Dental Sleep Medicine Blog

The complicated patient is often one of misinformation or miscommunication.

Today was a fun day where I had a patient come in for a foIlow-up visit. I have been trying to dial in a titration and get him to wear his Herbst appliance for more than an hour and a half each night.

Yesterday we sent the patient home with a home sleep tester because I wanted to know what was happening during his 1 hour of sleep.

The patient showed up with the sleep tester and stating that the appliance does not work and can't keep it in and breath. We downloaded the sleep study and when reviewing the patient informed me he was awake the whole time the tester was on and was goofing around the house.

The interesting part was there were oxygen desaturations and the breathing was reduced and stopped a few times even when there was activity. How could this be? I started talking with the patient and said the only way this could be possible is with COPD. At that moment the patient inform me he has mild COPD.

COPD is a contra-indication for an oral appliance. No matter what we do we can't treat him. He needs to have a BIPAP or O2 all the time. After I explained this he then said the pulmonologist told him the same thing and that is why he hid it from me.

Now he will wear the Herbst appliance and his BIPAP, and O2 during the day.

This is why we have to keep talking to the patients and dig out the real story. Complications are usually due to something else and not the appliance. Keep on your toes.

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Diplomate Credentials in Dental Sleep Medicine

4/20/2017

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Becoming a diplomate in a recognized association or board conveys a better knowledge of dental sleep medicine and sleep medicine. This also shows a higher level of training and commitment. The medical community will have more trust in you, as most physicians have completed specialty training and have achieved diplomate status. Since there is no recognized specialty in dental sleep medicine, it is the closest thing to a residency and specialization.
Hundreds of people teach courses in dental sleep medicine, with many different styles and focus. There also are a few mini-residencies in dental schools and private groups, and many small groups or organizations have their own credentialing and marketing focus. The top three associations for dental sleep medicine are the AADSM, ACSDD, and ASBA.

The American Academy of Dental Sleep Medicine (AADSM) is the largest association for dental sleep medicine. It offers continuing education, conventions, publications, lobbying for dental sleep providers, facility accreditation, policies and procedures standards, and more. This association is located within and as part of the American Association of Sleep Medicine (AASM), the largest association of sleep physicians and their sleep lab accreditation credentialing arm. They set the standard in sleep medicine specialty and practice. I personally recommend joining this association to everyone doing dental sleep medicine.
The AADSM also offers the Qualified Dentists designation. It is the credential for having the minimum skills and qualifications necessary for recognition in dental sleep medicine. They require twenty-five hours of approved continuing education in dental sleep medicine.

The American Board of Dental Sleep Medicine (ABDSM) is part of the AADSM and is the diplomate credentialing arm of the AADSM and AASM. It is currently the most recognized credentialing group within the dental sleep medicine world and is by far the most respected by sleep physicians. I am a diplomate with the ABDSM, and I recommend working toward diplomate status with the ABDSM for everyone doing dental sleep medicine.
To obtain credentials with the ABDSM, you need the following:
fifty hours of continuing education in dental sleep medicine. After 2017, those hours must come from a nonprofit continuing education program or a dental school. two letters of recommendation from two board-certified sleep physicians ten hours of observation at a board-certified sleep center and a signed letter stating that from a board-certified sleep physician. a 200-question proctored examination and submission of fifteen cases with documentation for evaluation

The Academy of Clinical Sleep Disorders (ACSD is a smaller association, and it’s relatively expensive to receive diplomate credentials. To receive their credentials, you need to take their training (forty-five hours), their proctored examination, and submit twenty cases for review.

American Sleep and Breathing Academy (ASBA) is a newer association that offers continuing education and credentialing. It requires forty hours of continuing education, ten cases for review, and a one-hundred-question proctored exam.
With the choices for association membership and credentialing, it is becoming more difficult to obtain diplomate credentials.

Facility Accreditation with the AADSM
I was the first in Arizona to achieve facility accreditation, but I have let my facility accreditation expire.
. I was also on the committee for approving facility accreditation. The process of applying made my office sleep program better and helped me to make clear standards and objectives. I think it is wise to go through the steps for application because it will improve the way you maintain your charts and policies. It’s beneficial to get facility accreditation first if you need more time to get the diplomate status; getting facility accreditation is easier than the diplomate status.

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After a few weeks in Asia and traveling long distances across several time zones in an Airplane I suffered from Jet lag.

Jet lag is where the circadian rhythm or internal body clock that regulates the 24 hour cycle of the biological process has be altered.

What are some ways to help with jet lag? Drink plenty of water when flying. Staying hydrated is essential Too much caffeine or alcohol can make you dehydrated. Wear sunglasses or an eye cover when trying to sleep on a plane. Avoid sleeping pills as that does not help and may hurt the biological clock.

What I like to tell my patients is to start taking 3-6 mg of melatonin a day before flying and the day of the flight. You may need to continue for several days after you return home. Melatonin is so good for helping adjust the internal clock.

I also recommend melatonin for shift workers that have their circadian rhythm altered.

Getting jet lag under control is important for people with sleep apnea because it just makes the condition worse and the patient more agitated.

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I am leaving in a few minutes to go to China and Japan to teach dental sleep medicine. I won't be making a blog entry next week, but will be back the week after.

Today I just want to remind everyone that a key part of evaluating your patients for an oral appliance is to make sure they have the dexterity to use the appliance.

How do we check the dexterity? Have the patient hold their hands out in font of you. Then see if they can open their fingers and rotate the hands. Then have the patient squeeze one of your fingers.

If the patient can't perform these simple tasks then an appliance won't work because the patient won't be able to insert or remove the appliance.

See you in a few weeks.

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Often times I am asked by dentists involved in dental sleep medicine if they should get their diplomate status with the American Board of Dental Sleep Medicine or not. This is my opinion on the subject.

Diplomate status indicates that you have put in the time to learn the skills necessary in dental sleep medicine. It involves going further than just learning about the appliances. To be a diplomate you need to understand how sleep labs work, what sleep physicians do, and about all the alternative treatments for obstructive sleep apnea.

It is not easy to obtain dilomate status with the ABDSM. If it was easy then there would be little respect for it in the medical communities it would not be taken serious. There are other associations that make it easier, but they do not have the ties to the American Association of Sleep Medicine and the credibility that caries. Still it is worth perusing Diplomate status even with other groups because it does give you a credential to market.

The diplomate status is good to open doors within the medical community. Unlike general dentists medical doctors have a required residency. To them diplomate status means everything in their profession. When you have that status they see you as having completed a residency and they give you a slight bit more respect.

There are some people advocating to the medical insurance companies that a diplomate status is important in sleep, and thus want to see payments going only to those with the diplomate status. I do not see this going anywhere, but it is still being discussed.

I like to teach people that they should be working towards their diplomate status starting day one treating obstructive sleep apnea. The means making sure to have a good sleep study, prescription and photos prior to the appliance, and a follow-up study after the appliance. Treat each case like a board case. Go to http://www.abdsm.org to learn about the requirements for diplomate credentialing.

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Why appliance material matters

3/15/2017

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Appliances come in many different materials or material combinations. With all the different types out there it is hard for a dentist or patient to choose what to use.
Here are my thoughts about each material and what I prefer.
There are a few sleep appliances made 100% out of metal. These appliances are very good for someone that grinds so severe they wear everything down. The downside is these appliances can’t be adjusted much at all. If any change happens to the teeth such as restorations or crowns or lost teeth you can’t change the appliance. Also, if there is a metal allergy it can be an issue. The more metal contact with the teeth in an appliance the less likely I would use it.
All acrylic appliances (no linings). These are great appliances and I have used them for years. It can be a Herbst, dorsal or a few other styles. The impressions need to be perfect and little to no cosmetic work done to the teeth. Veneers are a problem with a tight fitting acrylic appliance because they can be pulled off or broken upon insertion and removal of the appliance. If no cosmetic or major work was done to the teeth the all acrylic appliance can outlast most others and can be relined and repaired if there are tooth changes such as loss of a tooth or crowns.
Polymer material like the Narval appliance is very strong and works well with people that grind. They are great for people with allergies to acrylic or monomers. They are expensive appliances and you can’t make much adjustment to them like adding material or relinings.
Acrylic appliances with a soft lining have a lining like a sports mouth guard and are easy to insert and remove. They feel the most comfortable to the patient and easy for an assistant to deliver the appliance. The soft lining is gentle on veneers and restorations. This is my favorite type of appliance to use because less potential for damage to the teeth. The downside is you can’t reline the material or add to it. The lining does not last as long as the acrylic. In most cases the lining lasts about 3 years. The only way to change the appliance if major work has been done to the teeth would be to remove the lining and put thermoplastic lining instead (only Dynaflex lab is doing that right now).
Acrylic appliance with thermoplastic lining is made by Dynaflex. It has to be warmed in hot water and placed in the mouth for a very short time and removed. If it is in too long after heating it is hard to remove and may cause damage. This is technique sensitive to deliver to the patient. It can be re-heated and refitted over and over making the appliance very good for times where major dental work has been done. If you live in a hot climate like the deserts of the southwest where temperatures get over 100 degrees this may not be the best choice because the lining can be destroyed by the heat. Also it must be explained to the patient to not try and heat the appliance and refit it at home.
So what appliance material do I prefer? I prefer an acrylic appliance with a soft lining. I know the soft lining won’t last as long as an all acrylic or all metal appliance, but I also know they won’t damage restorative work and are easier to deliver. Since I changed over to the soft linings my delivery time was reduced significantly and the patients have been happier. I have not had any dental restorations damaged as a result of an appliance with a soft liner. I have however had to glue the soft liner back in on several patients and had to drill out some parts of damaged liners.
The key is to try the different types of materials and see what work best for your office and your patients knowing the limits and potential problems.

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Nutrition for sleep apnea

3/8/2017

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How do we approach nutrition for sleep apnea? Are there foods to avoid? When should people eat? What should they eat? Can we advise on diets?
First, let’s discuss what foods should be avoided. These are my opinions based off of discussions with ENT MDs, fellow sleep dentists, and nutritionists. There is no hard scientific research yet so I won’t be referencing anything.
Dairy products produce phlegm in the mouth and throat. This phlegm or mucus can cause the throat to close up or not breathe clearly. I typically explain to all my sleep patients to stop all dairy products at least 3 hours prior to sleep.
Peanut butter may have protein and help some people with their diet or post workout drinks, but late at night it does cause some stickiness in the throat and some minor allergy issues. We try to avoid all peanut butter 3 hours prior to sleep.
One of my favorite fruits is bananas, but it can cause mucus and airway issues. Bananas should be avoided an hour prior to sleep.
Alcohol is a central nervous system CNS depressant and should be avoided 2 hours prior to sleep. The heavy use of alcohol may cause central sleep apnea or elevate the snoring and obstructive sleep apnea.
Marijuana edibles inhibit the CNS and can contribute too many issues affecting sleep. None 3 hours prior to sleep.
Narcotics (not a food, but I bunch it in) these will affect the CNS and may cause central sleep apnea, and in particular opioid addiction.
Second, when should people be eating for sleep apnea? It is best to not eat two hours prior to sleep. A full stomach at sleep can lead to weight gain because the body does not digest as well when sleeping, and we also see more acid reflux problems with full stomachs in sleep.
I prefer my patients to have their last meal about 3-4 hours prior to sleep, but stress at least 2. I also try to get patients to a 3 meal a day program and snacks limited to 2 times a day.
Can we advise on diets? Yes, and we should. I like to point out that most diets work for the first 2-4 weeks and weight loss under most plans works well in the beginning. After a month it is no longer a diet, but more of a behavior change.
There are good diets I point my patients towards like the Mayo Clinic Diet online, Nutrisystem, South Beach diet, or Weight watchers and the list goes on.
Whatever diet we point them towards our follow-up is important to get them to start and follow through. People need encouragement and support. At each of my follow up visits for sleep apnea treatment I ask about their diet. Even though as dentists we can no longer get paid for this by Medicare or medical insurances, we can still help by offering the guidance and support.
If you want to make money from a diet program you could do an MLM program like Beach Body, or affiliate marketing with things like the Mayo Clinic diet, or even selling nutritional supplements.
Did you know medical doctors are required to provide nutritional guidance or refer to a nutritionist all their diabetic patients that they have on a diabetic care program?

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Home sleep testing HST in dental sleep medicine

3/2/2017

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The use of type III HST in dental sleep medicine has caused quite a bit of controversy. Some people in the medical community have voiced concerns about dentists being ill trained to use the HST equipment for diagnostic or even titration purposes.
There are companies selling type III HST equipment teaching dentists to screen their patients for sleep with the use of the HST. The dentist would then send the test data to a third party Board certified sleep physician to read, score, diagnose, and refer back to the dentist for treatment with oral appliances.
This practice of a dentist being involved in the diagnosis and using his/her equipment is the heart of major debates in dental sleep medicine. For the sleep physicians it is something they feel dentists should not be allowed. In several states the medical boards have worked with the dental boards to disallow it. Many of the medical insurances will not approve a dentist ordering a sleep test or using their equipment for diagnostic purposes. Medicare will not allow a dentist to be involved with the diagnostics or even to loan out the HST as this violates the Stark laws and can result in jail or large fines.
Using the HST for the purpose of checking the titration with the auto score features is an accepted practice. This is not a diagnosis and it is not an official scoring and interpretation. This is a guide to see objectively if the oral appliance is working and if not how best to treat. The use of the HST will allow the dentist to see body positions and snoring and apneic events. The dentist can then recommend adjunct therapies to help with treatment such as body positioning.
It is acceptable for a dentist to order a reading and interpretation from a board certified sleep physician with the titration HST for the purpose of board certification requirements documentation. It is however best to send the patient back to the diagnosing sleep physician to re-evaluate the treatment at 6 months post treatment.
For HST equipment used in titration studies I personally recommend equipment that can detect central and mixed sleep apnea. For most testers this requires the use of a RIP belt. I also want the tester to be under $10 per use in disposable supplies. We need to keep costs to a minimum because we may have to test several times. The equipment needs to be durable, and easy for the patient to use, and the cost to purchase or lease should be reasonable.
My favorite tester is the Alice Night One by Philips. It is about $1800 to purchase and cost about $6 per use. The Apnea Link Air by Resmed is another good one at a price about $2400, and the Medibyte Jr at about $3000 as well.
A question that is always asked of me when I lecture is, “can I put or loan out my HST equipment to medical doctors to use and in turn they send me the mild to moderate sleep apnea patients?” The answer is “probably not”. If the medical doctor accepts Medicare and you do this it is a violation of the Stark law for the medical doctor. If you are treating a Medicare patient even though you are not a Medicare provider then that is still a Stark law violation. If you are a Medicare provider and do this you have made a serious stark law violation. You cannot have any gifting or incentive to receive a patient. It is a non-influence policy with Medicare. For cash patients there are no specific laws I am aware of, but it is in bad taste and will offend other medical doctors and bring you unwanted negative attention.
Another question is, “Can I do dental sleep medicine without the HST for titration?” Yes you can, but not as well. You will never know the objective results unless the patient is tested and you would rely on the sleep physician to verify your treatment. Also you would not have all the tools to know if positional therapy is needed.

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