Your Role in Dental Sleep Medicine P7

Jan
2014
20

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Dr. Lavine:

I think so.  They’re still on the line.  So, they can do follow-ups if they like.  You showed a case where there was a patient that had a uvuloplasty and they were still falling asleep on the dental chair.  You talked about the HIV 43.  What is that?

 

Dr. Elliott:

The UPPP?

 

Dr. Lavine:

They’re talking about HV or HIV 43.  So, I’m not sure exactly what the question was.  We’ll invite them to maybe do a follow-up for that as well.

 

Dr. Elliott:

Oh, that AHI.  Sorry, it was the AHI of 43.  That means he still had severe sleep apnea.  If you look at the scale of AHI is, that’s the apnea-hypopnea index.  He was still have residual apneas or residual obstructions, but he was quiet.  So, he thought he was cured, but he wasn’t.

 

Dr. Lavine:

You said anything over 30 is not good.  Correct?

 

Dr. Elliott:

Correct.

 

Dr. Lavine:

Okay.  The foam wedge, how is it placed?  Is it place right-left, or is it on top of the bed higher than the foot?  Where exactly are you putting that wedge?

 

Dr. Elliott:

Well, there’s actually a couple of ways to do it.  The bed wedge. I think they’re made to be just put under the sheet, but we found that if you put it under the mattress, it’s a lot less noticeable, and it just gives you a little lift.  You can find it on Amazon.  It’s like $40, and if you have Amazon Prime like I do, you get free shipping.

There’s something called postural fluid shift that happens at night, and some people actually elevate the head of their bed on some elevators.  They’re made to elevate the entire bed, but if you just put them on the head of the bed, you actually sleep at a little bit of an angle.  You don’t get all stuffed up, and you’re throat doesn’t take on the fluid that can narrow the airway and cause snoring as well.  So, some people feel a lot more refreshed and less puffy when they do that, too.  So, there’s a few strategies.

 

Dr. Lavine:

Okay.  Again, just some technical questions.  How do you know that the mandible is forward enough if you don’t have an HST device before sending back for follow-up PSG?

 

Dr. Elliott:

You don’t, and that’s the tricky thing because I would go off the subject of symptoms such as snoring, feeling rested, that sort of thing.  Some people, though, sleep alone.  They don’t know if they’re snoring, and you’re kind of going blind.  Really, dental sleep medicine doesn’t have to be extensive to integrate.  It isn’t at all, and the home sleep study is probably one of the most important pieces.  I actually found a sleep study.  I only have one, and I lease it for about $350 a month for as many of the disposables as you want and the free software that comes with it. So, there’s many different ways to do it, and you can do it pretty inextensively.   I always do a titration check before I send them back to their physician.

 

Dr. Lavine:

Which HST device do you use in your own practice?

 

Dr. Elliott:

I actually use the Watermark because of the cost because I have a partner, and he doesn’t do sleep apnea.  So, I’m permitted a certain amount of budget, and we work within that.  He does the implant degree, and I do the sleep apnea.  So, that really agrees with my budget.  There’s other ways to do it, and can do medical for the titration.  So, if you are getting paid for them, then a lot of people use the Watch-PAT or the Braebon MediByte Junior.  So, there’s a lot out there that can be affordable, especially if you’re getting reimbursed for them.

 

Dr. Lavine:

Okay.  Speaking of equipment where do you purchase your bite gauges from?

 

Dr. Elliott:

You can get them in a lot of places.  I do own a George Gage as well as the Moses.  You have to get the Moses from Modern Dental Lab.  The George Gauge, I do order directly from SomnoMed, or you can just do a simple Google search and find it.  I have a container next to me, and they have them as well, but I order from SomnoMed.

 

Dr. Lavine:

What are the top appliances?  Any opinion on that?

 

Dr. Elliott:

My assistant is kind of my guinea pig when we started, I made her one of everything. With the TAP, there are advantages to it, but you are locked in.  Some people get claustrophobic-feeling with it.  There are patients who do really well with it.  In fact, I work with the Air Force here, and that’s what all the dentists are trained in.  It’s just what works best for your patients and what works best in your hand, and other than SomnoMed, I don’t have a lot of chair side time or even the Moses.

There’s advantages to each appliance, but TAP, like I said, is really good if you have dental work that needs to be done.

 

Dr. Lavine:

Okay, a couple of questions here related to the same topic.  I’m not sure how comfortable you are talking about this, but is there a fee range that you are comfortable talking about that you normally charge these patients or the national average that you’ve seen?

 

Dr. Elliott:

These are great questions.

 

Dr. Lavine:

It’s very educated.

 

Dr. Elliott:

Yeah.  The difference between dental insurance and medical insurance is vast, and if dental insurance, we know it’s going to cost this much and we’ll get reimbursed this much and this patient owes this much.  In medical insurance, you can charge up to with the whole package with evaluation and radiograph, charge up to $6500, but medical insurance, you talk about out-of-pocket expenses.  You never really give a total.  Like when I got my knee surgery, I said, “How much is this going to cost?”  They look at you with a blank stare like, “I don’t know.”  It’s because there’s so many variables, and there’s adjustments and all sorts of things.  So, when you talk to patients about their appliance, you’re talking about out-of-pocket.

I did have a patient that I had to [01:23:37], and he spent $4000 in California for a $200 appliance.  I charge basically $2700 for discounted Medicared because we only get reimbursed a certain amount.  So, I think some insurance pay $5000 for the appliance. I’m not seeing those numbers here I Idaho.  I don’t know if we’re behind the times or if our insurances are behind the times.  It can range.

 

Dr. Lavine:

Are you talking about medical insurance?

 

Dr. Elliott:

I am.  I think that’s one of the biggest things, and it’s what prevents us from doing it, entering dental sleep medicine.  Medical insurance is really difficult to navigate, but once you get it, once Crystal was trained, things were stimulated.  It wasn’t until I started billing dental insurance that things took off.  I was doing two, three appliances a month, two and a half years ago, and I was having the patients try to bill and they would have to pay me the full amount.  Now, I’m doing 15 to 20 of them because we take a lot of that load from the patients and make it easier for them.  That’s the goal.  It’s just to help get people sleeping again.

 

Dr. Lavine:

Okay.  So, if somebody wanted to get started with this, obviously, the first step is to come to the course in Detroit.  What next?  What do they really need to be doing to start incorporating this into the practice?

 

Dr. Elliott:

I think the first step is to try treating your staff once you learn it and know how to do the impression and bit registration and communicate with the lab.  Treat your staff or even family and friends, but do not treat them without studies.  I think reaching out to a sleep physician and saying, “My dad, my hygienist is really struggling out with their sleep.  I’d like to work together with you,” and they really are open to I a lot of times.  They know that a lot of dentists can’t.  Because of medical insurance, it does have to be done by a dentist.  I know there was an ENT that was trying to do it, too, but oral appliances have to be done by a dentist in most cases with insurance companies.

 

Dr. Lavine:

Okay.  Where did you get your training?  I know you were in Canada.  Was this a formal type training?

 

Dr. Elliott:

I took an introductory course, and there’s always so much more new studies coming out.  So, the AADSM is always a great source.  That’s the American Academy of Dental Sleep Medicine, and they have a convention every year in the beginning of June.  So, I went to Boston last year.  I’ll be in Baltimore, again, this year, and that is a great resource to hear from the people that are doing the research.

We’re on the front line treating people whereas they learn from the people in the university by doing the studies.  It’s really great interacting and great information.

 

Dr. Lavine:

Okay.  Now, Erin, typically we finish in a couple of minutes.  We’ve got more than a couple of minutes’ worth of questions.  I’m obviously around for another 5, 10 minutes.  Can you stay for that as well, or do you have to go?

 

Dr. Elliott:

Yeah.  That sounds great.

 

Dr. Lavine:

Okay.  We’ve got a lot of great questions here.  If you do not do a sleep study after the delivery of the appliance, how sure are you that the OSA is treated?

 

Dr. Elliott:

You’re really not. The sleep physician that I work with, I really am politically correct because I like working with the medical community that’s why I’m really careful not to say oral appliances replace CPAPs or come to me and I’ll cure you of everything, but I do have a sleep physician who says that if they’re mild to moderate and they’re not snoring anymore and they feel good, he doesn’t require a follow-up PSG.  He may do a [01:28:07] just to make sure they’re not desaturating, and that’s if they have no co-morbidities or any problems.

I always do that follow-up study just for me sake.  Because we’re dentists, were the type that if you see a cavity, you want to take it all out.  You want to make sure it’s not going to break 100%.  In the medical world, it’s not so black and white.  So, I want to see an AHI of 5. That doesn’t always happen, but the patient has a better quality of life.  Even reducing your AHI by half or under 10 is going to maximize their life by years as well as make it a better life.  So, sometimes you have to start thinking like a doctor and not a dentist.

 

Dr. Lavine:

Now, you were talking how in your marketing, you’re careful not to put down the CPAP.  Is there any literature out there that compares the CPAP with dental appliances?

 

Dr. Elliott:

There are not a lot, but there are a couple overview articles that do compare difference studies.  They did find in one study that when treating mild to moderate sleep apnea with oral appliance that they were 85% successful.  So was the CPAP, but they found that the patients were way more accepting of the oral appliance and preferred it.  So, that’s what they say in the mild to moderate category.  That’s the only study comparing them.   The other one.  When they have a severe patient, it’s about 60% successful and a lot higher with CPAP.

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