients can actually hold it together if they want to. If their jaw drops open and they get a dry mouth, the elastics actually help close it together, and it’s small enough to get a lip seal. This is called the dorsal fin pulling feature, and I believe there’s another one that uses this technology. By advancing the screw, you pull this forward, and the fin couples with it and moves forward as well. These are actually really comfortable. The patients think they look like vampire teeth, but they stay right off along the cheek, and can’t even notice it.
Now, this is my dad, and that’s my little sister. This is her 30th birthday party. It’s not a trophy life, but I want to tell you his story real quick. He is a dentist, but he practices in another town. We went to a course together, and in part of a course, we did a home sleep study. I just knew that I didn’t want to share a hotel room with him because he snores so bad, but I’m cheap so I ultimately did. It wasn’t a very good sleep. He ended up having moderate sleep apnea, AHI of 25.3, and you can see that he snored even when he was on his side. That’s what all these lines mean. Again, once you learn this stuff, you’ll be able to read this problem. All these blue lines are these RERAs or those arousals. So, he was not getting continuous sleep at all. The scariest part was his heart rate. It was a maximum of 137, and you can see how tachycardic it was all night long. His heart was working overtime when it was supposed to be resting.
Now, the second night, he wore his appliance. When he had sent in the impression and bite registration, he arbitrarily set the bite registration. We didn’t know how to do it correctly at the time, and that night it went down to a 14.8. As you can see, though, his heart was actually resting. So, there were a lot of blue lines and a lot of snoring, but he was resting already. He has [59:15] so we pulled him forward and titrated him. Now, he’s at a 5.1 and as quiet as can be. My mom actually thought he was dead the first time it worked because she had never heard him quiet, and looking back, I see all the signs and symptoms he had with the acid reflux and the gag reflex. Everything I look for in my patients was happening in my family.
So, what do I look for in my patients? A good place to start, this is actually my partner. He’s class II clincher, bruxor, headaches, everything you can think of. So, we actually treated him as well as my hygienist’s husband as well as my assistant’s husband. So, you can see that’s an easy way to start, and it’s an easy way to get fans. Of course, with patients that you see, the easiest ones are the ones who have been diagnosed. So, even adding, “Have you had a sleep study? Have you been diagnosed with sleep apnea?” is a good place to start because they’re already not getting treated. Of course, you want to get all the training before you start to.
Your relationship with the medical community. This is something that has really helped take off the dental sleep medicine part of my practice. Like I said, I fell asleep with dental sleep medicine, but I still get to do my general dentistry, too, which is what I love. This is something, too, that can be done in a small town, and I’ve figured out a lot of the systems and the communicating and the marketing to help you do that.
The external marketing, too. I’m really careful not to say, “I want to replace the CPAP,” because I work really closely with the medical community. I don’t want to say that oral appliances are the best thing ever and it’s going to replace the CPAP that you’re using, but we have a lot hunters and fishermen and campers and outdoorsmen, and this is an easy ad just to show that you can use your CPAP at home but take the oral appliance with you. I also market to snorers and write the articles and all those sorts of things.
So, the American Academy of Sleep Medicine really opened this up for us. What they decided is “oral appliances are indicated for use in patients with mild to moderate obstructive sleep apneas.” They found that in patients with mild to moderate OSA, oral appliances are just as effective as CPAP, and they have a better acceptance rate. So, it’s really beneficial to us that even the physicians say that. The problem is trying to get every physician in our town to agree to that. I’m lucky in this area that I do, and I’ve had the chance to educate them and show them how it works and show them that I don’t want to take over. CPAP is still the gold standard because oral appliances have a limited use in severe OSA and patients who have a high BMI.
So, before we do anything, we need a sleep study, and the presence or absence of OSA must be determined. That is probably the hardest part. That’s why starting with people who just snore is a difficult place to start, but I’ll tell you what. They are so thankful to you that you helped them do something that they’re own doctor couldn’t help them do. Do not make a snore guard for a patient unless you know that they are just a snorer.
You need to be serious about training yourself because there are a lot of nuances. There’s a lot of things that you need to learn as far as medical insurance and background as to what sleep medicine is and to dental medicine. There’s a lot of information out there. It’s hard to sift through. I get an e-mail every day from someone wanting to do my marketing for me. They want me to spend all this money on them, and they’ll guarantee me a successful dental sleep medicine practice. I just think there’s easy solutions to that, and I would like to teach you that.
With the consult, are they diagnosed or not? We show them different samples. We go over the informed consent. It’s really important to have a risk-benefit and alternative treatment. We go over what obstructive sleep apnea is, their treatment options, and we go over their sleep study. Before they walk in the door, Crystal has already called their medical insurance. We have a call intake form and an insurance verification form, and we have this information before they even walk in the door. When we go over the sleep study, what’s weird is they never heard of any of that stuff before.
It’s so fun to educate them and show them what can be done for them. We do an exam o the TMJ airway, teach them perio, go over side effects which can be light changes, teeth shifting, TMJ pain, but not as common as you might think. Some people charge for the consult. Some people do free. I actually do it for free. I did start out by charging, but it’s easier to do it for free.
A lot of times that consult appointment turns into impression appointment. At that time, I do a full exam and send letters to the doctors. It’s really important to keep the doctors informed, and it’s also a great marketing tool because the doctors know what you’re doing following through and treating their patients right. That’s all they care about. They send us fax, and they know their patients will be taken care of, followed through from beginning to end.
So, first impression. You need polyvinyl [01:05:11] impressions, or you could do a putty with a watch technique and the bit registration. There are four or five different ways to do it. I do [01:04:24] Gauge, sometimes the Moses bite. So, there are different tricks to that as well, and we use blue mint to set it up and send it to the lab.
In the delivery appointment, we go over the informed consent again and go over instructions. Keep it away from the dogs. Keep it away from the heat as well as morning exercises. Your jaw will feel different in the morning because the fluid-fills up in the joint, and just be even chewing on a piece of gum or giving a morning repositioner or an aligner, the bite goes back.