Welcome, everybody. I'm Dr. Vicki Cohn. I'm the moderator for this evening's presentation on collaborating with referring providers. So it is my great pleasure to introduce all of these providers because they are superstars, rock stars, and they're really great people. I enjoy working with some of them, and so let's talk. This is Ms. Rena Holzer. She is a senior nurse practitioner in the sleep division at Beth Israel Deaconess Medical Center in Boston, Massachusetts, which is an affiliate of Harvard Medical School. She is a board certified as a family nurse practitioner and has been practicing for over 22 years, which is hard to believe when you look at her. She is on faculty at several nursing schools in the greater Boston area. Her professional interests include health promotion, the care of patients with complex medical issues, and patient education. Her sleep practice includes the treatment of obstructive and high loop gain apnea, which is complex apnea, in the medically complex patient. Dr. Jonathan Lone, if you would just wave, Jonathan, so people know you, is a board certified in internal medicine, sleep medicine, and lipidology, and is the clinical director at Delta Sleep Center of Long Island, which is in New York. In addition to private practice and frequent lecturing, Dr. Lone currently serves as clinical assistant professor of medicine at Stony Brook University Medical School. He holds two diplomate statuses with the American Board of Internal Medicine, sleep medicine, and internal medicine. Dr. Joel Solis, give everyone a wave, Joel, is a board certified family medicine practitioner in McAllen, Texas. Dr. Solis graduated from the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, and completed a residency at the University of Texas Health Science. He has been in practice for 20 years and also specializes in emergency medicine and emergency services. Dr. Edward Weaver is a professor of otolaryngology, the chief of sleep surgery, and a co-director of the Sleep Center at the University of Washington in Seattle, Washington. He is also a staff surgeon at the Seattle VA Medical Center. He is board certified in otolaryngology and sleep medicine, and he practices a wide range of sleep apnea surgery. He has an active clinical research program studying sleep apnea. Now, each panelist will provide just a brief introduction that includes how long they have been treating their patients with sleep disorders, what percentage of their practice is managing patients with sleep disorders, and how long they have been referring to a dentist to provide oral appliance therapy. Dr. Solis, will you begin, please? Sure, and thank you for that introduction. That was very nice of you. So, I've been in practice 20 years, and we have been working closely as a clinic in collaboration with dentistry for probably about five years, maybe five to six years. As a practice, I would say collectively we have a very diverse practice, but obstructive sleep apnea definitely comprises a very large percentage of what we do, and most of that is undiagnosed, as a lot of you all will agree with. Being from the Rio Grande Valley, if y'all know, we have an obese population, lots of diabetics. So, it's something we've been working on as a community for quite some time to try to recognize this unfortunate underdiagnosed condition. So, if I say we have about, say, 10, 15% of our population with OSA, I would say I'm underestimating by far. It's something that that might be the percentile we currently have under ICD-10, but clearly it's not the percentage that actually represents our patient population. So, there's a lot of work to be done, and that's something I've been working very closely with, with UTRGV, our medical school, and trying to get the residency and the medical school to recognize this earlier and have the curriculum, better review it, and more importantly, start using our colleagues to collaborate care from the beginning and not at this point in my career. Yeah, that's great. Thank you, Dr. Solis. I think as an internist and primary care physician, you're at the kingpin for recognizing this disease, and we can only hope more primary care physicians get involved in the future. Ms. Holzer, can you give us a little summary? So, as Dr. Cohen said, I've been a nurse practitioner for 22, over 22 years, and I've been practicing in the sleep medicine world for over six. My practice is 100% sleep, and it's managing all sleep disorders from obstructive sleep apnea, complex apnea, insomnia, and I actually work and refer people to Dr. Cohen, and we've worked very closely for years, and that's been a pleasure, but I've been referring to sleep apnea dentists since I started in practice. And I think you also have another dental connection, don't you? Yes, my dad is also a dentist, general practice. Okay. All right, Dr. Weaver. Hi, Vicky. Thanks for inviting me to participate. So, I'm an otolaryngologist focusing 100% on sleep apnea surgery, so that's my practice. I've been in practice for 20 years, and my perspective here, I think, is a little different as another specialist who provides what is commonly a secondary treatment for sleep apnea, parallel to my dental colleagues, but there's a lot of overlap and a lot of collaboration. So, I've worked with a sleep dentist or dentists for the full 20 years, so long history of collaborating with folks in my area. My practice is pretty specific related to this background, and that is it's all patients who've had difficulty with CPAP. So, I'm not seeing patients primarily who have snoring, and that I refer to the sleep center. I'm referring all patients who've been diagnosed with sleep apnea, tried CPAP, and have had difficulty of one sort or another. So, it brings a perspective that I think a lot of the sleep dentists share. And then the other part of my background that I think informs this discussion a little bit, at least some of the questions, is my background in clinical epidemiology and outcomes research. Did a research fellowship after my clinical training and master's in public health, and my research is focused on outcomes. How do we measure outcomes? What should we pay attention to in outcomes? And these are ideas that affect my clinical practice. And I think might show up in some of the questions that come out and how I view how we should assess and evaluate our patients and the treatments we're applying. So, thanks again for having me. Oh, it's a pleasure to have you. And Dr. Lowne, not last, but not least at all. So, my name is Jonathan Lowne, and I've been in practice for 22 years. Ouch. And then I was diagnosed with OSA myself about 20 years ago. I've been using CPAP ever since. And I became interested in sleep medicine because of that. Also, I actually was a speaker at one time for individual and provisional. So, I got to cross paths with a lot of great sleep docs. And I do about 40% of my 40, 50% of my practice is sleep medicine. And we do obviously management of OSA, but we also do management of insomnia and RLS and other disorders that cause fragmentation of sleep. And about 10 years ago, I became interested in alternatives to CPAP. And so, I actually initially worked with a couple of dentists and then I settled with my actually personal dentist, who's Dr. Fagenbaum. So, he was my dentist for a number of years. And one day I kind of proposed to him that he should work in sleep dentistry. And he initially didn't have much interest. And then I said, well, why don't you come get some training and work in my office? And he pricked up his ears after that one. And so, we've been working for about seven, eight years together. He works in my office. And I think it's been an incredible opportunity to expand our approach and to also capture many more patients successfully. The other part about that, I'd say is that most physicians, including sleep physicians, are, I think, a little bit initially uncomfortable about the concept of oral appliances. And I do think it takes a little bit of time to get used to, or at least understand what the oral appliance is about. And that collaboration has really afforded me some insights that I would not normally have had without that collaboration. So, I strongly recommend that. And I think we all are sort of on board with that. And I want to thank you all for participating today. Hopefully, we can answer some good questions. Great, great. So, Dr. Lohn, how do you determine who you refer for an oral appliance therapy in your practice? Well, so, for all intents and purposes, I usually will leave it up to the patient, with some exceptions. I definitely, obviously, if the patient is particularly hypoxic, has pretty severe REM hypoxia, I'm a little bit less interested in trying the oral appliance approach. Although, I would say if they have no interest and I can't convince them to use CPAP, then I definitely will use oral appliance therapy. And that's happened on occasion. We actually have a patient who Artie and I collaborated on. And with the oral appliance, we were able to get his HI down. But it was still, his residual HI was about 40. And interestingly, he had actually a lot of central apnea. So, he's on, actually, acetazolamide. And he's done pretty well. He's down, he's now has moderate apnea. But to answer your question, I'd really kind of digress there. But to answer the question, I'd say my major approach is really patient preference, with the exception of hypoxia. And I sort of know that if, in particular, if they have pretty bad REM hypoxia, it means the degenerative process is really not, is really hypoactive during sleep. And it's unlike that I'm going to recover their degree of hypoxia to normal. Although, I mean, obviously, everybody's a snowflake. Well, you know, I mean, I agree with that. I mean, we know in general that oral appliance therapy doesn't increase the oxygen saturation as much as CPAPs. So, that sounds pretty reasonable. How about you, Rena? So, I usually will reserve oral appliance for, if I'm initiating therapy, with someone for, someone who has mild to moderate obstructive sleep apnea. I always give all my new patients, new diagnoses, that option. But like Dr. Weaver, sometimes I get people who have been failing CPAP, and we try to figure other things out. A lot of times I'll also use the oral appliance if someone is totally resistant to trying, even thinking about CPAP. Or if they have mild to moderate apnea, and they've sort of failed, or don't want to go back to try that again. With my population, though, I see a lot of patients with complex apnea, or obstructive, as well as central apnea. And together, we call that complex apnea. And in our practice, we do a lot of CPAP use for that with some alternative therapies. But we'll also use oral appliance plus PAP in those patients, in the complex patients, to lower the disease burden and decrease the instability of the breathing. So we do a lot of combination therapy. Great. Interesting. And how about you, Dr. Weaver? Yeah, so this is an example where my practice, and being selected as it is, I focus on some different factors. So all these patients that I see have all had challenges with CPAP. So in answering this question, I'm focusing on sort of some of the technical details. So obviously, they have to have adequate teeth to anchor the oral appliance device. And that's a quick, a few second screen on the exam. I also assess protrusive capacity. Are they able to jut their jaw forward to any capacity? Some people really can't jut it forward hardly at all. And then the oral appliance doesn't have as much of a chance to be able to have an adequate effect. Occlusion is another important factor, I think, because of the risk of moving teeth with an oral appliance. If a person has class two occlusion, meaning an overbite to start, the oral appliance effect on teeth might actually have a favorable side effect. And the reverse is true with an underbite, so class three bite where they have prominent lower jaw compared to the upper jaw. The oral appliance might exacerbate or exaggerate that effect. So if they have class two occlusion and favorable capacity to protrude, I'm excited about the potential for oral appliance. So you're a surgeon and those are your tools. So do you try to look for a non-surgical approach for these CPAP intolerant patients first? And that's why you're looking at oral appliance therapy. Are you also looking for really favorable surgical markers where you think surgically you may be successful? Yeah. So it's really case by case, Vicki. And I think one of the, for me, fun aspects of sleep surgery is every case is different. And so as Jonathan said, patient preference is a biggie. I mean, if they're not interested in surgery, obviously I'm not going to go into any depth on surgery with them. If they're not interested in oral appliance, I'll talk to them about that as an option, especially if I think it's favorable with these favorable features. Then something else, another piece that I can bring to the table sometimes is I've done say nasal surgery because they're nasally obstructed. I do a sleep endoscopy at the same time. I assess the effect of jaw advancement, a subtle jaw advancement that an oral appliance can easily get. And for some people it has a big effect on that exam and some people it has no effect. And that, that dictates a lot on where, where I place oral appliance in the treatment. So I might treat a nose and come out and say, listen, you should really have oral appliance therapy. Like, I think that has a really high chance to help you. And, and, and I, I take a little different approach than I think some of my sleep medicine colleagues where they rely on the sleep test to dictate that, you know, there's the dogma that mild to moderate sleep apnea is appropriate for oral appliance, but, but I'm going to challenge that notion, Vicki. Well, I'll challenge that clinically because when I get a mild patient and I know it's, it's, you know, it's not an automatic home run. It can be challenging. Yeah. And I would argue the reverse is true too. And here's why that I think that has come to be is if you're looking at as the outcome where you end up with an AHI, it makes sense. If you start with a low AHI, you're likely to end up with a low AHI, but it doesn't necessarily mean you've impacted the patient very much. And so if I have someone with a high AHI that I think has bad disease and I see these favorable factors, I excitedly will recommend an oral appliance and they may not get down to normal, but in a person who can't use CPAP, surgery may or may not be a decent option, but it's certainly invasive and oral appliance I think is going to be a good option. The AHI doesn't even enter the conversation. It's, I think this can really impact your disease. And so this is sort of the whole concept of disease burden. How do we assess it? And so I have the advantage. I have an exam with them asleep, looking what happens when they advance the jaw sometimes. And that gives me advantage to sideline the AHI and focus more on that. So my practice kind of gives me this little bit different perspective. And because of these things, I have close relationship with a number of dentists who I'll readily refer to in these situations where I think the oral appliance is the preferred option of the remaining options. That's great. So Dr. Solis, how often do you end up recommending CPAP therapy in combination with oral appliance therapy? Talked about that earlier today. I was talking with Michael, Dr. Adame. And it seems like that's happening more and more. So my approach from the beginning is considering we're having the discussion for the first time with the patient. That's the most difficult part, just getting them to see that they might have this condition. And I'm excited enough that we actually have some data that I could share with them that, hey, you have a problem. So at that moment, I just tell them, listen, we got options. We have your traditional option, which they've heard of and seen. But then at that moment, I always discuss the oral appliance. And that's where I say, listen, it's not like before. We have options. And I'm going to help you medically to conquer this from other aspects of your health, whether it be weight loss or what have you. So from that very moment, I tell them we have, say, two choices. And I also tell them there's a good chance you might need both. And so I lay the groundwork from that moment because what I don't want for them to do is just take that beeline towards one and think that's going to be all they need. And so I try to tell them that. And I just want them to feel like, OK, I got a few different treatments I can try. It'll be my preference. If I travel, I might want this, or I might want to start with this. So that's my angle. And obviously, I'm coming from a different perspective, not being a sleep specialist, more of just a general practitioner, which I think it's good to have me here because I have a lot of very bright and specialists in the room. But I keep it simple. I'm like, just try something. And they buy into that. Yeah, I agree. And actually, even as a dental practitioner, I kind of from the get-go for many of my patients kind of lead them down that same path of expectation. It's obvious that it's difficult to treat sleep apnea, and that's why there's all these different treatments for it. So if this doesn't work, we're going to go to this. I'm going to send you here. I'm going to do that. So I really appreciate that approach. All right. Dr. Lone, do you have any roadblocks that limit you from prescribing oral appliance therapy? And if you do, what are they? Besides the ones we discussed before in terms of the degree of hypoxia, is that what you're saying? Well, no. I would say just roadblocks at all. Some roadblocks would be the ability to have, for some people, have medical insurance benefits. So we only do, I'd say we basically only do, all our patients are getting oral appliance therapy through medical insurance with almost rare exception. Maybe like one or two in the last seven years haven't had to pay out of pocket. But everybody's getting really their appliance through insurance. I would say that in the interest of time, sometimes I may defer to a CPAP, especially if I know that it's a cardiovascular patient that I'm treating, and they may come in, let's say for a second opinion, or they've already used CPAP. But I do a study on them, and I know they're a high risk. I will tell them right up front, I may say, well, let's do the CPAP right now and see how you do, because maybe I'm delusional about it, but I really do think we do a decent job of managing CPAP. And that's one of the things, unfortunately, you really have to, you have to do a lot of handholding, change masks, change settings. It's a complex process that nobody really teaches you about. But regardless, so if I have a patient that really has an immediate need to be treated, then I might just defer to CPAP, because I know I can turn around CPAP in a week. But that would be a major, it would be one of the major roadblocks. And then the, obviously the, we mentioned before about how many teeth, obviously, they have in their upper lower arch. Obviously, that's an obvious one. But they really don't have many other roadblocks besides what I mentioned before about the degree of hypoxia. I'm gonna guess, go ahead. No, I was just gonna say sometimes, but I'm always curious about it when patients come in and they say, well, I had CPAP 10 years ago and I hated it. Well, obviously, things like anything else, obviously, oral appliances change all the time, and so do CPAP and CPAP masks. So it really depends on their other comorbidities, whether I'm gonna be aggressive about pushing CPAP or not. But like I said, if their preference is for oral appliance, and I would honor that, as long as, like I said, they don't have severe hypoxia. And even if they did, and I had nothing else to treat, I'd much rather do an oral appliance than obviously send them home with nothing. And I think that's part of the problem in sleep physicians in general have made this cookie cutter approach that it's CPAP or die. I'm gonna guess, Rena, because I know working with you, that you have some other roadblocks that may be present in your practice, correct? Usually, it's the insurance companies. That's my biggest roadblock. Some insurance companies aren't covering oral appliance. And of course, working with you, I know Medicare is one, you see a lot of patients with Medicare, and they're just, I won't use an expletive deleted tonight, but man, is it infuriating with that five-year rule, same and similar, it's not right. But I think for a lot of your patients that don't have the funds, it could be a roadblock for them. And also because we use so much combination therapy, what you're saying with the five-year similar stuff is that they'll only pay for one treatment. So if you have them on PAP, and then you wanna add oral appliance, you have to wait the five years before Medicare will pay for the oral appliance. Right, I actually let that slip my mind, but before they started instituting that five-year rule, we used to do a lot more combination therapy with your practice. I have to say, we haven't had any experience specifically, but I know there's other practices that actually have been able to get that covered. Because they really are, especially if you're talking about disease, if you're talking about resolution. So there are approaches to that. It may be difficult, you have to fight it, but if you're talking about improvement in patient's condition overall, that's really the argument you can make. It's like saying, well, I'm not gonna be able to use two medicines for hypertension. Exactly, that's right. I'll tell you in my experience, if a patient has some funds and they get to me, I'm usually able to let them see the value in it. But there are some patients that I know won't even leave Rena's office to come over. And it really, I can't, it's not our duty or to look at someone's finances. But if you can give any of us or me any information on how other dentists have been able to let, have Medicare pay for an oral appliance with combination therapy within the five-year rule, that would be awesome. Because there's tons of patients in Boston anyways that need to be treated that way. Vickie? Just to comment, another roadblock that, again, from where I'm at is, since they've rarely been into y'all's office, or let's say they haven't been there just yet, I really try to do my best to prepare them. Because their mindset is already blown away with the fact that now I'm gonna have to wear this apparatus or you're gonna put this in my mouth, they're lost. So I really try to bring them back in and I say, listen, this is a complex process, we just brought that up. I do my best to prepare them that this will take time. This is not a one visit, you're done. This will be at least two, three months of adjustments or whether it be the mask, et cetera. My biggest help is trying to prepare them for the road they're about to embark on. This is not one drug for blood pressure, I'll see you back in a few weeks and we got it fixed. So that's where I think that's another roadblock that we as primary care have to be better in prepping them for the next step. Because if not, they will not attend even if the insurance covers it and the compliance is gone. So it's really prepping them for what's in store. That's a good point. Do you have anything to say, Dr. Weaver? You know, the roadblock that I experienced here, I'm sure some places people experience a roadblock, they just don't have dentists who are interested and I'm fortunate, I'm in an environment where I have a number of dentists who are very interested and really do a great job at it. It's insurance. I would say, message to, I assume our audience is largely dentists. If you can build into your system, helping patients navigate the insurance, that to me is a roadblock I face. So some of the sleep dentist providers are excellent sleep dentists, but their offices just aren't good at helping the patients navigate that. We in medicine navigate in surgery, we navigate that every day. So, I mean, we're skilled at it, we meaning the staff. So that would be a barrier that your offices might be able to help remove for patients. Now, some insurances just won't cover it. But some will, you just have to know how to navigate. Yeah, no, I agree, Dr. Weaver. Actually, when dentists are first learning how to treat sleep apnea, the didactics are not that hard. I mean, you have to study and learn them and we all know how to make a plastic appliance and you can figure out what to do with it. But the medical insurance is the killer for most people, really is, that's what you're experiencing. Yeah, it's foreign to dental providers. And Vicki, I would say for you, specifically on the Medicare thing, you can influence the policy. You're not gonna probably succeed on a case-by-case basis, but if you can get involved in discussions on the people who write the policies, you can influence that. Now, you have to have a cogent case and it takes a long time. I did that with surgery and Medicare. I mean, it took me about three years to even get in the door. And then once I figured out that I was legitimate and I was presenting, I wasn't just trying to sell surgery. This is good, this isn't good. I spent several hours with the person and we went over and we rewrote the whole policy. That's great. So what we'll do is Rena, myself and you will get together at one point and you'll give us some insight in how you did it. And Rena, you've got, your practice has a ton of patients that need it. I can give you the insight right now. You just have to get a foot in the door and that's the hard part. Okay. I mean, persistence, but in some places it'll be more receptive than others. But I mean, that's a long vision, obviously. That's not what you're going to do day to day, but good luck. Thank you. Well, it needs to be done. Actually, I actually did help Medicare a bit. I did help them open up to digital scanning. That was a bit of an issue, but we got it done. So it can be done, right? We have to move on a little bit though. So how do you all like to determine if oral appliance therapy is working? Like what's your preferred method? You know, do you like titration studies? Do you order titration studies? Do you order home sleep tests? Would you prefer to have multiple home sleep tests? And then of course, as dentists, everybody wants to know like, especially since the AASM at one point said dentists should never touch a home sleep test. How do you feel if you're collaborating dentists uses some home sleep tests or HRPOs interim to try to get the best mandibular advancement before they send them back to you? So who wants to start on that one? I'll start on that. So unfortunately my initial experience in this field was no follow-up, no repeat testing, no titration, which really kind of turned me off initially to oral appliances. I didn't mention that from the outset, but so I'm a-okay with the dentist doing an HST. If their intent is to potentially adjust the patient's oral appliance or the level protrusion to achieve theoretically the maximum reduction in HI or improvement in degree of hypoxia, then I'm all for that. Because that also means that dentist really gives a you know what a lot, that that's what their interest is. And I think unfortunately it's like anything else. I don't think there's been enough follow-up. So if I'm collaborating with a dentist and they're looking to do that, that's awesome. The only thing I would argue is that I would like to at least have my hands on the initial study and on the theoretically on the final study because there's a lot that you can glean from obviously from any sleep study and HSTs included that I think are sometimes beyond the scope of at least the training for most sleep dentists. I agree. So that's I think part of the whole collaboration. I'm okay with that. But every sleep dentist may have it differently. We actually dabbled in Matrix and I really loved the concept initially. We kind of don't really do it much anymore. And not because we didn't like it, it was more because we didn't get paid for it, only from Medicare. But the concept I think is great. And there's obviously a number of different approaches. Even we mentioned about using DICE for oral appliance therapy. That'd be very cool if you can do that. But I'm okay with whatever approach. I usually would say that in my experience, you need to get pretty close to maximal protrusion or at least to 75% of maximal protrusion before you really start to see things. I know there's anecdotal studies that show that that's not necessarily true. And obviously that can be the case with each individual patient. But I think for the most part, we definitely want to achieve that. And then at the end there, I definitely want some kind of follow up HST. In our practice in particular, when Artie and I are working together, we do a lot of HST testing to kind of see where we are. I just, I mean, I have a very low threshold for doing HST in my practice. So I might be different in that regard. But like I said, I think if a sleep dentist wants to do the HST, that's awesome. Let them do that and let them titrate any way they want. But then send them to you at the end. Maybe you would like to do a PSG on them then. Is that what I'm hearing? Yeah, either a PSG or at least let me get my hands on that HST and to see where we're at. And because obviously there's a ton of stuff that you can get out of the HST or not get out of the HST. And that's, you want to be obviously very cautious about that. So I do, I'm sorry, I do interps for a lot of other offices and we get studies and they're complete nonsense. And if you went by what the HI was on that study, especially when there's like maybe two hours of decent sleep, if that, it's really hard to ascertain that. And I think that kind of subtlety is not necessarily, it's something that probably is going to be missed by most sleep dentists, not to be impertinent to anybody, but that's why I think you really should be collaborating. And it's also, it's a nice symbiosis anyway. I think that's, that ends up kind of fostering a good relationship. If I can make a recommendation, I would say that most sleep physicians, I would assume have no discomfort with doing, retesting on their patients. I can't imagine why they would after oral appliance therapy. So I think it works both ways, but to answer the question, I'm okay with them titrating any way they want, as long as the patient obviously is doing okay. My big concern is sleep dentists getting a patient, having a diagnosis, fabricating an oral appliance and then never doing any retesting. And say, well, how are you doing sleeping? And they say, oh, I'm dreaming now. And they say, okay, that's great. That means you're having REM sleep and everything's hunky dory and they don't really reassess that. And that's the problem, because we know there's lots of things that improve sleep quality and don't necessarily touch AHI. So for example, if I give you Ambien, if I give you a Zolpidem, I can improve your sleep quality. And I can give you Lunesta or Zapoclon, I'll improve your sleep quality, like tremendously, but I will not affect your AHI. So that's the major caveat I'd say, that you shouldn't assume that everything's better just because they're sleeping better. That's a great thing and I'm happy about that. But it shouldn't be the be all end all. I would say one of the major things for dentists that wanna have more interaction and more collaboration with their treating physicians is don't try to be a boomerang dentist, which means if you have a suspicion that they have sleep apnea and you send them to a physician for a consultation, don't expect to automatically get that patient back for an oral appliance. Expect that that patient will go there and get treated appropriately. And that may mean an oral appliance or it may mean an oral appliance after they fail CPAP. But one of the other things I wanna also ask you is any of you doing titration PSGs with an oral appliance where you will awaken the patient during the PSG, have them move it forward, go back to sleep like a CPAP titration? So we used to do that. We basically don't do that anymore. And I found that to be problematic. I mean, I think it's problematic in that you end up fragmenting sleep more than you need to. And then you end up with kind of sort of crappy data. But by the way, I just wanna say one other thing. I would really be surprised if the ASM, they should have made it maybe like a caveat about that. I'm sure most of the committee members, if they knew that the intention of the sleep dentist was not to like go rogue here, was to actually manage the patient better and then ultimately turn it back to the sleep physician. I can't imagine why anybody would argue with that. But I think the concern is that somebody is gonna go rogue. Really, that's why they probably made that blanket statement. But I'm sorry, I didn't let anybody else. This is all I think really appropriate. And I would think, I hope it's with everyone's interest here. So Vicky and I have a very collaborative relationship and she'll email me about, I think this patient is ready to have a study. I think that maybe it would be a better, a good idea for this particular patient to do a PSG titration. We don't do them on everybody, but we do them on some patients. And Vicky, sometimes you even come to the lab to do it. Right? Yeah, I have. But just like Dr. Long said, it has to be somebody that I really feel and that you feel can fall back to sleep. Right, right. Right. Yeah, but we'll do a PSG, we'll do an HST, something to just show that the hypoxia burden is better and yes, document the AHI is lower. But again, looking at everything, all outcomes meaning the patient feels better and the numbers look better. And I think what's important, and please everyone, let me know if you agree, but as a treating dentist, I might not always put them out to maximum protrusion. I may put them out to where they're feeling a lot better, their symptoms are great, or there might be some people that don't have symptoms, but my expectation is I send them back, you're gonna do a sleep study. And you know that if it doesn't meet your expectations and it's not optimal, you're gonna throw them back to me and we're gonna keep working. How about you Joel and you Ed, how does this fit into your practices? I don't get involved in these nuts and bolts, but I agree with Jonathan. I think it's a good idea to do some home sleep testing. You know, you might even be able to do multiple nights, especially if you're tweaking things. You definitely don't wanna just go to maximum protrusion, because as you know, Vicki, and probably most of your audience knows, that's where you get into the most problems with the devices causing side effects. So finding that sweet spot is an art, but sure, use technology to help you. I agree completely also with, ultimately when you think you're settled, you know, just confirm, see where you are. And it may not be perfect and that's fine. I mean, if it's enough improvement, you know. So, yeah, I'm in favor of doing, I'm in favor of kind of everything that's been said. Okay, how does it work with your practice, Joel? I know you work pretty tightly with a dentist. Yeah, you know, well, not many actually, and, but work very comfortably with them. And a lot of times I leave it up to them and they'll take it on and we will collaborate as they find the adjustment is where it needs to be. And then we'll decide on doing the home sleep test as an assessment of where we are, whether AHI or subjectively, and then we'll discuss together. Typically we, it sounds crazy, but we meet quarterly, Michael and I, and we just have a simple round table or now we get on telehealth or Zoom and we talk about our patient population. And that's worked real good for us just to see what we might wanna do next. That's something I've enjoyed, I think, with this ability, it's something I see our clinic doing more of with him. So that way we have an integrative approach, even though he's not in the office, this allows for us to discuss the five or 10 patients we might have and two or three that are actively being adjusted. So that's something that works out well between us. Great. One thing I just wanted to say that one of the reasons, I mean, we don't have great proof of this, but the only real evidence that we have is actually from the outcome evidence is really from the SAVE trial. So if you think about the SAVE trial in terms of compliance, obviously it was the issue, but in terms of the ability to titrate somebody down, we got the, in the SAVE trial, the AHI was reduced down below 10. So that's one of the reasons why, and we do have an outcome from that, even though it's post hoc analysis, we do have a 48% reduction in stroke in that study. Well, it's a subgroup analysis, excuse me. But so that's really one of the reasons why I go by that, that whole dictum that I still want the AHI as low as I possibly can get it. Anyway. Yeah, no, that's great. So I'm gonna go back to something that actually, Dr. Weaver, you started on kind of in the beginning, you started getting into it, which is a great thing. I wanna know what you, how do you determine success? What parameters do you use? Is it only AHI? Is it NADER? Is it ODI? Is it just symptomatic improvement? What's important to you in your practice? If you don't mind, Vicki, I'd like to take one minute to give a little mini lecture because this is, I give hour long lectures on this question sometimes, including yesterday, last night to an Australian conference. It wasn't an hour. That one was only 30 minutes. I agree with Jonathan. The physiologic effect of the treatment is important, but I'm gonna challenge Jonathan's thought that AHI is the way to, the best way to assess it. It's the way we most commonly assess it, but I'm not necessarily, it's not clear that it's the best way. In fact, there's data that suggests it's not the best way. But I wanna step back and take a bigger picture of you first. What are we trying to do when we're treating these patients? And especially in a patient who's failed CPAP, what are we trying to do? And I'd argue there's two things we're trying to do. We're trying to improve the patient's day-to-day life, which is usually what concerns the patients most. Snoring, most common. Sleepiness, common. A whole host of other potential symptoms. That's one whole category. The other thing we're trying to do is improve their health. And that's what Jonathan was alluding to. And that's reflected in the polysomnography of the home sleep apnea test. Interestingly, the sleep test tells us nothing about the day-to-day. This has been well-documented with multiple studies. In patients who present for clinical care, the sleep test has zero correlation with symptoms. Meaning, some people have really severe sleep apnea and very low symptoms. Some people have very mild sleep apnea on sleep tests and have bad symptoms and every combination in between. So you have to assess that independently. So how do I judge success? It's largely the same way I judge surgery success. If I can get the patient's symptoms and day-to-day life controlled, and get them down to the mild range of sleep apnea, however you define that, I'm satisfied. The reason why is if their symptoms are controlled, you've addressed that whole element of disease burden. If you get rid of mild disease, the epidemiologic data really suggests you've relieved the health burden. Okay, thank you for answering that. I just want to point out that I think you're both right, because this is your practice, right? And this is what you practice. And I think the important part for dentists to know is understand your practitioner, understand the managing physician, all right? We are not really, we're helping to manage a disease, but the physician is the managing physician. And so I would encourage everyone to understand and know the physicians that they're working with, so they know and understand what their philosophies are and the treatment avenues and successes of what is important to them. So that's a great contrast, and I think it's good for dentists to understand. Can I follow up on that, Vicki? Yes. I agree with you completely. And one of the challenges I face, and I think my sleep dentist colleagues face also, is sometimes sleep physicians get attached to the HI because they're looking at HI's all day long. It's hard not to be attached to that. But sometimes it's not realistic to get normal HI with our treatments. And that's not necessarily the only measure of success. And so being able to have a conversation with your sleep medicine provider of, listen, I don't think this therapy is gonna normalize the HI, but I do think we can really help this person's disease burden in other ways. And I think in this patient, that's gonna be valuable. Those are important questions. Those are important conversations. And so having the relationship is key, just like you alluded to. Right, right. If I can jump in here, Vicki. I think also, as a nurse practitioner, and I think, Joel, as a family practice person, making sure you understand what the patient's goals are too. Right, I think that's a big piece. Are they satisfied? Have their goals been met? And I think that's a piece of what you were talking about, Ed. Yeah, you know, that's interesting because I will have some patients that come in and go, you know, my goal is to get a low HI because I have a heart problem. You know, and they really do. They're looking at the physiological parameters and there are some patients that just want to feel better. Sometimes we leave it to the patient to perhaps, we'll refer them over and we expect they're going to carry over their chart with them. And that never happens. What we need to do a better job of is from my clinic, we're trying hard to, as we send the referral, we list carefully the diagnoses that they have, the chronic and acute, and we need to delineate what are they having subjectively at that moment. So that way the dentist understands, listen, here are the chronic diseases. Obviously there's blood pressure that he's struggling with, two, three meds, the obesity, the diabetes. It might be someone with, we talked about earlier, low testosterone at our previous discussion. There's a wide array of medical conditions that is important for us to share. And that sometimes never gets through. And then the dentist will start their own history, but the patient won't necessarily remember everything. So there's a gap of some very critical cardiovascular, other disease states that is imperative that I get fixed or the subjective concerns that the patient has. So that's where I think from the very beginning, we need to do a better job in providing that to you all. And that's something I'm working very hard on from our side. Well, maybe I'm interjecting myself too much during this panel, but that's a frustration as a dentist is that we have no platform to share everything, right? I'm not on Epic. I can't see Rena's notes. hire people to spend hours and hours and weeks trying to get that documentation and you're right collaboration would be so much better if we were able to not just talk to each other but we we don't always have the time for that but at least to get to get people's people's notes. I'll tell you how we do it. We have clinic liaisons. So I keep using Michael as an example because that's what I've collaborated for five years. We have a clinic liaison. He has someone designated in his office to communicate with my clinical liaison and they go one-to-one. Every referral goes to that same person directly to that person. All the notes and all the the screening data everything makes they make sure they receive it plus they also start the process of insurance so that they start finding out to advise the patient what are those gaps that might exist but we at least try to get them to have the appointment and review the cost with them. So having clinic liaisons or that has worked great for us. It sounds like it does. You know Vicki I just want to make one comment back to with with what Ed was saying. The reason why I brought up that H.I. I have to say it's really not I don't want people to get the wrong idea. It's really not the H.I. that I care about. It's really the way we generate the H.I. is really in my office in particular we do HST and we do actually it's really looking at adrenergic tone more than anything and you're absolutely right Ed about the association between H.I. and for example the Epworth. It's a scattergram which has always been kind of a mystery to people because they assume if they have severe apnea they should be very sleepy and I think that's also one of the obstacles that we have in some patients that they come in they think they can't have a severe degree of sleep apnea because they aren't necessarily they don't necessarily have daytime sleep in this and that's a bizarre component and a lot of actually outcome studies that some of these patients weren't sleeping. But what I was going to say is that adrenergic tone matters a lot because we know that other entities that fragment sleep like RLS is strongly associated with hypertension and for example narcolepsy is strongly associated with cardiovascular increased cardiovascular risk has nothing to do with that. OSA has to do with the fact that their sleep is fragmented. So I totally agree with you Ed that we need other measures but right now that's about the only one we have hopefully. And I want to make clear I think the measures of the physiology are important it's just it's not the only thing and it's a big debate that's way beyond what this panel should be of how should we measure that like which things on the sleep test should we be paying attention to that's a complicated conversation that's not got a clear answer. But yeah I think we're on agreement you know the physiologic testing is really important follow up on that but also paying attention as Rena said to what's bothering the person that's also very important and those are the ways I judge success Vicki is did we succeed in those two things and it doesn't have to be perfect to have success. Thank you. I this is amazing I love all of you and I would love to have a clinic with all of you with me to treat people and and I could go on talking all day but not everybody can so I've got we've got to answer some questions that have come in and one of them is is there's someone is one of our members is really frustrated because they're they're getting referrals for oral appliances from the physician and then when they send somehow they're getting back to the office and it's the NPS that are seeing them and the PAs and it sounds like the NPS and the PAs aren't very educated yet in oral appliance therapy and they're just saying hey it failed and putting them right on CPAP so my question for them is how would you how would you like a dentist to approach you to talk to you about that remember back Rena maybe when you you know when you didn't know that much about oral appliance therapy how how would that interact how would you like that interaction to go and how would it be fruitful I think picking up the phone and talking is you know it's difficult because we all have very busy lives and clinic schedules but I think that open communication is really the most key you know if if I couldn't just email Vicki about a patient or she couldn't just email me we would have a lot of problems but you know NPS and PAs do have quite a bit of training and if they're you know if they should have the knowledge base to work with you on this do you think most PAs and NPS would feel like they didn't want to be approached I think the NPS in my practice there are about five of us now I think we are all open to and really want collaboration with anyone that we're working with great good Somebody, one question is, what is your take on the recent AADSM? So the AADSM, I think you covered this really, the AADSM recently came out with a statement that says dentists should be able to do sleep testing. And I think, you know, Dr. Lone heartily agreed with yes, do calibration testing, not final testing. He wants to do that or at least see it. And it's not, trust me, it's not because they feel like they have to make money on sleep tests. That's what they need to do, but they, they want to make sure they're getting the data that they need. I, I'm going to guess everybody, does everybody agree with that, that that's okay for dentists to do some interim calibration testing? Good. A lot of those are on there. Somebody asked me if I titrate before I send the patient back to the sleep doctor, and usually not, but sometimes I do. Because what do I have? I don't want to give patient an HSAT. I have those in my office, but like Dr. Lowen says, what use of it if it's just a computer graded test? It's really not that accurate. So I don't want to do that. If I have a patient who has a huge AHI and I put them in an appliance and they're not very far forward and they go, I feel great, I'm going to send them home with an HRPO because I don't think they're really that great, and I want to get some feedback, and then maybe I'll do some multiple nights. And I guess part of my issue is I see I have a big practice with a lot of patients and just technically it would be difficult for me to do these on every patient. So I'll get them to a point of subjective relief, and then I'll send them back to do a follow-up sleep test. And based on those results, I'll look at the report, you need to come in, we need to move farther forward, or we'll keep working on that. Vicki, can I piggyback on that one? Yes, absolutely. I see that sometimes, the same thing with surgery. I do nasal surgery, not expecting it to have a great result, and the patient comes back and says, I feel great. I don't normally get sleep tests after nasal surgery, but I will in exactly that case, because I've already accomplished half of the goal, which is addressing the symptoms. And there's a chance, maybe an outside chance, that that limited advancement that you did satisfied the physiologic goal too, and you should stop there. And so I agree completely. That's a time when you should do a test when you weren't expecting that you would be doing a test yet. Yeah. Thank you. Thank you. Someone asked, Dr. Lohn, how do you feel about telehealth doctors reading HSATs? A doctor who's never maybe seen the patient before? That's coming to me, you're saying? You're asking me? Well, yes, I'm asking you, because someone directed the question to you. It says, Dr. Lohn, how do you feel? We definitely do that. We have, you know, I feel okay with that, especially because, I mean, it'd be me in particular than somebody else, but- Let me rephrase it. Let me rephrase it, because I think that this is the more interesting question, and maybe what it was supposed to be. How do you feel about like a patient just doing, like never going into an office, just signing up online for an HSAT with a doctor? So that's obviously where this is like, I'm going to toot my own horn a little bit, but I think, unfortunately, I've seen those reports, and I don't think they, first of all, I don't think they have any vested interest in really looking at the whole gestalt of the patient. I mean, ideally, it's always better to see the patient, and we definitely try to do that. There's plenty of patients who we actually do HST for, for other, you know, for dentists, and we don't necessarily see the patient, but the recommendations they usually make, I think, are kind of covering the basis of what may be, you know, potentially missed. So I think I do, in particular, in my practice, I think we do a very thorough job of doing that, with even, you know, being pretty demonstrative about how much limitation there may be in an HST, and what our suggestions are. But for the most part, I'm not a big fan of that, because I think that's just poor medicine. And the dentists that I may work with, who I'm doing interps for, those dentists, I, you know, I trust their management also, that they're, they're not, again, they're not going to go rogue here. But so I think that's a silly idea. I don't know really why that has to be done. And if I may, if I may, maybe I understood the question a little differently. But with telehealth, and some of these insurance companies that will allow you to use your Teladoc for a particular problem, and you might call in and inquire, or you just go through that, or maybe even with your established doc, I doubt that's the question, though. I'm not for just ordering it, without having a formal visit, and the full history and physical, and going through what the problems are, are at that moment in time. Telehealth is great for a particular patient, and a particular problem. But OSA is a monster. It has tentacles in every system. It needs to be treated with with that care and timeframe to get it right. So we cannot treat it very loose and just have someone sign up and get something done and carry that out on their own. Well, you know, I agree with that. And, you know, I don't know how you can rule out, there's lots of lots of other sleep disorders, right? But I will tell you that I treat a few epidemiologists, and they're like, yeah, I mean, if you if you just do telehealth and give people sleep studies, you'll get more people treated. So from that perspective, it's a little interesting, right, Joel? Yeah, it is. But then I'll end up still seeing them later with some other problem, and I got to backtrack and fix it. Well, sorry, but yeah, I'm on your camp. I just I just thought I'd throw throw that in there as an opposing. I'd like to challenge that one, too. It's true. You might get more people diagnosed, you probably get fewer people treated. And the reason why is the early experience with treatment has a long has a potentially big effect on the long term effectiveness of the treatment. And so having pop up, you know, you throw a test at people, they never see anyone, okay, you should use CPAP to get no guidance on it. And so like Jonathan was saying, you have to have careful guidance, they fail it, and then they just blow off the whole thing. And then they see Joel five years later, and he has to go backtrack on everything. So it's not so simple. Technically, it's that simple. Clinically, it's not that simple. And this is way beyond the scope of any one of us individual specialists, this is a population level challenge. No, but you bring up a great point there. And that is that, like a patient who comes in with a, you know, an upward sleepiness score of 16, the likelihood that they have only OSA is actually pretty small. And the likelihood that they have potentially have, you know, some other syndrome that's causing hypersomnia is very high. So that is obviously a major caveat, because obviously, everything that, you know, causes sleepiness is an OSA. And obviously, like in the case of narcolepsy, you mentioned before, that, you know, patients can have both. There's plenty of large percentage of narcoleptic patients have underlying OSA. So at least 40% of them. So you're bringing up a great point at all of your, I mean, you know, part of why I love sleep medicine is it's, it's fascinating. There's just so many legs to it, and so many things that, that are involved, and I'm going to throw it there. Just to go back to the question about AHI, blah, blah, blah, but how about, not that it's blah, blah, blah, but how about sleep fragmentation too? I mean, there are some people that really believe that just a tremendous amount of sleep fragmentation does a lot of damage as well. You know, that's what I was saying. The evidence is that if sleep fragmentation you get from RLS, for example, is strongly associated with hypertension. The sleep fragmentation associated with narcolepsy, I mean, it's something you don't think about in narcolepsy, but what the original pentad of narcolepsy, one of the components was sleep fragmentation. So sleep fragmentation definitely is probably one of the main reasons why narcoleptic patients have much higher cardiovascular risk. So you're right. I mean, there's lots of things that can fragment sleep, and that's not necessarily good, especially if it leads to increased adrenergic release or tone. And I think that's partly what goes back to just getting a blind study and not seeing the patient. You're not getting the picture. You really need to know when they're going to sleep. How long is it taking them to fall asleep? How many times did they wake up during the night? You know, looking at the medical history, looking at the whole person, everything that snores is not apnea. Everything that's tired is not apnea. That's right. Okay. I'm going to give you one more question just to answer. We have so many questions that we will not be able to answer all of them, unfortunately. But have you experienced, with Dr. Remmer, the Matrix Plus system? So Dr. Lowell, I think you used to do your Matrix in lab PSGs. Have you used the Matrix Plus with the HSATs? No, we haven't. No. So somebody asked. That's an answer. That's fine. Personally, you know, I think it can, number one, it's an HSAT, so it's the same problem as somebody awake or asleep. It becomes laborious to do, and you have to have a lot of them to do. And I'm waiting for one that goes on to any appliance. Yeah. I know. I've heard you say that in the past, and that's a good point. I mean, one caveat I would say about the Matrix that we learned was that, you know, the original algorithm was really that you wanted REM supine. You wanted, you know, one apnea or less, or less than two hot pops. The problem is that's not really how we titrate with CPAP. We titrate CPAP, believe it or not, to eliminate rares and snoring. So that was one of the original obstacles, or not obstacles, just the, you know, caveats I'd say about doing Matrix studies, and we learned pretty quickly that you just can't titrate to that. And that's what we did, actually. We'd say, oh, we found the protrusive position, we're great, and then the patient would come back and say, I'm still snoring. You know, maybe my HI is better, but I'm still snoring. And so you learn it, obviously, the hard way, that you really obviously want to titrate to more than that. But I haven't, I really don't have any experience, so I don't want to comment on the Matrix Plus. But that was an interesting answer. I can tell you for myself, and we did this in practice, I could go on and on and on, because I really enjoy talking to all of you, and it's so informative, and it's invigorating. But we actually do have a time limit, and some people may need to do things. So I just want to tell everyone who's been a participant, thank you very much for your questions. We're really sorry that we ran out of time. But they are noted, and they're saved so we can address them by selecting topics for future webinars or meetings. I certainly hope that this has been interesting for everyone watching. I think that, you know, the major message is get to meet your doctors, understand their practitioners, looking for the best care for their patients, you're looking for the best care for your patients, and find a way that you can do that together with them.

collaborating with referring providers

treating sleep disorders

oral appliances

patient preferences

insurance coverage

healthcare providers

challenges in treating sleep disorders

success of oral appliance therapy

telehealth

home sleep tests