Coordinating Professions Resolving a Broken Model · 2019-01-14 · Dental Sleep Medicine Promises...
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Coordinating Professions Resolving a Broken Model North American Sleep Symposium February 15-16 Hilton Clearwater Beach Resort
Transcript of 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.
