A dentist finds that the pulse oximeter is an effective tool to evaluate the response to OAT prior to sending patients back for follow-up PSG testing at a sleep lab.

Editor’s Note: The author provided modifications to the article on October 20, 2015, in order to correct a reference (reference 1), as well as to clarify several points. Because the clarifications are throughout the article (not in a limited area where we could easily note them to our readers), we have re-published the article in its entirety below. The original article published online October 2, 2015, remains toward the bottom of the page for transparency. The revised article appears in our November 2015 issue on pages 12-16.

The benefits of physicians prescribing out of center testing to monitor treatment for obstructive sleep apnea (OSA) are well known.1, 2 In addition, studies supporting the use of overnight pulse oximetry by dental sleep practitioners to confirm their patients’ response to oral appliance therapy (OAT) during treatment for sleep-disordered breathing (SDB) are well documented.3 In fact, the American Academy of Dental Sleep Medicine (AADSM) recently recommended in its treatment protocol that “the dentist may obtain objective data during an initial trial period to verify that the oral appliance effectively improves upper airway patency during sleep.”4 However, the practice of using a pulse oximeter to obtain this data and monitor effectiveness of the mandibular advancement splint (MAS) appliance has only recently entered the mainstream of care.

Overview

SDB includes OSA and is part of the scope of temporomandibular disorders (TMD). Not to consider SDB would be ignoring an important etiological factor in the pathology of TMD.

The most common treatment for OSA is a continuous positive airway pressure (CPAP) machine prescribed by a physician. However, studies have shown that more than half of all patients who use a CPAP machine stop using it within a year due to discomfort.5

As an alternative to CPAP treatment for OSA, oral appliance therapy is often deployed by dental sleep medicine practitioners, working in collaboration with referring sleep physicians. With OAT, the patient wears a mandibular advancement splint, which is a mouthguard-like appliance that positions the lower jaw forward to open the airway continuously through the night. Studies have shown that patients comply better with OAT than with CPAP.6 The American Academy of Sleep Medicine (AASM) recommends oral sleep appliances as first-line treatment options for those with mild and moderate levels of sleep apnea as well as for individuals who are CPAP intolerant.7,8

Overnight pulse oximetry monitoring is essential in preconfirming the effectiveness of OAT for OSA treatment. A pulse oximeter monitors a patient’s heart rate and blood oxygen saturation in arterial blood. In my experience, overnight pulse oximetry has been shown to be an effective sleep screening tool used to evaluate the response to OAT prior to sending patients back for follow-up polysomnography (PSG) testing at a sleep lab and final evaluation by the treating sleep physician.

As a dentist who limits my practice to orofacial pain and dental sleep medicine, my patients are referred to me for temporomandibular joint syndrome (TMJ), headaches, or sleep apnea. After my patients have been diagnosed by a board-certified sleep physician, I use overnight pulse oximetry screening to manage the MAS that I typically prescribe and thereby verify the appliance’s effectiveness before my patients return to their physicians for a final PSG. (Specifically, I use Nonin Medical’s WristOx2 wrist-worn pulse oximeter and Nonin’s nVISION data management software.)

Case Example

A 28-year-old female presented with BMI of 21, severe daily migraines, and a mandibular range of motion (ROM) of 10 mm (locked jaw). She had a previous PSG that showed an AHI of 13 and PSO2 of 83 (ESS of 16). She was CPAP intolerant since the straps and mask increased her headaches.

I treated her migraines with medications, her TMJ with splint therapy, and put her on CPAP with a combination device called a TAP-PAP (connect the CPAP directly to an oral device with nasal pillows that features no straps and mandibular stabilization). After her TMJ and headaches were resolved, we transitioned her to a MAS. We did a home sleep test (HST) with the pulse oximeter after the first week, which indicated a PSO2 of 89 (15% of time under 90% O2) with heart rate variable (indicating effort). She still had morning headaches.

Her MAS was advanced to the point that her morning headaches were resolved, but her ESS was at 12. We sent her home with a pulse oximeter again and her PSO2 was 94%, but her heart rate was still variable. This indicates possible effort still occurring, so we advanced her one more millimeter. Her ESS was 7, so we sent her home again with a pulse oximeter. This time the PSO2 was 94%, but her heart rate was smooth throughout the night. This indicated that her airway was now stable and she was sent for a final PSG with her sleep physician, which confirmed resolution of her OSA. Her headaches were resolved and her TMJ was pain free with mandibular ROM of 45 mm.

Conclusion

Diagnosis and treatment of OSA should not have to wait until patients’ symptoms are bad enough to drive them into their doctor’s office. Dentistry has, as part of its treatment structure, a yearly recall of patients. This presents an opportunity for sleep disorder dentists to partner with sleep physicians to improve patient quality of life and lower healthcare costs by working together to diagnose and treat OSA appropriately.

DrPrehn

Ronald S. Prehn, ThM, DDS

Pulse oximetry sleep tests are useful to dentists for managing MAS appliances but not for diagnosing or confirming resolution of OSA. Only a sleep physician who is board certified in sleep medicine can diagnose or confirm resolution of OSA.1, 2, 7 MAS is reimbursable, and overnight pulse oximetry sleep tests can be included as part of the cost-of-care. Medical insurance and Medicare reimbursement for the associated CPT code 94762 is inconsistent (even associated with OSA ICD-9 code of 327.23). But since there are no disposables, I just include the minor costs of monitoring in the total cost of the MAS and do not charge for this testing.

Oximetry sleep tests are easy and inexpensive for dental sleep practitioners to employ. When only used for titration of oral appliances, it becomes an effective tool for both the dentist and physician. Staff training is minimal, and patients appreciate the fact that their oxygen saturation levels are being monitored for verification of MAS effectiveness before they return to their physician for a final PSG. The sleep physician can also use the data in his or her final evaluation of the patient’s OSA. Performing these tests lets the physician know that the dental practitioner is serious about OSA treatment and knowledgeable about how to make treatment effective.

Exam and Treatment Routines

When patients are referred for OSA:

I perform an exam, conduct a cone beam scan or Panorex X-ray, and take the patient’s history. If patients have had a PSG already, then preverification of benefits will have been done. I will review the PSG with patients and recommend a MAS or combination therapy. If they have not had a PSG from a physician, I will refer them at this point and have them return to review results.

  • I fabricate and insert the MAS in the patient’s mouth.
  • I manage the MAS forward until symptoms are resolved—ie, the airway remains open.
  • I then send the patient home for a pulse oximetry HST.
  • If issues are identified, then I will repeat the process and HST until symptoms are resolved and I can determine that the MAS is effective. (See the worksheet I created for HST monitoring.)

PulseOximetryOATMonitoring

  • I send the patient and HST reports to the physician for a final PSG.
  • If the issues are unresolved, I fabricate a TAP-PAP nasal pillow CPAP mask (by Airway Management Inc) for combination therapy and send the patient to a physician for a CPAP titration.

When patients are referred for TMD:

  •  I perform an initial history and exam for TMD (or headaches) and SDB on every patient. I treat the pain or TMD, and if they have any signs and/or symptoms of SDB other than jaw clenching, I refer them for a PSG. If they have no other signs and symptoms of SDB, I will send them home with an HST just to make sure they are free of any issues. I especially look at the heart rate variability in these cases, as that is an indication of respiratory effort.
  • I will have the patient start with CPAP while I treat the TMD.
  • When the TM joints are stable, I will transition them into a MAS or combination therapy, depending on the severity of the problem.
  • Finally, I manage the MAS therapy with a pulse oximeter as described above and refer the patient to a physician for a final PSG.

Ronald S. Prehn, ThM, DDS, is the owner of Restore TMJ & Sleep Therapy, a patient-centered dental practice that focuses on the diagnosis and treatment of headaches/facial pain, temporomandibular disorders, and sleep-breathing disorders in The Woodlands, Tex. He is a member of the American Academy of Orofacial Pain, the American Academy of Sleep Medicine, the American Academy of Dental Sleep Medicine, and the Appliance Therapy Practitioners Association. He is a board certified diplomate of the American Board of Orofacial Pain and the American Board of Dental Sleep Medicine, of which he sits on the board of directors. Prehn has not received any compensation from Nonin Medical for mentioning Nonin Medical’s products in this case study.

REFERENCES

1. Collop NA, et al, Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med. 2007; 3(7):737-47.
2. Epstein LJ, et al, Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263-276.
3. Rogers RR. Oral appliance therapy for the management of sleep disordered breathing: an overview. Sleep Breath. 2000;4(2).
4. AADSM Protocol for Oral Appliance Therapy for Sleep Disordered Breathing in Adults: An Update for 2013. American Academy of Dental Sleep Medicine, 2013.
5. Gay P, Weaver T, Loube D, Iber C. Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. SLEEP. 2006;29(6):381-401.
6. Ferguson KA, Ono T, Lowe AA, Keenan SP, Fleetham JA. A randomized crossover trial of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea. Chest. 1996;109(5):1269-1275.
7. Menta A, Qian J, Petocz P, Darendeliler MA, Cistulli PA. A randomized, controlled study of a mandibular advancement splint for obstructive sleep apnea. Am J Respir Crit Care Med. 2001;163:1457-1461.
8. AADSM Protocol for Oral Appliance Therapy for Sleep Disordered Breathing in Adults: An Update for 2013, American Academy of Dental Sleep Medicine, 2013. AASM Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients: Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007;3(7).
8. Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients: Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007;3(7).

 

ORIGINAL ARTICLE PUBLISHED ONLINE OCT 2, 2015 BELOW

The benefits of physicians prescribing overnight pulse oximetry testing to prescreen for obstructive sleep apnea (OSA) are well known.1 In addition, studies supporting the use of overnight pulse oximetry by dental sleep practitioners to confirm their patients’ response to oral appliance therapy (OAT) during treatment for sleep-disordered breathing (SDB) are well documented.2 In fact, the American Academy of Dental Sleep Medicine (AADSM) recently recommended in its treatment protocol the use of pulse oximetry home sleep testing to manage mandibular advancement splint (MAS) appliances.3 However, the practice of using a pulse oximeter to manage MAS appliances has only recently entered the mainstream of care.

Overview

SDB includes OSA and is part of the scope of temporomandibular disorders (TMD). Not to consider SDB would be ignoring an important etiological factor in the pathology of TMD.

The most common treatment for OSA is a continuous positive airway pressure (CPAP) machine prescribed by a physician. However, studies have shown that more than half of all patients who use a CPAP machine stop using it within a year due to discomfort.4

As an alternative to CPAP treatment for OSA, oral appliance therapy is often deployed by dental sleep medicine practitioners, working in collaboration with referring sleep physicians. With OAT, the patient wears a mandibular advancement splint, which is a mouthguard-like appliance that positions the lower jaw forward to open the airway continuously through the night. Studies have shown that patients comply better with OAT than with CPAP.5 The American Academy of Sleep Medicine (AASM) recommends oral sleep appliances as first-line treatment options for those with mild and moderate levels of sleep apnea as well as for individuals who are CPAP intolerant.6

Overnight pulse oximetry monitoring is essential in preconfirming the effectiveness of OAT for OSA treatment. A pulse oximeter monitors a patient’s heart rate and blood oxygen saturation in arterial blood. According to the AADSM and the AASM, overnight pulse oximetry has been shown to be an effective sleep screening tool used to evaluate the response to OAT prior to sending patients back for follow-up polysomnography (PSG) testing at a sleep lab.7

As a dentist who limits my practice to orofacial pain and dental sleep medicine, my patients are referred to me for temporomandibular joint syndrome (TMJ), headaches, or sleep apnea. After my patients have been diagnosed by a board-certified sleep physician, I use overnight pulse oximetry screening to manage the MAS that I typically prescribe and thereby verify the appliance’s effectiveness before my patients return to their physicians for a final PSG. (Specifically, I use Nonin Medical’s WristOx2 wrist-worn pulse oximeter and Nonin’s nVISION data management software.)

Case Example

A 28-year-old female presented with BMI of 21, severe daily migraines, and a mandibular range of motion (ROM) of 10 mm (locked jaw). She had a previous PSG that showed an AHI of 13 and PSO2 of 83 (ESS of 16). She was CPAP intolerant since the straps and mask increased her headaches.

I treated her migraines with medications, her TMJ with splint therapy, and put her on CPAP with a combination device called a TAP-PAP (connect the CPAP directly to an oral device with nasal pillows that features no straps and mandibular stabilization). After her TMJ and headaches were resolved, we transitioned her to a MAS. We did a home sleep test (HST) with the pulse oximeter after the first week, which indicated a PSO2 of 89 (15% of time under 90% O2) with heart rate variable (indicating effort). She still had morning headaches.

Her MAS was advanced to the point that her morning headaches were resolved, but her ESS was at 12. We sent her home with a pulse oximeter again and her PSO2 was 94%, but her heart rate was still variable. This indicates possible effort still occurring, so we advanced her one more millimeter. Her ESS was 7, so we sent her home again with a pulse oximeter. This time the PSO2 was 94%, but her heart rate was smooth throughout the night. This indicated that her airway was now stable and she was sent for a final PSG with her sleep physician, which confirmed resolution of her OSA. Her headaches were resolved and her TMJ was pain free with mandibular ROM of 45 mm.

Conclusion

Diagnosis and treatment of OSA should not have to wait until patients’ symptoms are bad enough to drive them into their doctor’s office. Dentistry has, as part of its treatment structure, a yearly recall of patients. This presents an opportunity for sleep disorder dentists to partner with sleep physicians to improve patient quality of life and lower healthcare costs by working together to diagnose and treat OSA appropriately.

DrPrehn

Ronald S. Prehn, ThM, DDS

Pulse oximetry sleep tests are useful to dentists for managing MAS appliances but not for diagnosing or confirming resolution of OSA. Only a sleep physician who is board certified in sleep medicine can diagnose or confirm resolution of OSA.8 MAS is reimbursable, and overnight pulse oximetry sleep tests can be included as part of the cost-of-care. Medical insurance and Medicare reimbursement for the associated CPT code 94762 is inconsistent (even associated with OSA ICD-9 code of 327.23). But since there are no disposables, I just include the minor costs of monitoring in the total cost of the MAS.

Oximetry sleep tests are easy and inexpensive for dental sleep practitioners to employ. Training is minimal, and patients appreciate the fact that their oxygen saturation levels are being monitored for verification of MAS effectiveness before they return to their physician for a final PSG. Performing these tests lets the physician know that the dental practitioner is serious about OSA treatment and knowledgeable about how to make treatment effective.

Exam and Treatment Routines

When patients are referred for OSA:

I perform an exam, conduct a cone beam scan or Panorex X-ray, and take the patient’s history. If patients have had a PSG already, then preverification of benefits will have been done. I will review the PSG with patients and recommend a MAS or combination therapy. If they have not had a PSG from a physician, I will refer them at this point and have them return to review results.

  • I fabricate and insert the MAS in the patient’s mouth.
  • I manage the MAS forward until symptoms are resolved—ie, the airway remains open.
  • I then send the patient home for a pulse oximetry HST.
  • If issues are identified, then I will repeat the process and HST until symptoms are resolved and I can determine that the MAS is effective. (See the worksheet I created for HST monitoring.)

PulseOximetryOATMonitoring

  • I send the patient and HST reports to the physician for a final PSG.
  • If the issues are unresolved, I fabricate a TAP-PAP nasal pillow CPAP mask (by Airway Management Inc) for combination therapy and send the patient to a physician for a CPAP titration.

When patients are referred for TMD:

  •  I perform an initial history and exam for TMD (or headaches) and SDB on every patient. I treat the pain or TMD, and if they have any signs and/or symptoms of SDB other than jaw clenching, I refer them for a PSG. If they have no other signs and symptoms of SDB, I will send them home with an HST just to make sure they are free of any issues. I especially look at the heart rate variability in these cases, as that is an indication of respiratory effort.
  • I will have the patient start with CPAP while I treat the TMD.
  • When the TM joints are stable, I will transition them into a MAS or combination therapy, depending on the severity of the problem.
  • Finally, I manage the MAS therapy with a pulse oximeter as described above and refer the patient to a physician for a final PSG.

Ronald S. Prehn, ThM, DDS, is the owner of Restore TMJ & Sleep Therapy, a patient-centered dental practice that focuses on the diagnosis and treatment of headaches/facial pain, temporomandibular disorders, and sleep-breathing disorders in The Woodlands, Tex. He is a member of the American Academy of Orofacial Pain, the American Academy of Sleep Medicine, the American Academy of Dental Sleep Medicine, and the Appliance Therapy Practitioners Association. He is a board certified diplomate of the American Board of Orofacial Pain and the American Board of Dental Sleep Medicine, of which he sits on the board of directors. Prehn has not received any compensation from Nonin Medical for mentioning Nonin Medical’s products in this case study.

REFERENCES
1. Collup NA, Tracy SL, Kapur V, et al. Obstructive sleep apnea devices for out-of-center (OOC) testing: technology evaluation. J Clin Sleep Med. 2011;7(5).
2. Rogers RR. Oral appliance therapy for the management of sleep disordered breathing: an overview. Sleep Breath. 2000;4(2).
3. AADSM Protocol for Oral Appliance Therapy for Sleep Disordered Breathing in Adults: An Update for 2013. American Academy of Dental Sleep Medicine, 2013.
4. Gay P, Weaver T, Loube D, Iber C. Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. SLEEP. 2006;29(6):381-401.
5. Ferguson KA, Ono T, Lowe AA, Keenan SP, Fleetham JA. A randomized crossover trial of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea. Chest. 1996;109(5):1269-1275.
6. Menta A, Qian J, Petocz P, Darendeliler MA, Cistulli PA. A randomized, controlled study of a mandibular advancement splint for obstructive sleep apnea. Am J Respir Crit Care Med. 2001;163:1457-1461.
7. AADSM Protocol for Oral Appliance Therapy for Sleep Disordered Breathing in Adults: An Update for 2013, American Academy of Dental Sleep Medicine, 2013. AASM Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients: Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007;3(7).
8. Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients: Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007;3(7).

Have a case study to share? E-mail Sleep Review editor Sree Roy at sroy[at]allied360.com.