Every time you turn on the TV or open the newspaper there is some kind of story about sleep apnea. This is not totally surprising given the magnitude of the untreated patient population. Stanford has reported that only 1% of the total OSA patient population is currently receiving care. The increase in profile of the condition is leading to an increase in diagnostic procedures however patients under care numbers are still not where they need to be.

Enter David Gergen President of ProPlayer Health Alliance and lifelong football fan. David was inspired by a conversation he had with ex NFL quarterback and Cardiologist Archie Roberts MD. Dr Roberts completed research on apnea rates among retired NFL players that indicated that Apnea risk in retired NFL players is exceeds that of the general public (http://1.usa.gov/10cRgsG). David reached out to his friend Derek Kennard as his first contact to test the concept that retired NFL players need better options so that they can sustain sleep treatment.

David found that there was a fundamental problem facing almost all of the retired NFL players that he met. The first issue is that retirement has not affected all players equally some have done very well and are able to navigate the health system easily. Others need help getting diagnosed and then get treated. The unexpected discovery was that almost all of the players that David approached wanted to help raise awareness with their peers but also with the general public. This lead to the “AHA” moment that inspired the launch of ProPlayer Health Alliance. ProPlayer was founded to provide sleep care for retired NFL players and also raise awareness in the general public through public events that invite patients treated and untreated to share their stories and if necessary learn about alternative treatments for OSA. Retired players across the country have embraced this new initiative.

Recently there have been events in Dallas,Tacoma, Minneapolis, San Jose, Phoenix and coming up in May there will be an event in San Diego with Dr Bradley Eli. It is the David Gergen’s intention, that sleep care providers, physicians, dentists and DME providers, host these events in order that patients immediately recognize their need and meet someone with the advanced training and certification to communicate treatment options. The recent ProPlayer Health Alliance event in Phoenix saw a new level of engagement by the NFL player community. Syndicated sports writer, producer and talk show host Larry Fitzgerald Sr was a presenter at the event and his son Arizona Cardinal Larry Fitzgerald attended the event, sponsored by Dr Gary Core. Sleep Apnea runs in families as Derek points out in his video above. If you have a family member with OSA or you are concerned yourself please join us at one of our public events.

The following slide presentation was created to outline the excitement and OSA community awareness that a ProPlayer Health Alliance event can create. ProPlayer was founded to provide treatement for retired Football players and to raise awareness in the community of the dangers that untreated obstructive sleep apnea presents. I have been advised by David Gergen president of ProPlayer Health Alliance the retired NBA players association has made some overtures. I expect that the ProPlayer concept will change the way people learn about their sleep disorders and connect with medical and dental practitioners.

A CPAP machine may not be the first item that comes to mind when you consider the dirtiest surfaces in your household. But scientists say that some of the filthiest places in our home are where we would least expect.

Take a minute to think – What is the dirtiest surface in your home?

 Is it the door knobs? The remote? How about the toilet seat?

 All of these are likely offenders. But they might not be as dirty as you think. The toilet seat, with only about 50 bacteria per square inch, is the one of the cleanest surfaces in your home. Because we all fear the bacteria that might lurk on the toilet seat, we regularly clean it. So what, then, are the dirtiest surfaces in the home?

In fact, some of the dirtiest surfaces in the home are the ones we forget to clean. According to Dr. Chuck Gerba, a microbiologist from the University of Arizona, there are about 200 times more faecal bacteria on the average cutting board than the toilet seat. Even dirtier than the surfaces we forget to clean are the surfaces that provide an ideal home for bacteria. The wet environment in a kitchen sponge, for example, is home to some 10 million bacteria per square inch, says Gerba. But what about the warm, humid environment of your CPAP equipment?

 A study conducted by Dr Sandra Horowitz of Brigham Women’s Hospital concluded that CPAP masks are a source microbial contamination. CPAP equipment, commonly used as treatment for sleep apnea, should be washed daily. But researchers reported that a variety of bacteria were found inside CPAP masks, even the pathogen Staph aureus.

 While hand washing with soap is generally accepted as the best way to clean CPAP equipment, this daily process is often neglected. Many CPAP users simply forget to clean their equipment, potentially allowing bacteria and fungus to compound inside.

The Best Method for Cleaning Your CPAP or BiPAP machine from Jessica Cormier on Vimeo.

 But savvy CPAP users are turning to an innovative device released earlier this year by Massachusetts-based Better Rest Solutions. The SoClean, an automated sanitizer, uses activated oxygen to kill the mold, viruses and bacteria that grow inside CPAP equipment. Better yet, no disassembly is required to run the SoClean.

“Quite frankly, there is nothing else like the SoClean available today,” says Better Rest Solutions president, Michael Schmidt. “Whether it’s for the home user, or in an institutional setting, we feel that it will soon become the gold-standard for CPAP sanitizing.”

The SoClean is available for purchase through CareFusion http://bit.ly/Tc8vGb, or online directly at www.betterrestsolutions.com .

David Gergen CDT President of Pro Player Health Alliance and Dr Steve Marinkovitch DDS of Tacoma made a presentation to the 4th district of the American Legion on the dangers of untreated sleep apnea and daytime sleepiness.  This talk was attended by over 130 veterans many of whom have been diagnosed with sleep apnea and have completed a CPAP titration or were currently under treatment for their condition. Dr. Marinkovitch lead an in depth discussion on the treatment modalities available including CPAP, Oral Appliances and Surgery. There were many questions about comorbidities such as diabetes, congestive heart failure, hypertension and obesity. The dangers of daytime sleepiness and drowsy driving was also very much on the minds of the Legionaires.

After the presentation, David Gergen CDT conducted an oral appliance therapy “show and tell” where Seth C Bowles 4th District Commander was heard to say “I am so surprised at how small the Herbst and Respire appliances are compared to wearing that mask”. Mr Bowles has been on CPAP for some years and while he feels that the CPAP is “like a vacuum in reverse” he is generally compliant with his CPAP.

David Gergen CDT was very clear in his talk that “treatment is a necessity for quality of life. Make sure you see a physician for a diagnosis, then get treated. It is important that you sleep well and are able to stay awake when you are driving”. The VA has a very good sleep diagnostic facility in Seattle and I would expect that their phone was ringing this week.

Dr. Steve Marinkovich, DDS, ABDSM, is joining the national “Tackle Sleep Apnea” campaign in efforts to spread awareness on sleep apnea, the health dangers and possible treatment options. The Campaign will be holding its fourth event, in a series of events, that will be taking place at LeMay, America’s Car Museum, on September 26. The event will begin at 7 p.m. and is free to the public. The museum is located at 2702 E. “D” St.

Purpose:

Dentists have many choices for training to treat sleep apnea and snoring. Once the basics are understood, however, there are few options to explore the vast amount of learning needed to achieve mastery.  Puget Sound Sleep Scholar Study Club will give participants the opportunity to expand their understanding of sleep disorders and therapeutic options. The emphasis will always be on practical matters and how to achieve positive outcomes for the patients, the practice, and the dentist-physician relationship.

Introducing medical therapy into a dental practice creates many opportunities to design systems and create culture. Establishing best practices for medical procedures will give the dental team confidence and create solid operating systems.  If the dentist intends to seek ABDSM Diplomate status or AADSM Facility Accreditation, work done through the Puget Sound Sleep Scholar Study Club will provide much of the required material.

Meet the Mentors:

Steve Carstensen DDS FAGD, in restorative dental practice since 1983, has been an educator for many years. Since 1996 an invited Visiting Faculty member of the Pankey Institute for Advanced Dental Education, a guest lecturer for the Pride Institute, speaker at study clubs, regional and national dental conferences, and currently a faculty member of SomnoMed Academy. After completing a four year term on the ADA’s Council for the Annual Session, including chairing the 2010 meeting, he created and became Course Director for the Sleep Course at Pankey Institute. Also serves as Sleep Advisor to Spear Education.

Steve achieved Board Certification by the American Board of Dental Sleep Medicine in 2006 and has created good working relationships with every sleep physician in the Seattle area.

Randy Clare,  has been involved in the sleep industry since 1993. Randy has been working with Dentists and  Physicians to provide high quality care for their patients. This has required a broad  range of skills  in sales and marketing that will help build any practice. Randy has an intense interest in the diagnosis and treatment of OSA. He has served as mentor of the Scottsdale Study Club in the past and is looking forward to this new group.

Community Meetings

Puget Sound Sleep Scholar Study Club core curriculum will be realized over four modules of two day community meetings with individual practice assignments between events. Since dentists can clearly not achieve excellence without support, involving team members will be part of each community meeting and will have specialized learning opportunities aimed at their areas of responsibility.

This will not be simply another series of lectures.  Peer to peer learning in community is one of the most powerful tools available in education, and PSSSSC will take full advantage of the wisdom in the room to ensure that each participant is given the chance to maximize value for the time and resources committed to involvement.

MODULE ONE

• Day One

Participants will establish the goals of the community and individual members.  Requirements of Diplomate achievement and Facility Accreditation will be discussed so practices can begin to choose whether to adopt these benchmarks. We will also discuss how case presentations are put together for this group; assembling patient data in this manner will prepare the attendee for reports necessary for Diplomate application.

A discussion of the medical model and the legal requirements for treating sleep patients, including HIPAA, ICD and CPT coding by appointments necessary.  Medicare protocols, enrollment, and regulations will be detailed.

• Day Two

The examination process and record keeping for medical patients is significantly different than for dental patients. These details will be examined and practiced within the community.  We will discuss various ways of keeping records and the pros, cons, and experiences of the members with each.

Reading sleep reports provided by the sleep physicians is a key to understanding treatment choices, strategies, and how to measure outcomes. Members will read and discuss several sleep reports until they can extract the necessary data.

MODULE TWO

• Day One

Each attendee will present at least one case for group discussion. This will be the safest possible environment to gain confidence in presentation skills and data gathering.  Positive treatment outcome is not required; emphasis will always be on what the team learned during the case and what the community can learn from the discussion. This module will emphasize patient acquisition, entry into the practice, and appliance choice.

Out of Center Sleep Tests are becoming more common in sleep treatment; several devices will be examined and positives and negatives of each can be discussed.

• Day Two

Members of Puget Sound Sleep Scholar Community will learn to understand PAP therapy. An experienced respiratory therapist will demonstrate various flow generators, masks, and discuss how patients are treated during that phase of therapy. Compliance issues and strategies to increase patient use rates employed by therapists will be discussed.

An important adjunctive therapy to sleep is Cognitive Behavioral Therapy.  A local physician who spent years as a sleep physician and later became a psychiatrist to help patients with CBT will present the value of having such a practitioner on your sleep team.

MODULE THREE

• Day One

Case presentations by each member will generate learning opportunities for the entire community, with an emphasis on dealing with post insertion complications and strategies for dealing with what patients present.  Ongoing case management protocols will be discussed, including understanding when it is appropriate to perform an OCST and when it is best to return the patient to the diagnosing sleep physician.

There will be a unique opportunity to experience polysomnography.  An overnight sleep test will be arranged with a local accredited sleep lab and attendees will observe hooking up of a sleep patient and subsequent titration on a clinical CPAP device.  On the second night, a patient will have an OA that will be similarly titrated.  Two attendees will be given the opportunity to test an OCST and have the scores interpreted by the technician and the community.  This module will satisfy the requirements of the ABDSM Diplomate application.

• Day Two

Marketing your sleep practice is key to success.  We will explore as a community what has been successful and not successful in each practice.  Members will bring their marketing materials and share their stories. Outcome of this discussion will include specific steps each member team will take and a timeline for implementation.

Nutrition counseling is an area many sleep patients can benefit from but often find difficult to source. It is challenging for a dental office to add this service, but awareness of what is available may help manage the patient treatment.  A registered nutritionist who is used to working with obese patients and aware of sleep breathing issues will guide a discussion of possibilities.

MODULE FOUR

• Day One

Each member will bring a case for discussion with an emphasis on patients converted from CPAP to OAT and/or using both therapies in combination, hybrid or alternate.

Medical billing will also be discussed this day, with an experienced medical coder leading the group through some of the details associated with billing and gaining network status. 

Pediatric sleep medicine will be presented by a Board Certified sleep physician specializing in this area.

• Day Two

Sleep Bruxism will be discussed in detail; what is known of the etiology, expression and treatment of this condition so often associated with sleep apnea. TMD and other muscle function disorders will be included. The experience  of community members will be valuable as various treatment strategies are discussed.

The rest of this day will be reserved to wrap up questions in the community about ABDSM Diplomate application and Facility Accreditation requirements, as well as any other topic about best practices that is relevant.

by Barry Glassman, DMD

I want to bring some reality to the economics of dental sleep medicine, an area for dentists that is being promoted by many as a new profit center in the dental practice. There is no question that adding this valuable service to your armamentarium has the potential not only to improve the quality of lives of many of your patients, but also provide increased income.

Along with the ability to increase services and income, dental sleep medicine provides many new challenges to the dentist that are often ignored or underestimated. Only if these challenges are recognized and conquered will the dentist be in a position to provide a therapy that could be essential to the patient’s quality of life.

What is dental sleep medicine?

Sleep medicine is a relatively new specialty of medicine. In a 2005 article, Shepard, et al. state that “the history of the development of sleep medicine in the United States is relatively short and most of the individuals involved with its development are still living.” They go on to state: “Until 1975 sleep medicine was deemed ‘experimental’ and medical insurance companies routinely denied reimbursement claims.” In discussing the development of the specialty of sleep medicine, they conclude that “sleep is viewed as a basic biologic process that affects all individuals and has significant impact on the function of all organ systems.”

The International Classification of Sleep Disorders is a 400-page, stand-alone document that was written in 1990 and revised in 2005. Sleep medicine deals with sleep and arousal disorders that include all conditions encountered clinically. It deals with dyssomnias, which are those disorders that involve initiating and maintaining sleep, as well as with parasomnias, which are movements and behaviors that occur during sleep. Obstructive sleep disorders are classified as dyssomnias and represent those disorders resulting from airway obstructions that occur during sleep.

They are relatively common syndromes and by conservative estimates affect 5% of the Western world, but they are often under-recognized despite having substantial morbidity and mortality rates associated with them. Treatment for obstructive sleep disorders ranges from the extremely conservative measures of weight loss and sleep position training to variations of continuous positive airway pressure (CPAP), oral appliance therapy, and surgery. Many patients prefer the concept of oral appliance therapy to either the use of CPAP or surgery. A dentist should then be involved with patient evaluation, insertion, and appliance maintenance as well as managing postappliance insertion complications. Consequently, one might think that oral appliance therapy would be a considerable portion of many dentists’ general practices. But this is not the case.

I started teaching dental sleep medicine courses in 2001. Personal communication with many of those I had taught in the early courses exposed many difficulties that general dentists were facing as they attempted to implement dental sleep medicine into their practices. Ignoring those obstacles may lead to unrealistic expectations.

The carrot of economic success

It isn’t unusual to see an advertisement refer to the potential economic boom that a course will provide for the participant. This lure of increased financial incentive is common to many course advertisements, including periodontics, cosmetic dentistry, and orthodontics.

Silber states that 30% to 50% of the population over 50 snores. This is often interpolated to 40%. So, if 40% of your adult population snores, and you have a practice with 2,000 active adult patients, 800 of your patients snore. If you treat only 25% of them, and you bundle the workup and appliance fee to a moderate charge of $3,000, then your gross income should increase by $600,000 the first year.

Unfortunately, that is an unrealistic computation. The literature ignores the many challenges that face dentistry. Let’s examine some of those challenges.

The physician’s bias

Recent decades have seen the line between dentistry and medicine continually blur, as dentists made significant contributions to the care of patients with chronic daily headache, migraine, and facial pain. There was an early bias among sleep physicians against early attempts at oral appliance therapy. Pantino reports that when he began treating with oral appliances it was not only considered experimental, but with limited data and research and no consideration of coverage from the insurance industry and with limited physician support, he may as well have been “practicing witchcraft.”

The 1995 landmark study by Schmidt-Norwara opened the door to the need for dentistry and medicine to work synergistically and pointed out that as health-care providers, we are challenged to acknowledge the necessity for interdisciplinary communication. This early bias is complicated by the fact that obstructive sleep disorders are indeed a medical disorder. Obstructive disorders are a continuum of disorders that start with snoring.

Therefore, snoring should not be treated without a medical diagnosis, and that diagnosis should be done by a physician. In spite of the tremendous improvements in oral appliance therapy, the fact that oral appliances are usually preferred by patients over the alternatives of CPAP or surgery, and the fact that the Academy of Sleep Medicine has mandated by policy that some patients not only can but in some cases should be treated or given oral appliance therapy, physician bias against oral appliances still exists.

It therefore isn’t enough for dentists to know just the basics of sleep medicine and oral appliances. Dr. Schmidt-Norwara recently suggested that “dentists who offer this service need to become acquainted with the multifactorial nature of sleep medicine to serve their patients better and to facilitate their interaction with other sleep medicine clinicians.” A high level of mutual respect and open communication is required for the medical and dental professions to properly triage and treat patients. In a position paper on practice parameters by Kushida, et al., it is stated that oral appliances should be delivered and followed by qualified dental personnel “who have undertaken serious training in sleep medicine and/or sleep-related breathing disorders with focused emphasis on the proper protocol for diagnosis, treatment, and follow up.”

But there’s more than the science of sleep medicine

In order to be successful in incorporating dental sleep medicine into your practice, understanding the science of sleep medicine and possessing the ability to insert oral appliances is not enough. The art of implementing the science requires a different skill set than was required to develop a general dental practice.

In order to be successful, dentists must have strong communication skills. For the most part, general dentists can work within their own office walls and choose those specialists with whom they would like to work. In sleep medicine, dentists must immediately work to develop relationships of trust and mutual respect with physicians with whom they may have no past relationship and with whom they have had limited contact. Furthermore, because physicians hold the bias discussed earlier in this paper, they will often have to be educated and motivated to refer patients for oral appliance therapy. There is also the matter of “management” and the potential for failure. The dental model of practice doesn’t usually involve “managing” disease; we treat it and cure it. Obstructive disorders can’t be “cured,” a concept I have found not readily accepted by some dentists. Dentists need to develop a new mindset and a new definition of success for the practice of dental sleep medicine. They must learn that success cannot be determined with an explorer or depend totally on the polysomnogram results. They must also realize that some patients will be unable to wear their appliances. Dentists must quell their disappointment and acknowledge that although they have rendered the best possible care, there are factors beyond their control that impact the success of oral appliance therapy. This potential for failure should not dampen their enthusiasm. Fear of failure should not prevent them from helping many other patients. Making this realization and sharing this information with the patient prior to treatment is a total change in the model that dentistry routinely utilizes.

There is also the obstacle of postinsertion management. The oral appliance helps maintain the airway during sleep by creating an external splint, resulting in an increased tonic tone to the relaxing pharyngeal musculature. In order to do this, there is a strain placed on the muscles of mastication, as well as the temporomandibular joint itself. General dentists are not well trained in joint anatomy, physiology, nor in the treatment of joint dysfunction. These common complications will sometimes frustrate the dentist who may not be trained in the ability to diagnose, treat, or manage these adverse effects on the joints or muscles. This frustration has the potential to cause the dentist to stop treating with oral appliances. Training in these areas of treatment is readily available, and will allow the dentist to manage these complications and make wise risk/benefit decisions concerning the continued use of the oral appliance.

The most common adverse effect is occlusal changes. Dentistry has long emphasized the role of occlusion, and it is difficult for the dentist to make an informed risk/benefit decision if that role is considered more important than the resolution of the patient’s obstructive disorder. Ferguson states, “This presents a clinical dilemma when the patient is unconcerned about the occlusal changes and refuses to abandon the appliance citing that the perceived benefit of treatment outweighs the dentist’s concern with the altered occlusion.” Dental malocclusions created by oral appliance therapy may have no or limited effect on the patient’s esthetics or function. It may be more beneficial for the patient to continue to wear his or her appliance despite the occlusal changes. It is counterintuitive for the dentist to do anything that creates a malocclusion, but this may be in our patient’s best interest. This is a difficult concept for dentistry.

A vast bite-wing conspiracy?

Is the promise of economic gain, then, a conspiracy?

The answer is simple. Yes, it is a conspiracy if there is some implication that implementing dental sleep medicine is as simple as finding patients in your office who snore and treating them with oral appliances that you fabricate easily with impressions and bite registrations sent to a lab.

There are real challenges that face dentistry in the field of dental sleep medicine. These challenges include:

• Becoming a serious student of sleep medicine
• Educating your medical colleagues about the potential service you can provide their patients who may benefit from oral appliance therapy
• Understanding the need to manage patients and understanding their role as key players on the treatment team
• Learning how to communicate with local sleep labs and physicians by keeping them in the loop and referring patients back to them for post-treatment evaluations
• Establishing reasonable fee structures and understanding the need to process claims through medical insurance in order to get the most coverage for your patients
• Learning more about the craniomandibular structures you are compromising in order to support a compliant airway
• Carefully reconsidering some of your occlusal concepts that will prevent your potential bias from keeping patients from treatment for this serious disorder that is associated with substantial morbidity and mortality rates

Ninety percent of OSA remains undiagnosed. Our patient load would be well served if all dentists had a better understanding of sleep disorders. Our profession and our patients would benefit if all dentists were taught the basics of sleep medicine and consequently screened their patients. But more intensive study on many levels and a commitment to consider the model changes discussed are required before the dentist can provide oral appliance therapy and create another income source in his or her office.

So what is a “vast bite-wing” conspiracy? The conspiracy is on the part of those who may gain economically in the short run by having dentists construct snoring appliances for those patients who snore (even if it means without proper diagnosis) or by encouraging dentists to take courses because of the perceived economic gain without recognizing the obstacles to that end. Furthermore, the conspiracy often encourages the front-end purchase of equipment that is not required to perform dental sleep medicine; again, in the long run, this frustrates the general dentist who is not aware of the obstacles that prevent the successful implementation of dental sleep medicine in his/her practice.

Many Level I to V studies have now been completed to demonstrate over and over again the potential of oral appliance therapy to be successful in mild, moderate, and even severe sleep apnea. Certainly, oral appliance therapy has been implemented into many dental practices successfully. Some dentists around the country have actually limited their practices to dental sleep medicine. The obstacles can be overcome. But before they can be overcome, they have to be recognized and acknowledged. Then a plan can be made to overcome each obstacle.

It is essential, then, that the “bite-wing conspiracy” not result in frustration and the dentist deciding not to pursue dental sleep medicine. Those who have accepted the challenges and overcome the obstacles have placed themselves in a position to provide a potentially life-altering and life-saving treatment modality. The diligent dentist has the opportunity to add not only a new stream of income for his practice, but also a new quality of life for his or her patients.

Barry Glassman, DMD, maintains a private practice in Allentown, Pa., which is limited to chronic pain management, temporomandibular joint dysfunction, and dental sleep medicine. He is a Diplomate of the American Academy of Craniofacial Pain, a Fellow of the International College of Craniomandibular Orthopedics, a Fellow of the Academy of Dentistry International, and a Diplomate of the American Academy of Pain Management. He is on staff at the Lehigh Valley Hospital where he serves as a resident instructor of Craniofacial Pain and Dysfunction and Dental Sleep Medicine. He is a Diplomate of the Academy of Dental Sleep Medicine, and is on staff at the Sacred Heart Hospital Sleep Disorder Center. He was recently named medical codirector of the St. Lukes Hospital Headache Center.

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