You re saving teeth but are you saving lives? An Introduction & Overview of Dental Sleep Medicine Dr. Gy Yatros Diplomates, ABDSM

Transcription

1 You re saving teeth but are you saving lives? An Introduction & Overview of Dental Sleep Medicine Dr. Gy Yatros Diplomates, ABDSM Des Moines, IA May 2, 2015

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4 WHO WE ARE Dental Sleep Solutions was founded to provide alternative forms of therapy to treat snoring and Obstructive Sleep Apnea (OSA) to help maximize patient success rates. We believe that most patients can successfully treat their snoring and sleep apnea problems without surgery or frustrating medical equipment. DS3 Dental Sleep Solutions Software exists to successfully facilitate dental sleep medicine for dental offices. Our simple and effective approach has earned our reputation as leaders in the industry for team implementation and dental sleep software. Our team of dental sleep experts provide unmatched experience and customer service. Whether it is medical billing, IT issues or clinical challenges your answers are just a click or call away. With dozens of years of experience we have the answers and systems you need to succeed in dental sleep medicine. 4

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6 Simple Solutions For Dental Sleep Medicine Implementation Software Education Implementation Insurance 6

7 OVERVIEW Time Description 9:00 Introductions 2006 Practice Parameters OSA Etiology/Pathophysiology Health Ramifications, Clinical Signs and Risk Factors Bruxism Incidence of OSA Medical/Dental Models for Treatment 10:25 Questions & Answers 10:30 Break Time Description 11:30 Patient Screening Sleep Testing OSA Terminology (AHI, etc.) Pre-Consultation Medical Insurance Patient Exam & Bite Dental Devices Treatment Protocols (steps and titration) Side Effects Success Rates 12:50 Questions & Answers 1:00 End 7

8 CAUSE OF SNORING/OSA 8

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10 Normal Breathing Normally, air passes through the nose and past the flexible structures in the back of the throat such as the soft palate, uvula and tongue. During sleep the muscles relax but, normally, the airway stays open. Snoring Snoring is created by the vibration of the pharyngeal soft tissues as air passes through an airway that is too small to allow for smooth, unimpeded flow. Obstructive Sleep Apnea (OSA) OSA is a situation in which the entire upper airway is blocked causing air flow to stop.

11 Continuous Positive Airway Pressure (CPAP) BiPap AutoPap Dental Sleep Devices Mandibular Advancement Devices (MAD) Tongue Retaining Devices (TRD) Combined Therapy Surgery UPPP Geniogloslossus Advancement with Hyoid Suspension MMA Radiofrequency Ablation Tracheotomy Others Positional Therapy Weight Loss Provent

12 Myocardial Infarction Congestive Heart Failure Hypertension Ischemic heart disease Cerebrovascular Disease Excessive Daytime Sleepiness GERD Glucose Intolerance Obesity Diabetes Auto accidents Impotence Affects 15 Million Adults 1 in 5 Adults 48% of Diabetics 30% of Cardiac Patients 50% of AFIB 37% of Hypertensive Patients 11% - 37% of Patients with Heart Failure 66% of Pts. with Ventricular Arrhythmias 2 times greater in Coronary Artery Disease 17% Pulmonary Arterial Hypertension 40% - 60% End Stage Renal Disease

13 Most Common Symptoms SNORING Excessive Daytime Sleepiness Hypertension (High Blood Pressure) Other Symptoms Acid Reflux (GERD Gastro Esophageal Reflux Disease) Morning Headaches Diabetes Sexual Dysfunction & Decreased Sex Drive Social Problems/Irritability Memory Problems Alzheimer's / Dementia Dental Symptoms (Abfractions from nocturnal bruxism) Contributing Factors Obesity & Large Neck Circumference Menopause Mouth Breathing

14 Prevalence in Commercial Drivers Mild OSA: 17.6% Moderate OSA: 5.8% Severe OSA: 4.7% Total 28.1% Pack, Allen I.; Dinges, David F.; Maislin, Greg. A Study of Prevalence of Sleep Apnea Among Commercial Truck Drivers, FMCSA, Publication No. DOT-RT , Washington, DC,

15 BRUXISM OSA Dental Symptoms OSA has been linked to nocturnal bruxism. Clenching and bruxing occur when patients come out of an apneic event - the body activates muscles to regain control of the airway. Reports of OSA were two to three times higher in subjects also aware of teeth grinding. Sleep bruxism is secondary to exaggerated transient motor and autonomic nervous system activation in relation to microarousals. Dental Kryger, M. Roth, T. Dement, W, (2005), Principles and Practice of Sleep Medicine, 4th ed, elesevier Saunders,Philadelphia, pp ymptoms of OSA

16 The Problem in US 50% of US Snores 40 Million suffer from SDB 1 in 5 has mild/mod OSA 1 in 15 has mod/severe OSA 820,000 each year are noncompliant/refuse CPAP 16

17 Patient Flow Screen Baseline sleep test Consult Exam & Impressions Deliver Device F/U checks Titration sleep test Treatment Complete

18 IDENTIFY patients at risk Review Medical History Clinical Asking Questions Letter to existing Patients Marketing: Videos/Posters/Brochures/Lectures Screening Tools Paper Forms Software Tablet Screener

19 Patient Flow Identify Acknowledge Test Treat 19

20 SLEEP SCREENING QUESTIONNAIRE EPWORTH SLEEPINESS SCALE In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations? Use the following scale to choose the most appropriate number for each situation: 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing SITUATION Sitting and reading Watching television Sitting inactive in a public place (i.e. theater) As a car passenger for an hour without a break Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopping for a few minutes in traffic TOTAL SCORE A score of 8 or greater indicates the possibility of sleep disordered breathing. THORNTON SNORING SCALE Snoring has a significant effect on the quality of life for many people. Snoring can affect the person snoring and those around him/her, both physically and emotionally. Use the following scale to choose the most appropriate number for each situation. (Go to the 4th statement if you have no bed partner.) 0 = Never 1 = Infrequently (1 night per week) 2 = Frequently (2-3 nights per week) 3 = Most of the time (4 or more nights per week) My snoring affects my relationship with my partner My snoring causes my partner to be irritable or tired My snoring requires us to sleep in separate rooms My snoring is loud My snoring affects people when I am sleeping away from home (i.e. hotel, camping, etc.) TOTAL SCORE A score of 5 or greater indicates your snoring may be significantly affecting your quality of life. PATIENT NAME DATE:

21 Screening Patients All Patients receive a sleep screening questionnaire Flag Patients with potential airway problems Voice Concerns over problems and schedule to discuss further or do during initial appointment if time permits Purpose of screening form is to identify patients with potential airway problems 21

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23 Acknowledge & Agree Do Review screener Express Concern Relate red flags Do NOT Put the cart before the horse Use big words like apnea Talk too much 23

24 Sleep Tests PSG or HST PSG: local sleep lab HST: Personal device HST Company Local MD with HST

25 Apnea- a cessation of airflow for at least 10 seconds. Hypopnea- at least a 30% decrease in airflow lasting 10 seconds or greater with oxygen desaturations greater than or equal to 4%. Respiratory Effort Related Arousal (RERA)- an abnormal respiratory event associated with an arousal that does not meet the definition of a hypopnea. Snoring- a partial airway obstruction that reduces airflow but does not cause arousal from sleep Lowest Oxyhemoglobin Saturation (LSAT or O2 Nadir) - a measure of the lowest level of arterial oxygen in the blood during sleep. Normal oxyhemoglobin saturation is 95%-98%. AHI Apnea Hypopnea Index = (A + H) Hrs. Sleep RDI Respiratory Disturbance Index = (A + H + RERA s) Hrs. Sleep AHI Normal < 5 Mild 5-15 Moderate Severe >30

26 Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% Source: Behavioral Risk Factor Surveillance System, CDC

27 Obesity, OSA, Disease mechanisms, and Disease conditions (Gami 2003)

28 Consultation Diagnosis Obtained Copy of BASELINE sleep study received and reviewed Patient completes sleep questionnaire Software or paper forms Obtain patient s medical insurance Complete Verification of Benefits (VOB)

29 Verify it is a Baseline Test Date and type (PSG/HST) Place/Facility Diagnosis AHI/RDI AHI/RDI in Supine Position 02 Nadir/LSAT % SPO2 < 90% Other Explain the disease to the patient (very likely that no one has ever done this)

30 Sleep Questionnaire Subjective (Complaints & Symptoms) Epworth Sleepiness Score Thornton Snoring Scale Chief Complaint Other Complaints Sleep Quality Number of times wake up each night Morning Headaches Witnessed Apneas Bedtime Partner sleep in same room Previous treatments Health History

31 Medical Insurance/VOB Copy medical insurance card Obtain Verification of Benefits (VOB) Contact patient s insurance company, verify benefits for dental device therapy Detailed explanation in insurance program Patients want to know what treatment will cost! 31

32 Exam/Impressions Record height, weight, and neck circumference Record blood pressure Periodontal & Dental exam Soft tissue & oral cancer exam Airway exam Tongue Malampatti Classification Tonsils Classification Maxilla Mandible Soft Palate Uvula Gag Reflex Nasal Passages TMD (TMJ) muscle exam Range of Motion (ROM) recorded Photos Impressions Bite Device Selection

33 Dental Sleep Therapy

34 Treatment Success Subjective Success Wearing device through the night Confident it is helping them Pain free Subjective tests improving Objective Success AHI 10 and reduced by ½ and subjective relief of symptoms RDI 15 and reduced by ½ and subjective OR relief of symptoms NOTE: We also try to get the SPO2<90% < 1% of night when possible 34

35 Titration HST GOOD: One night, one position BETTER: Two nights, two positions BEST: Three nights, three positions TITRATING AT SLEEP CENTER PROTOCOL Patient to take adjustment key(s) / Bands / Rods Sleep tech to wake patient, but patient adjusts device INSTRUCTIONS TO TECH: IF AHI 10 OR RDI 15, ADJUST APPLIANCE 2 FULL TURNS. REPEAT AT 45 MIN INTERVALS UNTIL SUCCESSFUL. CONSIDER TITRATING CPAP AFTER 4 TO 5 HOURS IF UNSUCCESSFUL 35

36 Positive Predictors Female Normal weight Younger Positional apnea (supine) Retrognathic MP to Hyoid < 15 mm Shallow MP angle Protrusive ROM >9mm Negative Predictors Hypoplastic maxilla MP angle > 28 degrees Positional apnea (lateral) Lg. neck Muscle weakness diseases (ALS, myesthenia gravis) Females w chronic nasal obstruction Protrusive ROM < 6 mm Hoekema Results Oral appliance therapy most successful for nonsevere patients (84% compared to CPAP at 80%). greater advancement of the mandible usually increases efficacy of OA. For patients with severe disease CPAP was superior. Oral appliances in severe patients were effective in 18 of 26 patients or 69%.

37 Develop Insurance Policy Medicare decision Accept assignment of benefits? In or out of networks? Do global fee or charge individual codes? Send staff to courses Insurance billing companies 37

38 No Refer to MD (PSG) DIAGNOSIS NO Diagnosis Established? YES Yes Patient contacts Your office NO Request PSG, Gather Pt Demographics, & Verify Ins. Benefits Pre- Authorization Required? YES APPLICABLE CODING Initial Eval (pharyngometer) (pulse ox) (home study) Imaging (transcranial) (pano) (full mouth) (lateral skull) Fabricate OAT for Snoring (Insurance Doubtful) Pt pays you Pt files ins. Proceed Denied Appeal File Pre- Determination * Pt Demands Benefits Approved Proceed Letter Denied Appeal File Pre Authorization* Peer to Peer Approved (letter with Statement or Approval #) Procee d Fabricate OA Impressions Appliance E0485 E0486 Follow Up Noct pulse ox Unattended study Orthotic repair L4205 Letter Peer to Peer Follow Up *Include Supporting Doc s. Follow Up Testing

39 Consult appointment Consult/ Level 2/ 30 min. New/Estab patient Pharyngometer Rhinometer NOTE: We currently don t bill for these and payments are usually none to low Impressions/ Exam minutes, low complexity Dental Device Delivery E0486 Device Check Established patient/ 10 min Estab patient/ 15 min estab patient/ 25 min estab patient/ 40 min 1 year check estab patient/ 40 min estab patient/ 25 min 39

40 Occlusal / Bite changes Joint Pain / Discomfort Tooth pain / Discomfort Muscle pain / spasms Excessive Salivary Flow Dry Mouth Crowns / fillings dislodged Allergies to materials Posterior open bite Implants / perio teeth increased mobility Tooth movement Linguoversion max, labioversion mand, tooth spacing

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43 DENTAL DEVICES TRD/TSD Non-Adjustable Adjustable

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49 References OSA and Driving Pack, Allen I.; Dinges, David F.; Maislin, Greg. A Study of Prevalence of Sleep Apnea Among Commercial Truck Drivers, FMCSA, Publication No. DOT-RT , Washington, DC, OSA and Cardiovascular Disease /chest CHEST August 2011 vol. 140 no *J Am Coll Cardiol, 2008; 52: , doi: /j.jacc (Published online 28 July 2008). OSA and Diabetes Tasali, Esra MD et al. Sleep Disordered Breathing and the current epidemic of obesity. Consequence or contributing factor. Am J respir Crit Care Med. 2002;165: Snoring & OSA Am J Respir Med. 2002: 165; JAMA 2003: 289 (17); 2230 J Appl Physiol 2005: 99; Sleep Research Online 1999:2(1) Sleep Bruxism J Dent Res Oct;80(10): Sessle, B. Lavigne, G. Lund, J, (2008), Orofacial Pain From Basic Science to Clinical Managment, Edition of book, quintessence,chicago Sleep Med Nov;3(6): Books Kryger, Meir H., T. Roth, and William C. Dement. Principles and Practice of Sleep Medicine. Philadelphia, PA: Elsevier/Saunders Hoekema, Aarnoud. Oral-appliance Therapy in Obstructive Sleep Apneahypopnea Syndrome: A Clinical Study on Therapeutic Outcomes. S.l.: S.n., Print. How to Reach us at Dental Sleep Solutions Phone: or SNORE Dr. Richard Drake DrDrake@DentalSleepSolutions.com Dr. Gy Yatros DrYatros@DentalSleepSolutions.com

50 Example CMS 1500 Form

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