Sleep Medicine and Airway Dentistry Q&A by Dr. Devin Croft, with Dr. Dan Grob, Orthotown editorial director

CPAP machines and oral appliances

by Dr. Devin Croft, with Dr. Dan Grob, Orthotown editorial director

If you’re like me, in your free time you channel-surf between news, sports, DIY home shows and features on famous diners and dives. It’s hard to do this without coming across several commercials for a certain pillow or, as of late, a famous spaceship captain from the 1970s pitching a way to clean a CPAP machine.

What’s a CPAP machine, and how do you know if your patients may be current or potential users for such a device? Who would wear it in the first place?

As it turns out, the orthodontist across the street from my new practice has about 10 years of experience in the field of sleep-disordered breathing (dental sleep medicine) and its associated treatments. After spending a few hours with Dr. Devin Croft, I discovered that there’s a lot more to it than just making an appliance and hoping that you’ve done a service—or that you’ve not done medical harm or ignored more severe issues.

Croft has done an incredible job of educating himself, setting up a system to manage patients, and figuring out how to navigate the difficult landscape of medical billing for procedures—not only for private-pay patients but also those who participate in Medicare and PPO insurance.

We recently sat down to discuss one of the most life-changing procedures and services that a dentist can provide. — Dr. Dan Grob, editorial director, Orthotown

Dr. Dan Grob: I’ve heard that you’re helping to manage patients who suffer from sleep-disordered breathing.

Dr. Devin Croft: Yes—and the important fact is that I’m helping to manage the disease or disorder. It’s important to emphasize the fact that dentists are an important part in the management of these patients.

DG: How did you become interested in the field and get into practice?

DC: I opened my practice in a new office in 2009, before the Great Recession fully took hold. I needed to fill my schedule during the day because in the orthodontic world, the mid- to late day involves intense scheduling demands. There was a large retirement community 15–20 minutes from the office with people who have free time while kids are in school, and don’t like to wear CPAPs. The light went on and I decided to add another spoke to the wheel of my practice.

DG: What is a CPAP machine?

DC: Continuous positive airway pressure (CPAP) therapy is a common treatment for obstructive sleep apnea. A CPAP machine uses a hose and a mask or nosepiece to deliver constant and steady air pressure to patients while sleeping. Many patients do well with this treatment; however, it is somewhat cumbersome.

DG: I can’t imagine doing something like this without some insight or training. Certainly this isn’t the type of thing taught in dental school or orthodontic programs.

DC: I started to take CE classes through Dr. Edward Spiegel about incorporating dental sleep medicine into a dental practice, and he decided to personally train me as if I were his apprentice. He has since passed away, but there are courses that have begun to fill the void left in his absence. I am a member of the American Academy of Dental Sleep Medicine and the Academy of Clinical Sleep Disorder Disciplines, and passed the diplomate exam for the latter. I attend the AADSM annual meeting, but there are many other CE courses available.

DG: Was there any other motivation besides your abundance of free time and the desire to balance your practice offerings?

DC: I found that I myself felt tired during the day and had what I perceived to be low energy, but I attributed that to working long weeks to pay overhead for my startup practice. But I also was made aware that I snored loudly. So, as advised, I took a sleep test and found out I had sleep apnea. I’ve been wearing a sleep appliance for the past 9 or 10 years now, and after that experience, I decided to push forward and make it a part of my practice.

DG: Describe sleep apnea, in a nutshell.

DC: Let me start with some definitions and parameters that physicians use to diagnose sleep apnea. It’s important to understand that many factors go into the medical diagnosis of this chronic condition.

Apnea (A) is complete cessation of breathing for 10 seconds.

Hypopnea (H) is a 4% decrease in oxygen saturation from baseline.

An AHI score, or apnea-hypopnea index, represents the average number of apneic or hypopneic episodes experienced per hour during a polysomnographic evaluation or home sleep test. A score of 0–5 is normal; 5–15 mild; 15–30 moderate; and anything over 30 is severe.

The long-term effects of apnea include heart disease—hypertension, A-fib, stroke, myocardial infarction, etc.—because the heart works harder while not resting, because of desaturations and apnea events to maintain elevated oxygen. It’s also correlated to other health problems because the body doesn’t get the restorative sleep cycles necessary.

DG: Is there a method to screen patients in a typical dental or specialty practice?

DC: Orthodontists see a diversity of individuals, from kids to adults, who have malocclusions that could predispose to the problem. Wives often complain that their husband snores and is tired. Family or specialty dentists can screen in hygiene recalls and refer to medical specialists if suspected apnea has not been diagnosed.

DG: Are there specific questions to ask, or documentation that would be helpful?

DC: A few standardized forms and questionnaires are available on the internet, including the Epworth Sleepiness Scale, the Stop-Bang Questionnaire and the Mallampati score. You’ll observe the oral pharynx, of course, but you also take into consideration the patient’s BMI, waist and neck size, weight, and sleep history as reported by a partner.

DG: Is there a typical classification of anatomy or symptoms that one can observe?

DC: Yes—a Class II, constricted palate, retrognathic mandible, deep bite, enlarged tonsils many times go hand in hand with sleep disorders and breathing issues. But I also have many patients with normal Class I occlusion with normal overjet or overbite.

Adults with sleep disorders often report:

• Daytime tiredness.
• Low energy and poor concentration.
• Snoring.
• Witnessed apnea events.
• Waking up frequently at night.

We don’t see as much daytime tiredness with kids, but they do often present with hyperactivity (which can be misdiagnosed as ADHD).

DG: Once a potential patient is uncovered during screening, what’s next?

DC: At this point, you work with medical doctors to treat the patients and get the apnea under control.

Oral appliances don’t cure underlying disease; they control or maintain the airway during the night to prevent it from collapsing and stopping the patient from breathing. But our goal is to obtain maximum medical improvement for the patient.

For children, the first treatment option is usually to remove the adenoids and tonsils and only then move into CPAP, which can have a deleterious effect on a child’s maxillary development. Then we look at palatal expansion, increasing vertical heights to correct severe deep bites or Class II retrognathic malocclusions.  

DG: What long-term effects can we have on reducing future apnea cases when these kids are adults, by correcting the anatomy component of apnea?

DC: One may still see apnea because of weight, age, hormone imbalance, missing posterior teeth and decreased vertical height, medications or postural apnea—odds of the latter are greater if the patients sleep on their backs instead of on their sides.

Oral appliances are ideal for mild-to- moderate or CPAP-intolerant severe cases.

For treatment options, CPAP machines are the gold standard but we see poor patient compliance because of intolerances. There are some surgical options, such as uvulopalatopharyngoplasty (UPPP), but we see poor long-term success with those after more than five years. Oral appliances are good at controlling or treating apnea—not as effective for severe cases—and are often better tolerated by patients. There’s also an Inspire surgically implanted medical device that stimulates the nerves to prevent airway collapse, or orthognathic surgery.

DG: How does a dental practice help patients like this?

DC: The workflow of typical treatment usually goes:

• Treatment time is two to three months, starting when the patient sees you after a referral or after he or she returns from a diagnosis of sleep apnea.
• Scans or impressions are made to fabricate the appliance.
• Insert and titrate forward to the position of maximum medical improvement, based off the patient’s subjective assessment of symptoms from start.
• Do a follow-up sleep test to assess efficacy, and then recall. 

It’s important to note that all of this is done with medical guidance and follow-up! Stay in contact with the patient’s primary cary physician, because we’re the specialists treating the patient who returns to the doctor’s care once we’re fully titrated, but maintain recalls at 6–12 months to monitor TMJ, occlusion, tooth movement, etc., to help prevent side effects that can arise.

As far as compliance versus efficacy, the CPAP machine is more effective, but overall we see poor compliance with patients who use one. Oral appliances aren’t as effective in treating more severe cases, but have significantly higher compliance. 

Of course, the knowledge is one thing; putting your newfound skill set into practice is another.

DG: Was there a challenge to get a department of sleep started in your practice? How about fees and collecting payments?

DC: I became an in-network provider for medical insurances. We do a pre-verification of the patient’s insurance to know the estimated out-of-pocket expense, then submit the encounters for medical billing. After collecting the insurance portion, we will balance-bill the patient for the remaining difference that was not satisfied from the initial estimated patient payment and insurance payment. I block patients into typical consultation and have adjustments during the day to titrate and adjust the appliances. This care requires a little more doctor time than other appointments or adjustments, but not significant enough to affect the flow of practice.

DG: Is there special technology needed?

DC: I use an iTero Element scanner to fabricate appliances and an iCat/CBCT for airway analysis with TxStudio (Windows) or InVivo (Mac), which uses Anatomage to render the airway so we can assess where narrowing occurs. I look at the sinuses, septum deviation, tonsils, TMJ, spine, bone, carotid arteries, airway, pathology, etc., off the scan by sending them to BeamReaders, a company that employs certified oral and maxillofacial radiologists.