All right. Welcome, everybody. I'm Trish Braga, the AADSM Director of Education and moderator for this evening's presentation on the AADSM position on HSAT with AADSM President Dr. David Schwartz. Dr. Schwartz, take it away. Thank you so much, Trish. You know, I thought with 187 people registered that it must be the topic, the HSAT position paper that's drawing so many people to it. And I realized that maybe it's just me, my dynamic personality that drew 187 people to register. And then I was told by our staff that it's actually a free webinar. And that explained everything. So welcome, everybody. And thank you. I'm looking forward to providing you with some insights into the AADSM's recent position statement on HSATs. I'm going to do a quick review and then I'm hoping that we'll have plenty of time at the end for discussion. There we go. The objective for tonight's webinar are to explain our position on dentist ordering and administering HSATs and to provide you with the information you need to advocate for dentist helping to improve the model of care for patients at risk for sleep apnea. Last year, a study indicated that there are 54 million adults in the U.S. with obstructive sleep apnea. 43 million of those are undiagnosed. With increase in trends in obesity, I would imagine that these numbers will only increase. And we often talk about issues regarding access to care for patients. And access to care is more than just ensuring that there are healthcare providers in a community who can help diagnose and treat a disease. But it's also ensuring that diagnosis and treatment can happen expeditiously. Access to care is also the ability to see a provider that's within a geographic distance that's acceptable to patients seeking care. So as an example, in my community, I'm in the area of metropolitan Chicago, we have sleep physicians that practice near the city. They're concentrated there. There are, however, gaps in these surrounding communities that don't have close proximity to physicians. And many times these people will search online avenues to facilitate their diagnosis without ever even seeing a sleep physician. Access to care is also twofold. And I think it's important to point out that it's not just whether a patient has access to a specialist, it's also the amount of time it takes for that patient to be diagnosed and treated. We have to recognize that the patient's time, money, inconvenience, if you will, all play a role in their healthcare decisions. And if a dentist has the training to screen for sleep apnea and works with the physician to identify mutually agreed upon criteria to determine if the patient is a candidate for HSAT, and we can save appointments and time from screening to treatment, we've also addressed the access to care issues. I'll remind you that these patients are already seeking these things out on the internet in tunes of thousands of patients each month that are doing nationwide searches. We at the board directors level have had conversations with a company called Lofta, for example, that already does this type of direct-to-consumer marketing. And many times they're not even seeing having a telehealth visit with the physician. Currently, right now we have 5,700 board certified sleep medicine physicians in the U.S. with 165 that have matched for this year's fellowship program. So it's going to take another couple of years to even reach the 6,000 board certified sleep medicine physicians to treat our patients. We already know that we can play an important role by identifying patients at risk for sleep apnea. We're seeing patients more frequently than physicians just by the nature of what we do and our recall visits with our patients. The nature of our job as dentists, we are in a perfect position to make observations regarding the patient's airway. We formally recognized this by the ADA in 2017 when they came out with their role of dentistry in the treatment of sleep-related breathing disorders, where they stated that dentists were encouraged to screen patients for sleep-related breathing disorders as part of a comprehensive medical and dental history to recognize symptoms such as sleepiness, choking, snoring, and witnessed apneas, and to evaluate these patients and that these patients should be referred as needed to the appropriate physician for proper diagnosis. We, as the AADSM, have been advocating this for a long time, but we formalized this position in our policy statement in a dentist role in treating sleep-related breathing disorders. And we, in that policy statement, also say that dentists should screen patients for sleep disorder breathing with questionnaires and by evaluating the airway. Now, in 2017, the AASM sponsored the Now, in 2017, the AASM sponsored the Quan Schmidt-Noir paper that basically discussed the role of dentists in the diagnosis and treatment of obstructive sleep apnea, where sleep physicians recognized that they are overburdened and that they recognize that the dentist can play an important role as we have a front seat to the mouth, the nose, the airway, and we have a unique opportunity to help our patients. This does fall short of supporting the use of HSAT for titration and for allowing ordering by dentists. Now, in 2018, the AADSM published an article which contains a roadmap for dental sleep medicine formalizing a standard for screening, treating, and managing adults with sleep-related breathing disorders. The standard outlined the process for screening patients, and it also stated that physicians are responsible for diagnosing sleep-related breathing disorders and confirming the treatment efficacy. As our board of directors discussed its mission, which includes that we will strive to reduce the number of undiagnosed and untreated people with sleep disorder breathing, we recognize the need to implement a model of care which ensured optimal patient care while helping to get patients diagnosed and treated. This resulted in the development of the AADSM's position on dentist ordering and administrating HSATs. This position statement makes it clear that the AADSM believes that it's within our scope of practice for a qualified dentist to order or administer HSATs, and that licensed medical providers should be diagnosing and verifying treatment efficacy. First of all, it's a model where qualified dentists and physicians have to work together, but they have individual responsibilities and collaborative responsibilities. Many of our colleagues don't want us to utilize HSAT, and that will be a personal decision that you will have to make with your referring providers or new providers as you see fit, but understand that that decision will cultivate with respect to these doctors. In my practice, for instance, my sleep physician colleagues, they pretty much welcome the information that I provide them when it's ready to evaluate those patients for efficacy utilizing a titration protocol that we have in our office. So, what does the model of care look like? Well, it starts with a patient presenting to the dental office who has a medical history, signs and symptoms of a sleep-related breathing disorder by clinical presentation, and positive subjective screening that warrants further investigation. We see this all the time. These patients present to us in our hygiene visits. They present to us as new patients. This initiates either once we've identified that they are a candidate for sleep related breathing disorders, this initiates either referral to a physician ordering a home sleep apnea test or providing an HSAT for that patient to take home. Now, it doesn't preclude the fact that these patients may have other coexisting sleep issues such as insomnia, restless legs, periodic limb movements, narcolepsy. Ultimately, the physician will have the final say in the patient's treatment. So, once we've used our medical and family history and we validated the screening tools that we typically have with StopBang and Epworth and we perform our physical examination to determine if these patients are at risk, we now know that they, again, may be under mutually agreed upon criteria part of our workflow. We use our specific criteria as agreed upon by us as well as the physician that we might be working with to determine if the patient is a candidate for an HSAT. If they are, the dentist either orders the HSAT or admitters it to the patient and the patient will receive those instructions from the dentist or staff on how to use the HSAT directly and then will provide the physician with that pertinent patient information and access to the HSAT information. The physician is then responsible for diagnosing and prescribing the appropriate treatment. Should the patient have obstructive sleep apnea and be prescribed an oral appliance, the dentist will then provide the therapy and we will determine the appropriate therapeutic position for the oral appliance and then the patient is referred to the physician to verify treatment efficacy. Now, the model of care achieves several outcomes. Dentists identify patients at risk for sleep apnea, so these patients who might not, who might otherwise go undiagnosed and untreated, we're seeing them in our offices. Patients typically will have fewer appointments to be diagnosed in order to be diagnosed, reducing their expenses and inconvenience, and the physicians will allocate their resources primarily to diagnosis and treatment. Diagnosis of the medical disease and verification of treatment efficacy clearly remains the responsibility of the medical providers. There are also some additional benefits. We all know that patients can now purchase HSTs directly from online sources without their physicians ever even knowing this. There's a large contingency of dental sleep practitioners that are already using board-certified sleep physicians in a remote capacity via telehealth and third-party billing services. Now even the presence of CVS, local CVS outlets have been initiating direct-to-consumer testing using HSAT without physician involvement. They're typically utilizing nurse practitioners or physician's assistance in order to facilitate those tests. Qualified dentists have been trained to keep physicians informed, and I think that that's one of the most important things that I can tell you is in the model of collaborative care, at least in our practices, we're constantly communicating with our sleep physicians. So a collaborative model of care must be utilized if patients are going to receive optimum care. The reality of the situation is that the vast majority of state dental boards do not prohibit dentists from using HSAT. Physician colleagues expressed concern about some rogue dentists that use HSAT to diagnose with no involvement of the physicians. This statement clearly states that the ADSM does not support this process, and we don't support the rogue dentists using HSAT to diagnose or verify treatment efficacy without the collaboration of the physician. The ADA and ADSM both have policies supporting the use of HSATs for calibration. This position statement builds upon that to provide a more streamlined and cost-effective model of care. Read carefully, though, as it states that a dentist trained in the use of these portable monitoring devices may assess the interim objective results for the purpose of titration. That would be you're testing your patient, utilizing HSAT, and you feel that clinically that is not in an effective, idealized position, and then move on from there. As we did in 2018 when we created the mastery program based off the standards paper, the ADSM is developing education to train dentists on how to appropriately order and administer HSAT in collaboration with a physician. And in 2021, we'll be launching the Emerging Concepts course, which will provide this education. It'll be held in the fall of 2021. More details will be available early next year. God willing, we'll be able to do it together in one place, but that's still to be determined. We will obviously discuss HSTs with medical providers, the models of the HSTs in practice and how we're all using those, and have a hands-on review of various different HSAT equipment and the reports that are generated from those HSAT models. The ADSM is working to ensure that relevant stakeholders are aware of this position, and we're actively encouraging states that prohibit the use of HSATs by dentists to reconsider their policies. We will be presenting at the American Association of Dental Boards meeting in 2021. That meeting has been postponed due to COVID. We have asked the ADA to support us on this position statement, and we will be requesting that commercial insurance companies support this model of care as well. So how do you implement this? How should you use this position statement? And I think you should use the statement to open a dialogue with your physicians in the community and asking them how you can help get patients diagnosed for obstructive sleep apnea. It also gives us the opportunity to educate them about the comorbid conditions that they're already treating many of their patients for, but unfortunately they may not understand or realize that there is a high comorbid relationship with obstructive sleep apnea and the hypertension and the esophageal reflux and so many other clinical manifestations. I think it's important to remember that in developing these resources as this position statement, we always try to make sure that we do not interfere in the clinical judgment of our members. The flow chart is a guide. It's like our guideline paper. It's not all-encompassing and it was not intended to be. We expect that dentists will not provide oral appliance therapy if the person is not a candidate, just as we expect that a patient who does not have obstructive sleep apnea might have a different sleep disorder. We're not qualified to diagnose that. Not every patient will follow the treatment pathway perfectly. We fully expect a qualified dentist to adapt this flow chart to their own practice models and will do what works best in their community for patients, referring physicians, and themselves. So please adapt the flow chart to to work for your practice model. So I hope that this short discussion is finds on this position statements you found useful as a tool and you can consider ways to help reduce the, you know, the public burden of obstructive sleep apnea in your local communities. This is such an important topic. It's something that I've been passionate about for a long time, and I have incorporated it here in our practice. And I do work in a multidisciplinary sleep center. My doctors appreciate when I'm sending them reports, again, for them to be evaluating patients. So I think that we've got some questions that have come in through the webinar. I think we should spend some time doing that. So Trish. Thank you, that was a good presentation. Now, I'm gonna start with the questions that were actually submitted ahead of time. And the first of those questions is, does the ADSM position on a dentist ordering an HSAT require an evaluation by a board-certified sleep physician prior to the dentist ordering the HSAT? So the answer is no. You know, remember that there's still, I'm gonna use this in broad terms, it's still a limited number of board-certified sleep physicians, 5,700 as I mentioned before. Throughout the country. And we need to help them meet the public burden of obstructive sleep apnea. And as qualified dentists, again, we see these patients who present to us, we gather information, we have this purposeful, meaningful interaction with our patients. And I think that it's important to keep that in mind that that's what allows us to then make the judgment that these patients should be tested with an HSAT. So there will be times that a patient's not a candidate for an HSAT and needs to be referred to the physician. It's easy to not even, you know, to think we don't have to do this. But I think that this, again, I go back to the unmet burden that I believe is something that's ever present that we see all the time. Now, I'm gonna combine a couple of questions for you. So I'm gonna read them both, but I think you'll see why I'm combining them. Will the HSAT be covered by medical insurance when the HSAT is ordered by the qualified dentist and the patient has not had an evaluation by a board certified medical sleep specialist? That's the first one. Then the second one is related to that because if the interpretation of the HSAT must be done by a board certified sleep specialist, who bills for the technical fee and who bills for the interpretation fee? Yeah, I think that that would end up having to be washed out in some of the insurance contracts. I think that the interpretation fee would certainly without question be done by the physicians that are gonna be participating there. I would think, and I know that in our practice, we do get a technical component fee, but no interpretation. We're not billing for that. The, I think that you're asking, it's a great question. I think it's gonna be dependent on the practice model and the insurance contracts with each dental practice and even a physician practice that might be doing this. Currently, dentists either bill the commercial insurance or they bill the patient. And many dentists don't even bill the patient at all. They just use a reusable HSAT that is available. Is that, it might, maybe the only thing that I think I did not talk about maybe would be for Medicare. I was just gonna ask about Medicare. Do you want me to ask it? Yeah, let's ask it because I think a lot of patients, a lot of our- Attendees. Are gonna wanna hear that. Yeah, I think so. So for Medicare patients, is it the position of the AADSM that the qualified dentist may order the HSAT and then refer the patient to a sleep position for the interpretation, but can then dispense an OAT as a DME provider without violating CMS guidelines? So that's a little bit of some nuance in that question, but- Yeah, I mean, it's a great question. There is no, this is not a model for Medicare patients. Under Medicare guidelines, an HST is not an appropriate test and dentists are not allowed to do that. It has to be read by a board certified sleep physician as I understand it. So no, this is not a model of care that would be utilized in the Medicare world. I'd like to see the ability for dentists to provide patients or provide Medicare patients appliances. I'd love to see a model that we'd be able to utilize HSAT for titration, but under the Medicare guidelines, we don't have that option. It's not something that's been condoned at this point. So future work, it's a future position statement. So those were the questions that came in ahead. Now I've got some coming in on the discussion forum and I just want to remind everybody, if you want your question answered, asked and answered, make sure you're voting for questions that you like. So the top question right now is somebody who says, I practice in Ohio and the dental board has determined that I can no longer use HSAT for ordering or titration, which is a reversal from their previous position. What is the AADSM able to do? And what can I do to help change their position? This is what we're trying to deal with. It's a really good question. And we are approaching these state dental societies to see what we can do about increasing scope of practice to include it. I think that we'll have more power if we can get the ADA to embrace this position statement as well. So from our perspective, what we are doing, we are reaching out to these states that are not permitting the utilization of HSAT. You have to understand that this is a lot about control and remember that the scope of practice many times is very hard to determine what is and what is not in scope of practice. And I think this is a challenge that we have to, as the AADSM, we have to meet and we're gonna meet it with as much we can with each state that is experiencing just like you're experiencing in Ohio. You know, could I add to that, Dr. Schwartz? You know, the AADSM is the largest nonprofit that represents this section of dentists. And by writing a position paper like you have done, that is going to be really the standard by which we can go forward and get some of these reversals that this person is asking about. And so what he could do as an individual is certainly collect, I mean, having seen your webinar and going and having the recording of it, he can go back through it and he can use all those talking points that you had to speak to people in his community because that grassroots effort is going to matter in the long run. Yeah. So this is the start. It is the start and understand that this, it's a bold statement, it's a bold position statement. And I think that it's meant to do that. It's meant to stir up some discussion, to try to change some people's opinions. But without starting that, we as an organization no longer become relevant if we don't work towards improving, you know, if you look at our mandate as an academy and that we're trying to diagnose, I'm sorry, we're trying to treat more patients, get more patients diagnosed and treated. Surely we can't do that. The physicians can't do it on their own. We can't do it on our own. And that's where the collaborative effort has to come. Unfortunately, you're gonna run into walls like this. I practice in a community that welcomes it. You know, I think that you've got to really look at the scope of practice from that dental association and see, is it strictly prohibited? Right. Saif, I promised to remind you and then I forgot. Could you unshare your PowerPoint? Stop share. I will stop sharing. Thank you. All right, the next one is how would a verification of efficacy be properly documented? Signed form from MD that treatment is effective or needs more titration? So that's one person's question. Like how should he record keep? How should he or she record keep? Another really great question. So in our office, we will, if we're doing an HSAT, I'll send the HSAT to the physician. The patient will have that. And I will say, I believe that this patient is titrated appropriately. Here are the results of the study. And the patient will go to the physician. The physician will either accept that or perform their own in lab study and document that. When I get those reports back, those patients, then that goes right into our patient's record. If it comes back that the efficacy has not improved, we will advance further. And sometimes we'll actually have to send the patient back for further advancement. A lot of our patients though, if it comes back where we were only reasonably successful, many times the doctor wants to do an in lab titration PSG with the appliance that we fabricated for the patient. But to your question about the record keeping, I think it's a great question. Make sure we get in writing that, patient has met either maximum medical improvement or that further titration is necessary. We don't live in a perfect world. And many times I'll see these reports that we've reduced the AHI or RDI to a significantly reduced amount, 80% post titration PSG. And the patient's already failed. The CPAP refuses to use it. So we are now at a position where the patient's subjectively feeling better there. And objectively we've shown that they have a significant improvement as well. So in many of those cases, we've taken those patients from severe to mild. We have reduced the comorbid conditions that we reduced. We haven't eliminated. We've reduced those comorbid conditions. So I do feel it's worthy of getting whatever in writing you can from the physicians that you're dealing with. Will it upset our board certified sleep medicine physicians if we use HSAT? Well, if you're not screening your patients and documenting the subjective testing and proving to them that you have some medical history you've done that this patient is presenting to you in a certain way, I think you're gonna piss off a lot of people. So I think that's why the mastery course is so important. That's why having a mutually agreed upon criteria with the physicians that you're working with, I think will make perfect sense so that you don't irritate, upset the apple cart, if you will. If you follow this mutually agreed upon model and provide excellent care, I see no reason why that would be something that they'd be upset about. I'd like to jump in on that one a little bit too, because I think if you arm yourself also with, for example, Sheet's paper, her collaboration on calibration and how we need to use subjective improvement when we're calibrating, but we also need to verify that with objective testing and you are really open and honest about the positions of the different bodies, governing bodies. If you have an open discussion, I think you make such, it's a great way to start a conversation with a physician. And I think they just have a great deal of respect for what you can do for them. And then eventually they will come around. Would you agree with that? I would. And let me pose this discussion point. And that is, think of the literally millions of people that would be fed into the funnel of undiagnosed patients that the sleep physicians aren't seeing right now. Now we have highly screened patients that would be coming to them that they now have the ability to treat these patients. Whether it's CPAP or oral appliance therapy, again, I'm not dictate, we're not gonna dictate what they're gonna choose. Of course, I'd love to think that we could treat everybody. We can't, we all know that. But think of the large funnel that we would be creating for our sleep physicians, our colleagues that we're working with, and our primary care physicians, our integrative medicine physicians that surely need some help. I saw one of my patients as an integrative medicine physician, I saw yesterday. And she said, it's amazing to me how many physicians aren't picking up the HPA axis increase issues from patients who aren't sleeping well. And one of the things she said is, I really would like to consider utilizing home sleep apnea testing in her practice to start diagnosing patients. And we went through a whole discussion. It was a lovely conversation because I think that we as practitioners who are looking in the mouth all day long, we identify so many things that lead us to that fact finding. So I think that it would be a phenomenal way for us to increase the referral base to our sleep providers. And I'm gonna ask a question out of order here because I think it kind of addresses that a little bit. The question is, should I give all patients an HSAT? No, no. First of all, you should be screening your patients with medical family history, of course, and using a validated screening tool like StopBang and Upworth. And with a physical examination. And again, we're dentists, we're looking in the mouth, we're doing a physical examination on these patients. That also includes body mass index. It also includes neck circumference. So we're doing all these things that we typically would do when we're screening these patients. Once and only then should you consider using an HSAT. And again, I think it needs to be mutually agreed upon by the physicians that you're collaborating with. It's a good question. Okay, this question's gonna seem like it's not in the right place, but I think it's a really good question. So I wanna ask it. Cause the other questions are kind of based on this. So the question is, what is a qualified dentist? Has anyone defined that? Is it a board certified dentist by the ABDSM or anyone who takes a weekend course? So could you address that please? Sure. Well, that's a good question. First of all, I think that you're in a better position to answer what a qualified dentist is based on the criteria that we've set out for mastery. And that's not to say that patients who are taking a weekend course from some of our other lectures who may not be under mastery are not disseminating really good information. So does that make them unqualified? I think that you have to separate in this case, uh, those neophytes that are coming out of dental school that have no training in dental school from those of us who have been practicing this and have gone through mastery and have done, you know, hundreds and hundreds of cases. There's definitely a distinction there. Uh, for those of us who've done restorative dentistry, I can tell you, um, I, am I qualified to do a veneer the day that I come out of dental school? Absolutely not. Uh, talk to me 10 years later. I still feel like I, you know, I need to work on that. Um, so the, the, the ADSM has a definition of a qualified dentist and you can talk to that in a moment, but I think it's, uh, it's not just about the numbers, I think you have to look beyond, um, beyond that. So does that make sense? I hope that does. Yeah, it does. And you know, I'm, I just love that question because, um, I think this is everything. It goes back to the very first question. The fellow said that I, or the woman I practice in Ohio and the dental board has determined that I can no longer use HSAT and what can we do about it? Well, the qualified dentist designation was one of the first initiatives of the ADSM to try to get people with common knowledge base, because like you said, when somebody graduates from dental school, they're not ready to do this. We don't learn this in dental school. And in fact, there is like a minimum competency that we want all of our members to attain through nonprofit lectures. Like you said, it doesn't have, it doesn't have to be, um, someone, uh, although now for the, for the qualified dentist designation, it is through the mastery program, which, you know, currently they can access online. So it's just like having, like, we are stronger if we are in this together and we are all operating at a minimal acceptance of competency and dental sleep medicine. So I agree. I think that's the biggest strength that we're going to have going towards these states, uh, state dental boards. And that is, look, we didn't have it before. We have it now. Here's our core competencies. Here's what we're doing. We're providing a, a mastery program or providing a definition of qualified dentists, uh, to be able to utilize these things. And this will continue to grow with our emerging concepts course. There's no question about it. Yeah, exactly. It's just, it's stepping stones. Um, okay. So now this is, this is interesting. How do you justify using HSAT when they don't have a lead to read brain activity and therefore can't be used to diagnose OSA? So I think what they're, I think what they're really saying is if they don't read brain activity, how like EEG apparently, then how would you recognize sleep versus just quiet? It's it's, I mean, I think it's a really good question. I think that the, the practicality is this is that unless there are underlying comorbid conditions that are significant, uh, or a patient presents in a, in a manner that, um, presents with a chief complaint of possible or differential diagnosis of narcolepsy, um, it's going to be very hard to get these patients into a lab to do a PSGs. I walk into my sleep center two days a week and I see eight empty beds. Um, uh, and it's, it's disheartening because we used to do PSGs all the time, uh, in the sleep center. Uh, and now the insurance companies are dictating the level of, uh, the level of care that they can take. That being said, uh, uh, the, the question's absolutely correct is that we can't read EEG. We're not looking at brain activity. Um, I think that you've got to choose an HSAT that is appropriate for what you're trying to do. If we know that the patient is, has a high pretest probability of OSA, uh, then we're going to rule in that patient, um, you know, more than we're going to rule out. Uh, but again, we're not looking at brain activity and I would say that for titration purposes, uh, do we need to use brain activity? Look, we can look at HST and we can tell that someone has by a hypnogram, uh, when they're in REM sleep. Uh, now I'm not using EEG. Uh, I'm not looking at brain, uh, or eye movement on that, but you can typically tell when someone is experiencing, uh, REM exacerbation based on the time and based on the, uh, the way that that looks on the hypnogram, um, we have to draw inferences. We have to, we have to be practical in the, in the way that we're, we're looking at these things. And again, uh, I, I'm thinking that if it's much more complicated than that, then the patient will have an opportunity to have a, a, a overnight polysomnography, uh, even though the insurance will not necessarily cover it. We have to provide that supportive information. We do it all the time. Uh, if the sleep center, we have to provide supportive information to justify doing a much more costly test. Good answer. That was a good answer. Um, I'm okay. This is another good question, Dave. If using telemedicine for diagnosing, who then manages the patient? It's a great thing to clarify. Can primary care physicians do this or does the patient have to be physically seen and managed with a board certified sleep physician or ENT or pulmonologist? So it's a really good question. So let's look at this from a standpoint of my practice. I'm not going to be sending that patient to somebody else, unless I've already seen them in the office. I can't perform a physical examination on the patient by telehealth. Can we do telehealth deliveries and telehealth followups? Absolutely. And we're doing it all the time now. Uh, and I think it's a very efficient way for patients to be, um, to have access to care. I like to use that word to have access to care. That's really, uh, ideal. Uh, we, we no longer have the issues with, uh, space and time. Uh, we're, you know, we, we turn up, click on a button and we're, we're instantaneously in front of the patient, uh, with regards to, can the physician manage the care by telemedicine? Um, again, that's going to be the model of care that the, that, that, that doctor's going to have, he's going to have to decide if that is the type of, uh, practice that they're going to be able to, to implement or not. That's again, that's out of our realm. I think that that's important to remember. Okay. Now this next question, I have kind of answered a little bit, um, uh, in writing on the conference IO, um, and I'll just, I'll read you what I answered, but I think there's more to it here. So I'd like you to answer it as well. So in choosing an HSAT, which signals would be recommended? Okay. So let me just read you what I've written and you can kind of use that as a jump off point. Um, so obviously this is a home study. The device provides, um, oxygen level, heart rate, airflow, snoring, and other parameters. And so, you know, it's that the other parameters, um, maybe you could speak to that a little bit. This is such a, uh, individual choice. I don't want to talk. I don't want to talk in branding because I think that's, it's, it's not appropriate for this conversation. When I look at channels that I would like to see in a, in a, uh, a home test, I'd love to see position. I think it's so important. I love to see flow. Uh, I think that's also so important. We, as you know, dentists, those of us who are trained, we look in the nose all the time. I think, you know, I think in my practice, I bring more referrals to the ENTs than a lot of, uh, our physician colleagues who are, are, are evaluating our, our, our patients. Um, so I'd like to see flow. I'd like to see position, obviously. Oh, two. Um, and, um, uh, unfortunately, uh, not all of them have a, uh, a determination of effort. Uh, I think that that's also very important, um, you know, and some of them, uh, use it through a different signals, but, uh, those are the things that I look for in a, in a home test. Unfortunately, I'll tell you the truth. Even the sleep center that I work at doesn't have the ideal. H set, and this is, this is interesting. This is an economy of scale. This is some of the things that we deal with on a daily basis, just as insurance companies are dictating, uh, the fact that we have to use HSA T versus PSG, um, the business decision for a company that distributes CPAP machines. For instance, uh, the CPAP manufacturer actually makes a home sleep apnea test. So that's something that's provided very easily to a group. This happens around the country all the time. So they might be using an inexpensive, uh, HSA T that has disposables that are very reasonable, reasonably priced versus a much more expensive HSA team. So I think it's a, again, a good question. Um, doesn't, we don't, we don't always have the options to make that choice as dentists. I think we're kind of the tech geeks. We like, we like things. So we like to, we like to play with things. We like to touch things. So it gives us a better idea of what works in our hands. You know, I want to add to that question. If I could, Dave, um, how accurate are home obstructive sleep apnea tests and how often are they effective? Uh, that's, that's a good one because portal monitors are better, um, at, at, at ruling in sleep apnea than they are ruling out. Um, you know, so what I prefer to see EEG, what I prefer to see sleep time. Absolutely. We don't always get that on, uh, on the home sleep tests. Um, it's, it's, again, it's not a perfect world, but, uh, I think that there, there is accurate. And again, if they have a high pretest probability and we have the signs and symptoms, uh, based on physical examination and medical history, uh, I think that that makes, uh, makes it a better, a better positive, uh, diagnosis. Yeah. So I'm going to kind of paraphrase something that someone has asked. Um, I'm going to ask it this way. Uh, what are the current obstacles inhibiting wider use of home sleep apnea testing? Uh, I think, I think that for the dentist, we need to make sure that they're trained, the people who are using these are trained and know what they're doing. The selection of those appliances, the, uh, monitors, just like you just asked that question. It's important. And I think that, um, that you have to have qualified dentists that know how to perform in a history and perform a clinical examination before, uh, you know, before you start utilizing HSAT, the obstacles are going to be from the physician side, they're going to be finding a dentist that knows what they're doing, the obstacles on the dentist side are going to be finding a physician that respects you enough, respects the fact that you know things and that you can make these clinical judgments to, to utilize an HSAT. Um, you might also find it as an obstacle, uh, insurance companies and getting paid for these things. You know, I, uh, I salute my colleagues who, who don't charge for these things because they say that it helps them make a better, a better decision on treatment. That's great. But you know, at the end of the day, we, we are in our professions. To make a living as well. Uh, and that's not to say that, you know, that that's going to make us wealthy. It's not, it's going to make us better at what we do. And I think that, uh, I, I, I live by that. Um, you treat the patient well, everything else will take care of itself. Um, so I think that, uh, those are some of the barriers as well. You know, there's a couple of, uh, really statements on here that really show how membership, um, is supporting this paper and this position. And I think there's a certain level of frustration among some of these questions that, um, you know, state boards can block some of the things we're trying to do that are going to help patients. But, um, again, um, I, I would also say that, that, um, the course that we're going to put forward that's called emerging concepts, and it's going to focus on HSAT in the 2021 year. Is really going to address a lot of these questions and make us stronger in, um, supporting this position statement. Um, Kev, I, I, I'm going to throw it back to you here in just a second, but I have one, I, there, one question just did come in. Um, and then if you have anything else you want to address, then I'll just, um, you know, questions like you would like to ask yourself even, um, but let me ask you just one more. Um, since, since HSAT can't be used to diagnose OSA, wait a minute. It says since HSAT can't be used to diagnose, and maybe they mean in the hands of a dentist. Is it malpractice to fabricate the appliance without a proper test? Okay. So there's some confusion in that question. Do you want to address that? Let's assume that he's saying since HSAT can't be used to diagnose OSA, if dispensed and interpreted by a dentist, is it malpractice to fabricate the appliance without a proper test? Okay. Go. So, so here's an, this is an interesting discussion point. Cause there are some continuing education courses in the restorative world that are advocating, um, some things that are very fringe that I'll call fringe. Um, let me give you an example. Patient walks into your office and says, you know, doc, I just snore. And you say, okay, you're a thin person. You just snore. And have you seen an ENT? Yeah, I saw the ENT and he doesn't think I, um, I'm a candidate for surgery. Do you make that patient an appliance? Cause he snores. Now in my world, I don't touch that patient until we test them. Uh, that means that he's either, if he meets the criteria, he's either going to be referred to a sleep physician, or I'm going to administer an HSAT and then send him to a physician for diagnosis. And, uh, that's a, that's a very, it's a, it's a slippery slope, a slippery slope because of the fact that, um, you know, I'm not doing a diagnosis. And it's someone coming in and is presenting again, if they're presenting with all these comorbidities and they're presenting based on physical exam and screening tools, that means that I don't feel comfortable, um, making a snoring appliance or an appliance for snoring without having a test done. That is read by a physician. Let me clarify that. Does that make sense? I think it does. I think it's perfectly clear. Um, um, now, is there anything else you'd like to address that you don't feel like it's been asked this evening that you want to cover? I just think that we are in a wonderful position to, to treat these patients, to get them treated sooner, uh, and we can do it the way that dentists know how. And that is by meeting the patient, by knowing the patient, uh, by evaluating them, talking to them and having, um, and them having confidence in what we're doing. And I think that that's going to hopefully lead, uh, lead us out of this, this maybe, uh, discussion and, uh, and make some fruitful changes, uh, different at different state, uh, levels. Agreed. That's a great, great spot to end the evening. I think, thank you all for joining us. I know that Dr. Schwartz will agree with me that we wish we could see you have a good evening. Thank you, Dr. Schwartz. That was great for helping. I appreciate it. And good night, everybody. Stay safe. Good night.

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