K Don Bigelow DDS PC DASBA

Transcription

1 K Don Bigelow DDS PC DASBA Graduate Medical College of Virginia School of Dentistry Diplomate American Sleep and Breathing Academy AASM Dental Sleep Masters International Academy of Dental Sleep Utah Sleep Society American Dental Association Utah Dental Association Past President of the Salt Lake District Dental Society No conflicts of interest to disclose

2 Treating OSA with OAT

3 AASM on OAT Oral appliances (OAs) are indicated for use in patients with mild to moderate OSA who prefer them to continuous positive airway pressure (CPAP) therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for SLEEP,Vol. 29, No. 2, 2006

4 THE DENTAL PRACTICE William C. Dement, M.D., PhD The great irony about the emergence of dental sleep medicine is that generations of dentists have looked in the mouths of countless individuals with sleep-disordered breathing without knowing of the disorder Given that the dentist is often the first and only health care practitioner to look in the oral cavity, a good knowledge of sleep apnea should be part of the profession s knowledge base.

5 THE DENTAL PRACTICE Patients seen on a biannual basis Dentist and team can recognize patients who may be at risk for sleep disorders Time- dentist and team spend more time with patients

6 THE DENTAL PRACTICE Estimated that 93% of women and 82% of men with moderate to severe OSA have not been clinically diagnosed

7 THE DENTAL PRACTICE 1,506 respondents 26% met Berlin questionnaire criteria indicating a high risk of OSA 31%, 21% 1700 patients 440 at risk Prevalence of Symptoms and Apnea in the US Population * Risk of Sleep David M. Hiestand, Pat Britz, Molly Goldman and Barbara Phillips Chest 2006;130; DOI /chest

8 WE MUST LEARN TO SPEAK AS THE PHYSICIANS DO Know the proper terminology Understand the diagnosis Understand treatment and options Our role as health care providers Know our limitations Communication with physician and sleep lab! Interaction with the physician(s) and sleep lab...we have entered their world

9 OSA Diagnosis comes from Physician A Dentist would never Consider Starting A Full Mouth Reconstruction Without A Diagnosis. Why would anyone treat OSA without a diagnosis?

10 Referrals between Physicians and Dentists

11 Overview of Oral Appliance

12 Oral Appliance Therapy [OAT] 3 methods Mandibular Repositioning Appliances (MRA): advance mandible in a protrusive position Tongue Retaining Device (TRD): hold the tongue in an advanced position Combination Therapy: CPAP and Oral Appliance Therapy, lower air pressure, more comfortable for patient.

13 Treatment Options

14 Oral Appliances as a Treatment Option YOUR T R E A T M E N T O P T I O N S A R E I N F L U E N C E D B Y T H E S E V E R I T Y O F Y O U R S L E E P D I S O R D E R E D B R E A T H I N G Oral Appliance for Mild to Moderate, Snoring/RERAs

15 How the Oral Appliance Works Repositions the lower jaw, tongue, soft palate and uvula. Stabilizes the lower jaw and tongue. Increases the muscle tone of the tongue

16 Oral Appliances Pros Cons Oral appliances are comfortable and easy to wear. Most people find that it only takes a couple of weeks to become acclimated to wearing the appliance. Oral appliances are small and convenient making them easy to carry when traveling. Treatment with oral appliances is reversible and non-invasive Effectiveness of the appliance cannot be determined prior to use Not indicated as a first line of treatment for severe sleep apnea

17 Dorsal Type Appliances SomnoDent $600+ Dynaflex $349 Respire $200

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19 Herbst Appliance Most Common Medicare Design. Range $300 - $600

20 Herbst Herbst appliance only appliance approved by CMS Mico adjustable arms up to 10mm Patient can speak, drink take pills with the appliance in place Adjustable Chairside

21 Thornton Anterior Positioner Anterior fixation device Precision attachment Posterior support with hook placed inferior to the incisors Patients report reduced tongue room Can cause pain in tip of tongue

22 $350 - $450 TAP ELITE

23 NARVAL - RESMED $550 Narval CC CAD/CAM Custom MRD

24 MOSES (ALLEN MOSES) Key Attributes: Anterior Opening Tongue Space

25 A Two Piece Design THE MOSES

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27 EMA CUSTOM Completely Metal Free Latex Free Elastic straps are easily changed Tongue Space Vertical Component Lateral Movement

28 EMA ADJUSTABILITY Minimum Protrusion Medium Protrusion Maximum

29 Oral Appliance Side Effects Jaw Discomfort Excessive Salivation Sore Teeth 60-65% of patients complain of side effects after 4 mos No permanent cases of TMJ have been reported

30 Definition of an Effective Oral Appliance for the Treatment of Obstructive Sleep Apnea and Snoring A Report of the American Academy of Dental Sleep Medicine The purpose of an oral appliance is to treat obstructive sleep apnea (OSA), primary snoring, and associated symptoms. Oral appliances are intended to decrease the frequency and/or duration of apneas, hypopneas, respiratory effort related arousals (RERAs) and/or snoring events......it maintains a stable retentive relationship to the teeth, implants or edentulous ridge and retains the prescribed setting during use. An oral appliance maintains its structural integrity over a minimum of 3 years.

31 Effective Treatment* Oral Appliance CPAP Total Population (n=103) Non-severe OSA (n=50) 76.5% (39/51) 82.7% (43/52) 84.0% (21/25) 80.0% (20/25) Severe OSA 69.2% (18/26) 85.2% (23/27) (n=53) *AHI 5, or AHI of at least 50% from baseline to 20 in a patient who had no symptoms while using therapy. Hoekema, A Oral Appliance Therapy In Obstructive Sleep Apnea-Hypopnea Syndrome. A clinical study on therapeutic outcomes. 2008

32 SUCCESSFUL OAT What will be your definition of successful treatment? What is the physicians definition of successful treatment? DMD/DDS=MD/DO definition?

33 Referrals between Physicians and Dentists

34 WHO IS THE BOSS? PHYSICIAN! Medical disease with dental solution

35 Partnering with Dental Colleagues What to look for... Prior Oral Appliance therapy experience Training and Education Board Certification Practical Knowledge of the OSA patient History Exam Treatment Options

36 Communication Builds Bridges Bi-Directional Support Frequent appropriate communication about management. Respect the relationship between provider and patient. Refer patients back to the provider for Post OAT therapy follow up. Support patient compliance and maximize patient efficacy Patient efficacy is obtained via follow up with the sleep physician by way of follow up testing on OAT therapy. Optimal patient outcomes the goal. This supports the dentist AND the sleep physician. Have a back up plan if OAT therapy is unsuccessful

37 Due Diligence Always check insurance policy for OAT stipulations Understanding insurance guidelines for OAT therapy is essential to a successful insurance model Some carriers require a patient to try and fail PAP therapy prior to covering OAT therapy.

38 CP T Current Procedural Terminalogy CPT CPT is registered trademark of the American Medical Association E0486 ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON- ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

39 What do I treat? I treat the patient not numbers

40 Konnie

41 MAKING A DIFFERENCE Assist your patients in having a higher quality of life Assist your patients in decreasing comorbidity Add 10 years to someone s life!

42 My Sleep Team Kenra, Michelle, Monica

43 Contact Information K Don Bigelow DDS kdonbigelow@gmail.com saltlakesleepsolutions@gmail.com cell office

44 THANK YOU

45

46 m Use LQZ or LRK for product code

47 A Medical Disease with a Dental Solution

48 Documentation and Communication

49 MANDIBULAR ADVANCEMENT SPLINT (MAS)

50 Oral Appliance Therapy for Obstructive Sleep Apnea: An Update by Sutherland K; Vanderveken OM; Tsuda H; Marklund M; Gagnadoux F; Kushida CA; Cistulli PA in the Journal of Clinical Sleep Medicine (Journal of Clinical Sleep Medicine, Vol. 10, No. 2, 2014, pp ) is a landmark in the field. The review was carried out by preeminent investigators under the auspices independent ORANGE (Oral Appliance Network on Global Effectiveness) Registry and indicates that OAT has reached a pivotal point. The full article can be reviewed at 64/jcsm.3460

51 PUBLICATIONS

52 PUBLICATION S

53 ORGANIZATIONS / SOCIETIES

54 KLEARWAY

55 $600 SUAD

56 SUAD Ultra Elite (SUE) $600

57 (WAYNE SILENCER HALSTROM) $700++

58 BITE EXERCISER A good option for OAT Patients John H. Tucker, DM D

59 Establishing and Maintaining Communications Raise the Objections Avoiding the Black hole Never keep em guessing Stay out in front Physician Communicaion Sleep Technician Communicaion

60 BITE REGISTRATIONS The AP (Protrusive Bite) - George Gauge Phonetic Neuromuscular

61 + Starting Position: -4 mm Habitual Bite

62 Maximum Protrusion: +5 mm Starting Position -4 Maximum Protrusion +5 Total mm Protrusive Range = 9mm

63 70% of Maximum Protrusion (9mm)= 6.3 (.7 x 9 = 6.3 ) ( = +2.3 mm ) Bite is taken at Final Position + 2.3mm