Coordinating Professions Resolving a Broken Model · 2019-01-14 · Dental Sleep Medicine Promises...

CoordinatingProfessionsResolvingaBrokenModel

NorthAmericanSleepSymposiumFebruary15-16

HiltonClearwaterBeachResort

DentalSleepMedicinePromises

•  Sleepgurusandindustryhaveclearbiasintheirattemptstorecruitmoregeneraldentistsintothefieldofdentalsleepmedicine

•  Onthesurfacethereareseeminglyobviousadvantagestolearningtopracticesleepmedicine– Savinglivesasopposedtorestoringteeth– Economic– EaseofPractice,physicallyandmentally–  IncreasedPatientAppreciationandLove

DentalSleepMedicinePromises

•  YETmanystruggle–andmanyfailovertimeintermsofsuccessfulimplementation

•  HIDDENCHALLENGES

ChallengesofDentalSleepMedicine1.  Dentist/Physician Bias

2.  Competitive Arena 3.  Issues of Diagnosis

4.  Economic 5.  Communication with Physicians and Dentists

6.  Referral patterns 7.  Learning Curve of Sleep Medicine

Oral appliance Selection and Therapy and Testing 8. Bruxing : Dealing with Dental Myths of Occlusion and Parafunction

9. Other Untoward Effects

10. DENTAL MODEL VS. MEDICAL MODEL

Glassman, B. H. (2011). "The Hidden Challenges of Dental Sleep Medicine." DentalTown Magazine

12(5): 20-24.

ChallengesofDentalSleepMedicine1.  Dentist/Physician Bias

2.  Competitive Arena 3.  Issues of Diagnosis

4.  Economic 5.  Communication with Physicians and Dentists

6.  Referral patterns 7.  Learning Curve of Sleep Medicine

Oral appliance Selection and Therapy and Testing 8. Bruxing : Dealing with Dental Myths of Occlusion and Parafunction

9. Other Untoward Effects

10. DENTAL MODEL VS. MEDICAL MODEL

Glassman, B. H. (2011). "The Hidden Challenges of Dental Sleep Medicine." DentalTown Magazine

12(5): 20-24.

ChallengesFacingtheDentist•  FollowupCare&ManagementofComplications– TheimportantRisk/BenefitDecisionConcept– OcclusalConceptsandMyths

MODELCHANGINGandDEFININGSUCCESSEDUCATINGPHYSICANSANDPATIENTSNote:PhysiciansOftenuse“TMJComplications”asacontraindicationforOAT.

TREATINGATRUEMEDICALDISORDERWHICHINVOLVESMANAGEMENTRATHERTHAN“CURE”

TheBrokenModelWeakestLinkintheChain

TheBrokenModelUnderstandingtheHistory

Medical Dental

HistoryofSleepMedicineAYoungScience

•  CatondemonstratesactiveEEGinanimalsin1875,butnotidentifiedinhumansuntil1929(Berger)–formanyyearsthesleepingbodysleepingbrainconceptcontinued

•  CatonR.Theelectriccurrentsofthebrain.BrMedJ.1875;2:278.•  BergerH.Überdaselektroenkephalogrammdesmenschen.Arch

PsychiatrNervenkr.1929;97:6–26.

•  KleitmanidentifiesREMin1953•  AserinskyE,KleitmanN.Regularlyoccurringepisodesofeyemobilityand

concomitantphenomenaduringsleep.Science.1953;118:273–4.[PubMed]

HistoryofSleepMedicine•  1956-Burwellpublishestheirclassicdefinitionofobesityhypoventilation

•  1966-DiscoveryofOSAwithPSG’sbyGastaut•  1978– RemmersrelationshipbetweengenioglossusEEGandintraluminalairwaypressure

BurwellC,RobinE,WhaleyR,etal.Extremeobesityassociatedwithalveolarhypoventilation:APickwickiansyndrome.AmJMed.1956;21:811–8.[PubMed]GastautH,TassinariCA,DuronB.Polygraphicstudyoftheepisodicdiurnalandnocturnal(hypnicandrespiratory)manifestationsofthePickwickiansyndrome.BrainRes.1965;2:167–86.[PubMed]RemmersJE,deGrootWJ,SauerlandEK,etal.Pathogenesisofupperairwayocclusionduringsleep.JApplPhysiol.1978;44:931–8.[PubMed]

HistoryofSleepMedicine

•  1978CertificationinSleepCreated

•  TheAcademyofDentalSleepMedicine(ADSM)wasfoundedastheSleepDisordersDentalSocietyin1991byeightdentistswithaninterestintreatingpatientswithsleep-disorderedbreathing.

•  1991AmericanBoardofSleepMedicine

HistoryofSleepMedicine

•  1979ColinSullivan/CPAPIntroduction

•  PSGbecomestheGoldStandardforDiagnosis

•  FinancialCommitmentsbyHospitalswithSleepLabs–The“GoldenAge”ofsleep

•  Resistancetochange:–  “Aspecialtywithonediagnosisandonetreatment”–  HSTvsPSG–  Decreasedreimbursementsovertime–  Oralappliancetherapy–  RoleofESSindiagnosis–  CurrentStateofResidencyPrograms

ORALAPPLIANCEHISTORY

•  In1923,PierreRobindescribedglossoptosis(tongueobstruction)andusedamonoblocfunctionalappliancetomovethemandibleforward.

•  LATE70’sCartwrightintroducestongueretainingdevice

•  Thetitratableappliancethatallowedlateralmovementfollowe

AlternativeTherapyHistory

•  MedicineenamoredwithCPAPduetoitspredictablesuccessrate

•  Compliancenowbeingmeasuredbyquestionnaires

•  SurgicaleffortsgradedbysuccesswithoutposttreatmentPSG’s

•  OralappliancesdeemedunsuccessfulbasedonpatientreportsandposttreatmentEpworthresults

Landmark1995Study•  LiteraturereviewinSleep–  Firsttoestablishboththeefficacyoforalappliancesandestablishsuggestedpracticeparameters

–  Reviewed21publications/320patientsexamined–  IndicatedOA’seffectiveinsimplesnoringandmildOSA– AppropriateformoreseverecaseswithnoncomplianceofCPAP

–  Schmidt-Nowara,W.,A.Lowe,L.Wiegand,R.Cartwright,F.Perez-GuerraandS.Menn(1995)."Oralappliancesforthetreatmentofsnoringandobstructivesleepapnea:areview."Sleep18(6):501-510.

1999Schmidt-NowaraStudy•  DemonstratesOATTherapysuccesswithsevereOSA•  Unfortunately,theinitialstudyremainsimbedded

1999 Schmidt-Nowara Study Sleep and Breathing Vol 3 #3

n  Reviewedpublicationsn  ImagingofopenedairwaywithOAT

n  3controlledtrialsshowpatientsconsistentlypreferOATtoCPAP

n  Laboratorycustomappliancesmorecomfortableanddurable

n  FollowupisessentialduetoocclusalchangesandTMJcomplications

Meanwhile……BackintheMedicalandCPAPWorld

•  NSFnowgettingfunding•  PrivateinsuranceandMedicareinvolvedinreimbursements

•  “GoldenAge”offeesforPSG’sdropping•  InsurancecompaniesbegintoexploreactualuseofCPAP—

•  SMARTCARDSREQUIRED…COMPLIANCEDISCUSSION

OATPotentialRecognized

•  JohnRemmers•  ColinSullivan•  GrowthofSDStotheAADSM•  Industrysupport– FDAAPPROVEDAPPLIANCECHOICES– ADVANCEMENTOFHSTFROMREMMERSTOWATCHPAT

ThePhysicianBiasTheDentalKneeJerkReactionTheResultingCompetitive

Environment

BiasContinuesDespiteMDAStudies

•  Anandam,A.,M.Patil,M.Akinnusi,P.JaoudeandA.A.El-Solh(2013)."Cardiovascularmortalityinobstructivesleepapnoeatreatedwithcontinuouspositiveairwaypressureororalappliance:Anobservationalstudy."Respirology18(8):1184-1190.

•  Vanderveken,O.M.(2013)."Perspectivesonthereductionincardiovascularmortalitywithoralappliancetherapyforpatientswithsevereobstructivesleepapnoeaintoleranttocontinuouspositiveairwaypressure."Respirology18(8):1161-1162.

WhytheBias?•  TMDQUALIFIEDEXPERTVSRESTORATIVEGURUSANDMYTHS/CHIROPRACTORS

•  WEEKENDCOURSESCREATEDENTALEXPERTS–  TRUESPECIALTYORTHEFALLINTOTHETRAPOFOSAORNOOSA

–  ISDIAGNOSISREALLYANUMBER?–  SHOULDDENTISTSBEMORETHAN“TECHNICIANS”CARRYINGOUTTHERX

•  FRUSTRATIONHASLEDTOSIMPLIFICATIONANDATTEMPTSATENDRUNSAROUNDTHEMEDICALPROFESSION

•  NONEOFTHISCREATESAUNIFIED“PATIENTCENTRIC”MODEL

CLEARINDICATIONOFBROKENMODEL

CLEARINDICATIONOFABROKENMODEL

•  LOOKINGATREFERRALRATESTOSLEEPCENTERSFROMCARDIOLOGYOFFICESINHOSPITALNETWORKPLANS

•  INABILITYOFSLEEPCENTERSTOENCOURAGEINCREASEDREFERRALS

•  EPIDEMILOGYOFSLEEP•  SLEEPSPECIALTYRESISTENCETOCHANGE–  CPAPVSORALAPPLIANCE– HSTVSPSG–  ROLEOFAHI–  POLITICAL:EXECUTIVEDIRECTOROFAASMREMAINEDTHESAMEFOR21YEARS

ResolutionoftheBrokenModel

•  Medicinehastochange– HSTresistance– ReturntomorethanOSAconcernsandgivemorethanlipservicetoimprovequalityofsleepacceptingtheimportantroleofsleep

– DiagnosisandTreatmentneedstobecome“patientcentric”acceptingthescienceofalternativecaretoCPAP

– Needstopoliticallysupportevidencedbasedgrowth

ResolutionoftheBrokenModel

•  Dentistryhastochange–  Educationalrequirementsneedstobelesspoliticalandmorecompleteandlessindustrydriven

–  Thefactisthatsleepmedicineisdifferentthandentalspecialtiesandrequiresanalteredmodelforsuccessfulimplementationofapatientcentricmodel

–  Thirdpartypaymentsneedtoberevamped–insurancecompaniesarenotwelleducatedintermsoforalappliancetherapy.

TheDentalModelChangesRequired

•  Needtobewelleducatedinanareatotallyforeignfromdentistry

•  Needtobeabletoeducateourselves,ourpatients,ourstaffs,andphysicians

•  Patienthistoriesandrelationships•  Communicationwithphysicians,insurancecompanies,

CommunicationIssuesWhoseDiseaseIsItAnyway?

1.  BLACKBOXConcept2.  Diagnosis3.  TreatmentDecisionMaking

1.  TechnicianworkingonPhysician’sRX?2.  ORvaluable,respectedmemberofthe“team?”

4.  SOAPNotes?TreatmentUpdates5.  Ultimateresponsibility

“EDUCATION: THE PATH FROM COCKY IGNORANCE TO

MISERABLE UNCERTAINTY.”  

MARK TWAIN

TheDentalModelChangeRequired

•  Diagnosis– Morecomplex–  Historydependent

•  Treatmentdecisionmaking–  NotsimplybasedonAHI–  Coordinatedwithphysician

•  ManagementvsResolution•  Definitionof“successfultreatment”•  PredictingSuccess:FearofFailure•  RecordKeeping•  Thirdpartypaymentrequirements•  DealingwithdentalmythsincludingocclusalchangesandTMD

CoordinatingProfessions

•  TheGOAListocreateapatientcentricmodelthatappropriatelyscreens,diagnosesandintelligentlytreatspatientstodecreasethelikelihoodormorbidityandmortalitywhenappropriateandimprovethequalityoflifewhenappropriate

CoordinatingProfessions

•  GOALSMUSTBEIDENTIFITIEDANDAGREEDUPON

•  AMODELTHATISWIN-WIN-WINMUSTBEESTABLISHED

•  GREEDAND/OREGOWILLDESTROYANYCHANCEOFSUCCESS

MODELCHANGESAREREQUREDBYBOTHTHEPHYSICIANANDTHEDENTIST

CoordinatingProfessions

CoordinatingProfessionsPossibleSolutions

•  Acceptingtheappropriategoals•  Mutualrespectwithlackofego•  Developingamodelthatiscoordinatedwithcurrenthealthcaredistributionrequirements

•  Providingeasetothepatientastheymovethroughthescreeningallthewaythroughthetreatmentandmaintenancephases

CoordinatingProfessions

•  Howdowefindtherightphysician?•  Howdoweeducatetherightphysician?

•  Possiblemodelsincludingtelemedicine

OPTIMISMFROMDR.REMMERS

•  Currentandanticipatedtechnologicaladvancessuggestthatwearenowembarkingonanewphaseofthisrelationship,onewherethesleepdentistandphysicianwillcollaborateefficientlyinwidespreaduseoforalappliancestomanageOSA.Inotherwords,wemaybeenteringaneweraofsleepmedicine,onewheredentalsleepmedicineplaysacentralrole.