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Sorting Out Dental Sleep Medicine

David Schwartz, DDS, is a speaker with the SomnoMed Academy and has been a practicing general restorative dentist since 1988, with a concentration in dental sleep medicine for the last 12 years. He is a featured expert on Sleep Review’s Expert Insight, offering readers advice on the benefits of dental sleep medicine and treatment with oral appliances.

David Schwartz, DDS

David Schwartz, DDS

Sleep Review reader: We are a hospital-based DME (durable medical equipment company) and are considering staffing a dentist 1 to 2 days a week to provide oral appliance therapy for patients. What can you bill for with an oral appliance?

Schwartz: I am working in an accredited sleep center two full days a week in addition to my restorative practice. We have contracts with most of the medical providers, and therefore the fee schedule is limited to the contracted price. Medicare also is covering these appliances now at a very reduced fee.

Sleep Review reader: Can a patient with either a few or no original teeth use a dental device?

Schwartz: The stability of those teeth and the arch can make a difference in whether an appliance can be used. Even denture wearers can have an appliance if the retention is sufficient to hold the appliance in place. Some of these patients have implants, which can also further stabilize an appliance.

Sleep Review reader: What is the process for getting the devices paid for by third-party insurers, both commercial and Medicare?

Schwartz: These devices are billed under DME and have their own codes; however, there are devices that are not code verified so be prepared for denials from Medicare. Durable Medical Equipment Medicare Administrative Contractors have established reimbursement terms for appliances, but they need to be delivered by a dentist and fitted by a dentist. Private insurers have been covering these for a while now with proper documentation and coding. Information about these codes can be obtained from the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM) Web sites. Most of the dentists fabricating these have routine information that is needed to submit to the payors. It is always best to work with an experienced dentist to provide this care.

Sleep Review reader: How do you treat the bite changes that inevitably will occur with long-term appliance use (ie, opening of posterior contacts, increased anterior contact)?

Schwartz: That is the $64,000 question. Dental sleep medicine professionals have to anticipate that the changes will take place and make sure that the patient and their dentist are aware that changes may occur. When they happen, I make certain that the patient realizes that only cessation of the use of the appliance and possible orthodontic correction are needed to obtain normalcy again. I make sure to tell the patient at the initial consult that there is a good chance of occlusal changes. In some cases, minor retainer use can move teeth back again, but my experience has shown that these are condylar and temporal changes, not tooth movement per se.

Sleep Review reader: Who can dispense oral appliances and do you see this being set up so only dentists who belong to the American Academy of Dental Sleep Medicine can do so?

Schwartz: As of now, the way it has been working with compensation is that dentists should be the ones providing the treatment. It definitely makes sense, as there are oral concerns that should be addressed by the dentist first. The truth is that any dentist can provide this care. The more important concern is the knowledge and experience that the dentist has with regard to sleep apnea and the various treatments. I think that the AADSM provides a great platform for learning. The American Board of Dental Sleep Medicine also certifies those dentists who meet the requirements. If you are looking for qualified dentists, that is a good place to start.

Sleep Review reader: What have you found to be the most effective method for identifying patients appropriate for dental appliances versus other forms of treatment for OSA?

Schwartz: Patients can be screened in the primary care setting using simple subjective tests such as the Epworth Sleepiness Scale. With regard to who is an appropriate candidate, there are several criteria. First, based on a polysomnogram or similar ambulatory test, those who present with an apnea/hypopnea index (AHI) in the mild to moderate ranges are acceptable candidates. Those in the severe category, AHI >30, are candidates if they cannot tolerate CPAP. Of course, many patients may prefer an oral appliance as a first line choice. The mild and moderate patients are absolutely appropriate candidates.

Now, dentally, there may be a different story. Many patients want oral appliances but don’t qualify as they have poor dentition or poor periodontal status. If you are looking to see who might be a better responder to oral appliances, then we could probably spend a day talking about the anthropomorphic identifiers such as jaw length, facial contours, crowded dentition, and previous extractions for orthodontics. The list goes on.

Sleep Review reader: How well do over-the-counter (OTC) oral appliances work? Is it better for a dentist to fit an OTC appliance?

Schwartz: Over-the-counter type appliances are, unfortunately, inconsistent in their fit and comfort. Usually, they are bulky by design requirements, and then, of course, the people [patients] making them are not very good at doing it. While they can be used in the short term, I have found that they have a larger amount of complications, like jaw pain, tooth movement, etc. I would always recommend a dentist specially trained in dental sleep medicine be the fabricator of the appliance. It is really important to have the patient ask how many appliances their dentist has made, and if the answer is not too many, then they should look up a dentist on the AADSM Web site.

Sleep Review reader: Physicians and home medical equipment companies are able to look at objective data from the patient’s CPAP device to see how the patient is doing throughout therapy. How is efficacy measured for patients using oral devices?

Schwartz: Great question! Dental sleep medicine practitioners usually use several ways of identifying effectiveness. One is the use of ambulatory monitoring such as the ARES test from Watermark Medical. It is a very effective way to have my patients titrate their appliances at home over a 3-night range. Now the difficult question to answer is how does the sleep dentist know they are using it? Right now, there are several monitors being introduced into appliances; however, they are not FDA approved, so sleep dentists must rely on self-reports of compliance.

Sleep Review reader: I have to deal with a board-certified sleep physician who will not send my referrals back until they fail CPAP. Every patient gets CPAP regardless of AHI. The problem is, as you know, many patients stop returning to the sleep lab, put the PAP in the closet, and figure they have no options. What is the solution?

Schwartz: I think at this point dentists have shown sleep doctors that both professions can play nicely together and that they will get more follow-up, which translates to happier patients and ultimately more profit for them. And yes, I said the “P word.”

Sleep Review reader: As I counsel patients on their diagnostic sleep results, the topic of oral appliances frequently comes up. How would you suggest that I approach this subject with my patients?

Schwartz: I would not wait for the patients to bring it up; I would offer it for all the mild to moderate diagnosed cases. The AASM has said that for mild and moderate OSA, oral appliance therapy can be used as a first line treatment; then, of course, severe range patients where CPAP has failed for whatever reason. Patients are happy with choices for their treatment.

Sleep Review reader: I frequently see patients who experience retrocondylar pain in the morning after removing the appliance, even though the appliance itself is comfortable. I’ve asked several people and have yet to hear a helpful answer. What do you think causes this and what can I do for these people?

Schwartz: I have seen this time and time again, where there is retrocondylar pain. In my patients, it appears to come from several mechanisms. I believe the primary one is that there is effusion of fluids in the joint space, and when a patient tries to close their jaw in the morning, the hydrostatic pressure requires a few minutes of constant closure or at least repeated efforts of closure to eliminate the pressure there. When you see that there is unilateral pain, it suggests more of an occlusal issue with the appliance. In any event, muscle movement, exercise, and anti-inflammatory medications work very well. I will, in some patients, build an anterior disclosing ramp like an NTI (nociceptive trigeminal inhibition) appliance, or in stubborn cases make an NTI for them to use as well. I am also looking into a TMJ exerciser to see if it offers a better solution.

Sleep Review reader: Is there a standard of training or certification process for dentists? How do we know that a dentist knows what they’re talking about when it comes to sleep?

Schwartz: This is one of the biggest concerns for those of us who make dental sleep medicine a specialty in our dental practices. The standard that many of us have achieved is the diplomate status from the American Board of Dental Sleep Medicine. Recently, the AADSM has established an accreditation process for practices that want to be considered more experienced in dental sleep.

Sleep Review reader: Is there a pediatric application to oral appliances? How young would you go to perform this procedure?

Schwartz: Sleep dentists can do this procedure in young adults who have permanent teeth and are not wearing orthodontic appliances at the time. CPAP still seems to be the best choice for those young kids who have been diagnosed with OSA and have not responded to tonsillectomy and adenoidectomy. It is very hard to use these in children where there is significant growth yet to occur. Most of my young patients are in their late teens (18- to 19-year-old males) and even some younger females.