Dentistry's new frontier: the treatment of obstructive sleep apnea

By Bryan Keropian, DDSWith the advancements in design and treatment of oral sleep appliances — and in combination with the high rejection rate of the CPAP — dentistry has moved to the head of the line in providing the most widely accepted treatment for obstructive sleep apnea and snoring on the planet. Cancer, AIDS, and obstructive sleep apnea (OSA) are the most dangerous and destructive diseases on earth. OSA is reported to occur as many as 83% of women and 92% of men.¹ This phenomenon occurs nightly when the tongue falls back and blocks the airway. This means that every hour of every night there are multiple periods of no O2 to every cell in the body. These periods occur five to 100+ times an hour, for 10 to 90 seconds an episode. With insufficient oxygen, cellular regeneration is unable to transpire nightly during sleep. Poor cellular regeneration results in an individual being more susceptible to numerous pathologies anywhere in the body. This nightly cellular breakdown has a destructive effect on the health of mankind. The co-morbidities for sleep apnea are numerous.^2,3,4,5 OSA is the disease that dentistry now leads the world in for accepted treatment of the afflicted.The most successful treatment for OSA is CPAP. It is the No. 1 treatment prescribed by the medical community. CPAP is highly successful when it can be used. But the big problem with the CPAP are the numerous difficulties patients have using it. The CPAP is not tolerated by up to 60%,^6,7 and some estimate up to 83%, of users.⁸ With an inability to tolerate the CPAP, these patients find themselves at great risk in regard to their health and longevity. It is a major problem for mankind when medicine’s most effective treatment tool is rejected by 60% to 83% of the users. With the high rejection rate of the CPAP, the American Academy of Sleep Medicine designated dental sleep oral appliances as the No. 1 nonsurgical alternative for the CPAP intolerant.⁹ Numerous sleep appliances are available to the public and distributed through dentists. These are double-arched appliances that gain success by opening the vertical dimension and advancing the mandible. Vertical opening can range from 2 mm to15 mm. The advancement can be as much as full forward prognathic extension, with forward movement up to three-quarters of an inch. The problem presented by these appliances is that they can cause pain or malocclusion.Another dental sleep appliance called the Full Breath Solution Sleep Appliance (FBS) was introduced to the dental profession at the end of 2006.¹⁰ It is a single-arched sleep appliance that fits over the maxillary or mandibular teeth. The FBS presents a very different paradigm to treatment. Rather than pulling the tongue forward by advancing the mandible, it works by utilizing a posterior bar and tail that restrains the tongue from moving upward and backward.

Mandibular Full Breath Solution illustrating Posterior Tongue Restrainer (PTR) and Translingual Bar The FBS has its success based on four main factors:1. The tail will be expanded to provide a tongue depressor similar to that used by a physician to view the pharyngeal airway.2. There is minimal to no advancement with the bite being set at CO or 1 mm to 2 mm anterior advancement. Treatment is successful in CO since the success of treatment is based upon restraint and depression of the tongue to open the airway, not advancement.3. The patient can open his or her mouth and have complete freedom of movement. And with all the movement, the tail still stays in the same position on the teeth, depressing the tongue.4. The FBS is small, very comfortable, and one-arched.The real success of the FBS comes with utilization of the tongue depressor and no mandibular advancement with vertical opening of 1 mm to 2 mm.Tongue depressor created with wax and then changed to acrylic on lower FBS

Wax removed and acrylic added to tail. It is thinned on the superior surface so that it more comfortable and not so bulky.The Full Breath offers a number of advantages in addition to the mandibular advantages. One is no pain incited by treating in CO. The FBS exhibits clinical success above all the other appliances. In June 2009 the FBS obtained its fifth FDA government approval. In the data submitted to the FDA, there was a drop of 79% in the pre- and post-treatment AHI (number of times the airway is blocked hourly by the tongue) in patients treated with the FBS.And finally the FBS offers an avenue of remuneration for treatment unavailable with the mandibular advancers. The FBS has the posterior translingual bar and the posterior tongue restrainer/depressor that depresses and fixates the tongue. The code 41500 — Non-Surgical Fixation of the Tongue — is labeled for the procedure. In the course of treatment, we employ this procedure an average of three to six times. Reimbursement ranges from $200 to $600 every time the procedure is applied, with the average reimbursement being $400.In this time of economic pullback, we are searching for new patients, and we all know how hard it is to attract them. Ah, but there is an area that has a surplus of patients who desperately need the help of dentists: patients who suffer from snoring, mild and moderate sleep apnea, and CPAP intolerance. And the great news is that medical insurance and Medicare pay very well. Let’s review some of the statistics available to us in regard to our treatment population:

• 100 million Americans snore.
• 60% of all Americans over age 40 snore.
• 27% of all married couples snore.
• 50% to 75% of those who try the CPAP reject it.
• The CPAP industry grosses $4 billion each year.
• 20% of the grosses are for reusables, and this leaves $1.6 billion to $2.4 billion for dentistry for the treatment of apnea and CPAP intolerance.

Medicare and medical insurance reimburse for treatment of patients with sleep apnea. The number of patients is bolstered with the high rejection rate of the CPAP. Medicare and the insurance industry pay for the CPAP because they recognize the grave threat to one’s health when there is no air to every cell in the body five to 100 times an hour, for 20 to 30 seconds an episode. Bodies are oxygen-starved. And with the recognition that this disease needs reimbursement, insurance plans also recognize that dental sleep appliances are the No. 1 nonsurgical alternative for the CPAP. Thus dental community members who treat dental sleep disorders and understand the intricacies of billing Medicare and medical insurance are well compensated.You may have heard many practitioners and practice-management leaders advise you not to get involved with Medicare, saying there are states where Medicare will not cover treatment for dental sleep disorders. That may have been the case in the past, but as of Dec. 2, 2009, Medicare changed the whole regimen. Payment is not fee-for-surface, but one global fee for the total treatment. If a dentist submits code E0486 for a custom appliance, he or she will be reimbursed $2,500 to $5,000 per case. The rationale for this pay range requires more space than is based on the amount of treatment delivered. This subject requires a paper of its own. The gist is that the more intricate and involved the treatment, the higher the reimbursement. Dental sleep disorders are a tremendous avenue of reimbursement open to patients and the dental community.Since Dec. 2009, this is the procedure that Medicare has posted on its Web site, and it applies to the entire country. They pay one fee for treatment throughout the entire country. The claims paperwork is very precise; you will be rejected if not 100% correct. To get paid by Medicare for providing a sleep appliance, you must become a DME provider. DME stands for Durable Medical Equipment. Medicare classifies beds, wheelchairs, and — unbelievably — oral sleep appliances as DMEs. To get reimbursed for an appliance, you need to get the DME provider approval. You can contact the Full Breath Corporation at (888) 285-8038 for directions on how to become a DME provider. It requires some effort, but the upside is that a sleep case can be reimbursed from $2,500 to $5,000. Treating one new case a week could yield up to $250,000 a year to the treating dentist.If you don’t become a provider, you can still treat Medicare patients. Medicare will cover the cost of treatment, but they will send the money to the patient. Then you’ll need to collect from the patient. Good luck on that one. The most painless route is to become a DME provider and have the reimbursement sent to you. Medical insurance reimburses well for treatment of OSA and CPAP intolerance. Reimbursement procedures include the consultation, exam, radiographs, office visits, pharyngometer and rhinometer, tongue fixation, and home sleep tests. Reimbursement ranges from $1,000 to $6,500 per case, with an average reimbursement of $3,000 to $6,000.Some areas of treatment and reimbursement require discussion and explanation. First let’s look at the radiography we utilize in treating OSA. Radiographs are taken with a cephalometric machine. And for those few who have the machine, we take a dental CT. In the examination phase, we use many of the same X-ray views that a TMJ case uses: four views of the TM joints, a lateral cervical, three views of paranasal sinuses, and a panoramic view. In treatment, first take a view of the TM joints with the appliance placed and a lateral cervical to check the size of the oropharyngeal airway. When completed, we take a lateral cervical to see the finalized size of the oropharyngeal airway with the appliance in place. These radiographs are reimbursed at the rate of $500 to $1,500 per case.The pharyngometer is computer designed and patented at Harvard. It has a sensor arm with a mouthpiece connected to it. The patient bites on the mouthpiece, and then the pharyngometer is directed to shoot out sonar waves that measure the size of the oropharyngeal airway. The airway can be measured without anything in the mouth. Then measure with the sleep appliance in the mouth, and next measure the airway after making changes to the appliance to improve the case. The dentist can see his or her treatment success as the opening of the airway increases.The pharyngometer plays a major role in patient case acceptance. At the consultation, an initial baseline reading is taken with nothing in the mouth. Then the patient is given a small square of wax and the bite is opened 3 mm to 4 mm with the patient biting at end to end. This positioning is similar to a mandibular advancement. At this point, a pharyngometer reading is taken. The patient can see that there is a 50% to 200% increase in the size of the oropharyngeal airway. And, with the FBS, a piece of baseplate wax a quarter-inch thick and two-and-a-half inches long is placed in the mouth covering the tongue from the right second molar to the left second molar. This acts as a canopy over the tongue and restrains its posterior movement. The pharyngometer is then run and the reading can indicate a 75% to 300% increase in the airway. The patient is greatly impressed with the fact that the airway is open further and a large volume of air goes to the lungs. This results in a higher percentage of case acceptance.Insurance reimbursement for use of the pharyngometer runs from zero to $90 for 30% of the cases. For the other 70%, reimbursement runs from $160 to $360. The average in this group is a $250 reimbursement every time the pharyngometer is used and billed. And let’s not forget that with the FBS we utilize tongue fixation that is billed three to six times with an average of $400 per procedure.Obstructive sleep apnea is one of the most dangerous and destructive diseases on the planet. The medical community’s No.1 treatment, the CPAP, is rejected 50% to 75% of the time. This leaves dental appliances as the next most viable treatment modality for this malady. And Medicare and medical insurance have established good reimbursement fees. Sleep dentistry offers many reasons for dentists to look into treating patients in this arena.

Bryan Keropian, DDS, practices in Tarzana, Calif. He has a large, full-time sleep disorder dental practice. Dr. Keropian is the inventor of the Full Breath Solution Sleep Appliance. He can be reached at (818) 344-7200.References1. Sleep 1997; 10:705-706.2. Cardiac Consequences of Obstructive Sleep Apnea-Hypopnea Syndrome, Mt. Sinai Med. 2005; 72(1):10-12.3. Sleep Med. 2006; 7(1):73-75.4. Clin. Exp. Hypertension. 2005; 27(2-3):259-267. 5. Risk Factors and Treatment for Obstructive Sleep Apnea Amongst Obese Children and Adults, Mark Kohler, Medscape Abstract posted 2/5/2009.6. Redline S, Adams N, Straus ME, et al. Improvement of mild sleep-disoriented with CPAP compared with conservative therapy. Am Journal Respiratory Critical Care Med. 1998; 157:858-865.7. Engelman HM, Kingshott RN, Wraith PK, et al. Randomized placebo-controlled crossover trial of continuous positive airway pressure for mild sleep apnea/hypopnea syndrome. Am Journal Respiratory Critical Care Med. 1999; 159:461-467.8. Kribbs NB, Pack AI, Kline LR, et al. Objective measurement of patterns of nasal CPAP use by obstructive sleep apnea. American Journal of Respiratory and critical Care Medicine 1993.9. Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman Jr J, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Owens J, Pancer JP. Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005, An American Academy of Sleep Medicine Report. Sleep 2006; 29(2). 10. Seminar, Introduction to the Full Breath Solution Sleep Appliance, At the Center for Snoring and CPAP Intolerance, Aug. 2006, Bryan Keropian DDS.