Expert Insight - Dental Sleep Medicine
Dental Sleep Medicine |
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Steve Carstensen, DDS
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Steve Carstensen, DDS, earned his DDS from Baylor College of Dentistry in 1983, and is in private practice in Bellevue, WA. Beginning in 1988, he has been a continuous student at the Pankey Institute, and since 1996, visiting faculty. Long a client of Pride Institute, he has lectured for them on team systems and practice management. In 1998, he worked with his first dental appliance for sleep apnea, and in the past several years has helped hundreds of sleep apnea patients using oral appliance therapy. In 2006, he was awarded Diplomate status by the American Board of Dental Sleep Medicine. Many local, state, and national organizations have invited him to speak; Steve is the Sleep Education Chair for the Pankey Institute, Spear Education, and the American Sleep and Breathing Academy. He has spent countless hours volunteering in organized dentistry for local and state dental societies, chaired the ADA’s Annual Session in 2010, and has served as Director and Officer of the American Academy of Dental Sleep Medicine. |
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Can you comment on the ability of dentists to order sleep studies as part of their evaluation? -
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I have been ordering sleep studies as part of my evaluation for a long time. I am aware that some insurance companies will not pay for the study if not by a MD or sleep physician. I think it is good medicine for dentists like myself to be able to order these; it would be no different in my mind than to order a blood test to check for certain metabolic issues, blood counts, etc. I do use ambulatory testing such as the ARES from Watermark to screen these patients. I do not under any circumstances diagnose! Those patients that the ambulatory test suggests have a more aggressive issue, we then send for PSG and consult with sleep physician. |
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What is the pediatric application of this technology? How young do you go? Will anybody pay for it? Any studies for Evidence Based Medicine (EBM)? -
In children with deciduous teeth it is hard to make an appliance such as this. The ideal appliance in kids could very well be a palatal expander that will help not only open the mid palatal suture but also change the craniofacial structure. Tongue retaining devices can be used in kids in a mixed dentition stage or who have Downs, where the teeth may not be in an ideal position or shape. The insurance companies will pay for oral appliances; however, it depends on the diagnosis to support the treatment. As far as EBM, there are studies that discuss the use of Rapid Palatal Expansion in treating OSA in pediatric population. Probably less on oral appliances for pediatric patients. I would like to see more proactive use of palatal expanders to improve the quality of life for these kids.
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How often should orthodontic appliance be inspected by a dentist if there are no apparent occlusion problems with the device? -
These appliances should be checked at least every 6 months to a year at the longest. Many of those unwanted occlusal changes can take place in a short period of time and the more we can ward off bite changes the better. We try to be certain that the appliance has been titrated objectively in the lab as well. This might precipitate another follow-up visit to the dentist to adjust the appliance again if needed. The appliance should be brought to their regular dentist for cleaning in special tartar/stain removal solution. It keeps things clean and allows better inspection for fractures and wear.
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We are a hospital based DME. We are considering staffing a dentist 1 to 2 days a week to provide oral appliance therapy for patients. I'd like to know, what can you bill for with an oral appliance? I know the HCPC code E0486 is billable; however, do you know if you can also bill the evaluation and/or fitting of the device? In your experience, what kind of compliance rates are you seeing with oral appliances? I have heard such a wide range it is hard to make a solid decision on oral appliance therapy. -
The oral appliance compliance is excellent with most patients approximately 95% using them the entire night. I believe that the better question is when to use them and in what instances can they be used effectively and how successful can they be. 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. It ranges from $2,200.00 to $2,900.00. We have a "no insurance" price of $2,600.00 and there is one provider that covers only 50% of our regular fee. Because of this we have established a fee of $5,800.00. Of course this could be a million dollars but they will still limit coverage and the other providers have a contract to provide it at an established fee. It is very crazy the way we have to deal with some insurance but it is a big game all over the country. Medicare is also covering these appliances now at a very reduced fee.
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What problems develop from children grinding their teeth, and what treatment is available? -
Some children grind as a normal way of exfoliating their primary teeth; others from unknown etiology, but suspected anxiety, brain wiring, increased serotonin. There are a many young adults taking recreational drugs that can increase the serotonin and it causes bruxism. Smoking crack or taking ecstasy can contribute to this phenomena. The problems can be broken teeth, sensitive teeth and of course the loss of teeth and tooth structure. Periodontal bone loss can be part of this trauma to the dentition if there is also periodontal tissue inflammation. The treatment is really to have them wear a night guard to protect the teeth. But in many, the grinding continues but it is the plastic that is worn down instead of the teeth.
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Can a patient with either a few or no original teeth use a dental device? -
Depending on the stability of those teeth and the arch that they are in can make a difference in whether or not 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.
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What is the process for getting the devices paid for by third party insurers, both commercial and Medicare? -
These devices are billed under DME and have their own codes; however, there are several devices that don't have the proper FDA numbers so be prepared for denials from Medicare. The DMERC are paying for appliances but it needs to be delivered by a dentist and fitted by a dentist. The private insurers have been covering these for a while now with proper documentation and coding. These codes can be obtained from the Academy of Sleep Medicine and Academy of Dental Sleep Medicine websites. Most of the dentists fabricating theses have routine information that is needed to submit to the payers. It is always best to work with an experienced dentist to provide this care. In some cases, as in my area, I work out of a sleep lab two days a week and we bill DME through their organization
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How do you treat the bite changes that inevitably will occur with long term appliance use (i.e., opening of posterior contacts, increased anterior contact)? -
That is the $64,000 question. We 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 that the patient hears it from me originally when we do our 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. It is going to happen!
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I am a dentist on the faculty of a university. Are there any courses regarding sleep apnea, for dentists, that you would recommend? -
I am on the Somnomed Academy Faculty and we give lectures all the time. The introductory course goes over sleep basics and also treatment protocols. In fact we have a course coming up in Orlando in March 2012. If there is enough interest amongst the members of your faculty, we could arrange a course right there. We are always amazed at how such an important global health issue gets overlooked in our dental community. This is such a huge health concern that all our dentists should be taught to understand and treat obstructive sleep apnea using oral appliances as an alternative to CPAP and surgery.
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Who can dispense oral appliances and do you see this being set up so only dentists that belong to the Academy of Dental Sleep Medicine? -
As of now the way it has been working with compensation is that dentists should be the ones providing that 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 regards to sleep apnea and the various treatments. I think that the Academy of Dental Sleep Medicine provides a great platform for learning. The American Board of Dental Sleep Medicine also credentials those dentists that commit to further study, cases, and board examination. If you are looking for qualified dentists that is a good place to start.
