Welcome, I'm Rubina Winn, moderator for this evening's webinar on managing long-term OAT users. I'm joined with our speaker, Dr. Alan Blanton. The AADSM does not endorse any services, products, devices, or appliances. The use, mention, or depiction of any service, product, device, or appliance during this webinar should not be interpreted as an endorsement, recommendation, or preference by the AADSM. Any opinions expressed or communicated regarding any product, device, or appliance during the webinar is solely the opinion of the individual expressing or communicating that opinion and not of the AADSM. Whenever possible, presentations should be supported by evidence. In instances where evidence is lacking, speakers have been asked to verbally disclose that their presentation is case-based or based on clinical experiences so that you can use independent clinical judgment to make decisions for your practice and patients. And now, I will turn it over to Dr. Blanton. Okay, great. Thank you. Hello, everybody. I was just checking to see, I figured that tonight there may be only like three people viewing this, but I saw it was over 70, so that's great. I hope everybody's doing well. I am going to talk a little bit about managing long-term oral appliance therapy patients. And by long-term oral appliance therapy use, we're talking about the period of time after we've done the initial delivery and what we call the short-term, the initial follow-ups with the patient to get them accommodated and adjusted to the appliance to what we subjectively feel like is their maximum efficacy or effectiveness of the appliance. So we're talking about that period after the delivery and the 90-day follow-up. As Dr. Wendt said, I'm Dr. Alan Blanton, I practice in Tennessee. My practice right now is dedicated solely to dental sleep medicine patients, oral appliance therapy patients for sleep-related disordered breathing, and orophacial pain or TMD patients, where we end up finding that a lot of the patients that we see for orophacial pain are in fact sleep disordered breathing patients and their orophacial pain is related to their airway. So just a quick caveat, if you're not seen or you don't feel comfortable in the realm of orophacial pain, it's something that you really ought to look into because like I said, a lot of these patients with joint and myalgia of masticatory muscles and the whole TMJ complex will actually result in patients being sleep patients, that's the underlying problem. So I don't have any conflicts of interest to disclose. I don't make any money off of anything. So we'll go into the objectives. What I'd like to go over is for all of the participants to, after this presentation, to appreciate the critical nature of long-term management for these patients, what protocols are in place for long-term management, how to critically evaluate long-term follow-up appointments and the patients for any problems, and to identify those kind of changes that we need to look for that may impact patient outcomes. So we'll get into, let me move this out of the way, we'll get into the critical nature of oral appliance long-term management. It's important and we all understand, I think, that structural sleep apnea is a chronic, progressive, potentially fatal disorder and it needs a lifetime of multidisciplinary management, both from the dentist who's providing the oral appliance therapy and the sleep physician or nurse practitioner, whoever is managing the sleep disorder breathing issue. We want to look at the risk factors for OSA that can worsen over time and we want to look at those guidelines and protocols that we have in place. So the 2015 guidelines established by both the Academy of Sleep Medicine and the Academy of Dental Sleep Medicine, we all should be very familiar with this, is just that qualified dentists provide the oversight, that no follow-up is not recommended. There are potential side effects, dental related side effects, that we need to be aware of. And they also suggest the sleep physicians, qualified dentists, instruct the adult patients' treatment with oral appliances for obstructive sleep apnea to return for those periodic visits so that we can do the follow-up. The long-term follow-up intervals everybody should be aware of. After the initial delivery of the appliance and we've gone through the 90 days of adjustments and accommodation to the appliance and trying to subjectively, or in some cases objectively, make the appliance or titrate or calibrate the appliance to its maximum effectiveness, that we should see the patients again six months after delivery and then six months after that or a year after delivery of the appliance. And then we see them on an, recommended to see them on an annual basis. What we do at those follow-up appointments is we obviously want to verify the effectiveness of the occlusion of the patient because there are potential dental changes that could occur from the use of mandibular advancement devices. We want to check that structural integrity of the appliance itself. We follow up on ensuring that there's a resolution of symptoms. The subjective symptoms of snoring, daytime sleepiness, sleep efficiency, you know, the patient's feeling like they have restorative sleep. We want to definitely inquire about the patient's comfort and adherence to therapy. A lot of times a bed partner evaluation or survey can give us a lot of information about how well the patient themselves are doing with the appliance therapy. And we definitely want to screen for any possible side effects. A couple of the things that we'll definitely look at and question about as we're working with the patient for the long-term is how is their sleep? You know, the whole realm of sleep itself. How effective, how restorative is it? How well are they sleeping? Blood pressure is a great indication because we want to take our blood pressure during our vitals and our objective follow-up with the patients because we would love to see blood pressures or average blood reducing over time. Many patients, this happens a lot, that once a patient starts to sleep well, they have the energy level, they have the cortisol regulation going, everything has improved in their total systems and metabolism, that they can see weight changes, particularly decreases in weight. You have to be concerned about also increases in weight and how that affects the outcome for these patients and any risk factors. Are they doing things now that they, are they drinking more? Are they smoking? Has anything changed for them in their behaviors over time? I put this in because Dr. Braga asked me to remember that just, I'm going to be talking about compliance with therapy and the new word that is being used a lot now is adherence. So, compliance equals adherence. So, as you hear me talk about compliance, if you ever run across adherence to oral appliance therapy, we're talking about the same animal. So, how do we determine if we got adequate compliance with oral appliance therapy? Well, a fully compliant patient, in my practice, a fully compliant patient is somebody that uses their appliance every night, but we need to realize that that's, there are going to be times when patients can't or won't, don't choose to use it every night, but fully compliant would be defined as oral appliance usage for at least 80% of the nights for greater than five nights a week, just as there's a range of time for pap therapy being compliant. There's also a term that you'll hear run across that the patient is improving over time, that they're getting better. Sometimes patients struggle initially after delivery of an oral appliance with being adherent or compliant with the therapy. And then a non-compliant patient is a patient that is not wearing the appliance. The definition is one year of non-compliant with any component of the definition where they're not wearing the appliance for the appropriate amount of time or nights and they're not improving. So, that would be a non-compliant patient. We want to stress to the patients when we're talking to them, and this, when we talk to the patient, we want to be talking from the very beginning. I mean, before we ever make the appliance, about what we're hoping to achieve with the patient and what their responsibilities are. We'd like to see the patients sleeping at least seven hours a night with the appliance and they're practicing proper oral hygiene. I mean, not wall hygiene, my gosh, I hadn't done general dentistry in two or three years, but proper sleep hygiene. Sleep hygiene, no, being the room cool, dark, not doing screens right up to the time of going to bed, doing all the things that promote good sleep with the patients. And then you want to document. It's always about documentation. You want to document when the patients are being fully compliant or if they're improving over time, or if this is a non-compliant patient, or even if it's a patient that has given up on therapy and is inactive. How do we motivate compliance? Well, again, if you go back to the very beginning of treatment, it's something that you want to emphasize with your patients from the very beginning that what you basically are doing is you're the health care provider that is responsible for managing and doing follow-up and just managing the appliance itself. You as the sleep dentist are not the person that's responsible for their sleep disorder breathing. It's something that I emphasize with patients all the time from the very beginning is, look, this is a coordinated effort between me and your sleep physician or nurse practitioner, whoever has referred the patient to me for the sleep disorder breathing, that they are the ones that are responsible for your sleep disorder. And they're the ones I'm going to be communicating with when I gather data on how effective the oral appliance is. You want to talk about barriers to compliance, particularly if patients bring things up and then to talk together with the patient about how we can work around those things, make those things better, kind of strategizing modifications, maybe like a patient that I had today that was expressing to me that, you know, I'm always waking up with a dry mouth. I feel like I'm doing a lot of mouth breathing. On all the appliances that I do, I always make sure that they incorporate into the appliance the ability to add elastics. Adding elastics to an oral appliance really can stabilize the lower jaw for those patients who have a lower jaw that's much more mobile and kind of going all over the place. So those kind of modifications you want to talk about and see if those kind of things may help the patient do better as far as compliance or adherence to therapy is concerned. You'd obviously want to discuss baseline complaints and symptoms and see how those are resolving and review the impact of the sleep disorder breathing on their medical history, the things that they come in with, particularly if it's something like hypertension. Are we starting to get the blood pressure under control? Are they actually seeing a primary care provider for their hypertension? You know, if not, we want to be sure we're communicating with a primary care physician about blood pressure readings that we are getting that are hypertensive because they can help us with those kind of being compliant with those kind of issues. If the patient's annual assessment reveals symptoms of worsening, sleep disorder breathing, that may indicate that we need to adjust the appliance further out. We definitely want to be able to communicate with the patient's physician, their particularly, excuse me, their sleep physician or the person in charge of their sleep disorder breathing. It may be a primary care physician. It could be an internist that has diagnosed them with sleep disorder breathing through, you know, a home study device. So we're seeing a lot of change in who the providers are and who's responsible for the patient, but we want to be communicating with all those medical healthcare personnel that's involved in the patient's care, particularly if it's patients like neurologists or cardiologists, not just only their pulmonologist or sleep physician, but their rheumatologist, their endocrinologist. A lot of patients have multiple healthcare providers when they have multiple comorbid conditions. So you want to be communicating with all those patients about what your insights are with that patient. Let's look at the protocols that have been set for long-term management of these patients. We want to establish a recall system. Now dentists are great at recall systems, much better than the medical community. Many of those in the medical community are unaware of what a recall system is. We as dentists do a great job of recall with our hygiene patients, so we understand the importance of the recall system. So now we have the ability to communicate through phone call, email, an actual letter. Those are all great ways that we communicate with the patient, but we want to reinforce the importance of those follow-up visits because over the course of time, this being a chronic progressive disorder, things can change over time, and we want to be constantly aware of that in communication with our patient. And we want to document all these attempts to get the patient back for follow-ups. If they don't schedule, just like with a hygiene patient, and if you're doing general practice and doing sleep and incorporated with general practice, you want to track those patients. You don't want to just lose them through the cracks, and if a patient is not compliant or adherent to to their long-term follow-up visits with you, you definitely want to be notifying the referring physician that the patient's not following up because you want to take the responsibility of providing this management for them, and if they're not adherent, and they're not showing up, or if they've gone inactive, we want to make sure that the physician, the health care provider that referred them to you is aware of that. So a lot of the long-term follow-up visits, particularly, not particularly, but in my practice, my assistant does a lot of the data gathering before I ever walk in the room. So a trained assistant can update the, go over the medical history, see if there's any changes in that, and prescriptions and any habits that the patient may have changed. They can document the symptoms, if there's any change there. They can use screeners to screen for, let's say, any changes in TMD, or oral facial pain complaints. They can also document the oral appliance care and compliance or adherence by the patient, and talk to them about exercises, and make sure that they're using their morning occlusal guide or their AM positioner. And they can also document side effects and complaints that the patient may have. Generally, long-term follow-up visits are pretty straightforward, and things are going well, and all of this is documented. Team member can also talk about, after doing that evaluation, you wanna be sure that they know how to evaluate, that they're trained in asking the proper questions. It's good if you don't use a software program that has this outline for you, that you set up specific questions that you're gonna ask the patient at the follow-up visit, like how many hours on average, and I always make the caveat of, I wanna know over the past couple of weeks, not what's been going on six months ago, but over the past couple of weeks, on average, how many hours are you sleeping? How is your sleep? Are you, is your bed partner saying that you're snoring again? Those kind of things, just how is their sleep going? Are they having any discomfort? Are they having any problems with retaining the appliance at night? Are they having any issues with adherence or compliance with the appliance? And you wanna be sure that you've got a systematic way of recording all that information. We use photos a lot to evaluate at long-term follow-ups, any changes in the occlusal relationship of the teeth. Does the bite look the same? We check everything, everybody, whenever they come in for any type of follow-up with Shemstock to make sure we still got occlusion in the posterior, that we're not developing any kind of posterior open bite. You wanna, a team member can also look at the previous notes and know what the position ought to be of the appliance, how many millimeters, where we've advanced the appliance since delivery. They can look at the appliance itself and make an evaluation of, hey, there's a problem with buildup, there's things are delaminating, things are not doing well, go over the cleaning instructions with the patient. They can also talk to the patient about how they're doing with their morning occlusal guide insertion evaluation, and talk about any exercise protocol that you may have them on. Of course, it's up to the dentist, the sleep dentist that's responsible for the patient to review that information, a team member, a clinical exam to verify what's going on, if there's any issues, generally with the patient, make the assessment and a treatment plan. And then it's always a good idea to communicate those informations, either through soap notes being sent back to the physician in charge of the sleep disorder breathing or the nurse practitioner, whoever's involved with the original referral of the patient to let them know where we stand on things. So in the dental evaluation, you're comparing to what your baseline was, things like occlusal changes, any mobility that may be present with the teeth in a proximal context. This is all stuff that's pretty common and common sense type of things that you do. You wanna check and see if there's any muscle or joint tenderness, any changes with the functioning range of motion and palpating for any muscle myalgia. If you're picking up any new sounds in the joints, it has dyskinesia in here. I've never run across a problem with involuntary movements or stuff, but those are the kind of things we're looking for. And we wanted to verify, even after the team member may have verified this, we wanna verify that we've got the oral appliance in the right position, that we're symmetrical in our advancement of the appliance if we've advanced it, and whether or not we may all be thinking about any further advancement based on the symptoms that the patient is presenting with. So again, it's easy to just basically, if you're not on any kind of software, say you're just seeing one or two patients a month, it may not justify the expense of going into a software dedicated to dental sleep medicine, oral facial pain, but you wanna have records in a way to quickly monitor what your baseline was for the vitals on the patient and any changes in those, and you would like to see improvement in those things if possible. And when you do see improvements or you see the patient going the other way, you wanna be able to share that with the medical team that's involved with that patient. Seven out of eight studies show a significant decrease in the mean blood pressure of patients. So that's one thing that we strictly monitor through the vitals, is any changes and hopefully decrease in the blood pressure of these patients. And when you share those kinds of things with your physicians, your referral physicians, it really demonstrates your focus on the outcomes. What you don't wanna present yourself as a person that just makes an appliance, throws it in the patient's mouth and says, hey, have a great life, hope everything gets better for you. These are patients that we want to be a partner with in making this an effective therapy with them, excuse me. Your management role as the dentist is you wanna definitely discuss these findings that you have with the patient, deciding if there's anything that you need any co-therapy for. Occasionally, I have in the past referred patients for follow-up therapy with counselor for issues. Patients go through a lot over time and maybe there are issues with stress or life issues or work issues and things that can affect their sleep. And you can be an important person in that patient's life in making suggestions like, hey, you may need to routinely get a deep tissue massage for the stress you're carrying for the muscle tightness you have in your shoulders and neck because of your work environment. You wanna make sure that the patient remains on the long-term management schedule. The patient returns for the follow-up and that you're getting, you wanna emphasize that the patient stays current with their medical provider. It's so often the case that patients, no matter how many times you tell them that you are not the one responsible for their sleep disorder, breathing, their primary care physician or their sleep physician are the ones responsible for that. You wanna emphasize by just asking the question, when was the last time you saw Dr. So-and-so, your sleep physician? And if they're not staying, because the sleep physicians need to follow them on a routine basis too, usually on a yearly basis, they would love to see that. But again, physicians are not the best at recall. We as dentists have been trained for recall. So it's good to take it on yourself to remind the patient, hey, we really need to get you back with your sleep physician for them to make an evaluation that everything's going well as far as your sleep is concerned, your sleep disorder is concerned. And if a patient no longer comes to you for follow-ups, is not seeing them for follow-ups, then to be sure to communicate with that medical provider that this is the case, the patient's inactive. The AADSM website has a lot of information on communicating with the medical team that's involved with this patient. So if you remember, go onto the website, that's constantly being added to and upgraded. So there's a lot of good resources, particularly for those of you who are not using a commercial software program to help with this. Those of you who are, utilize the option on the software to generate meta. I know that over the course of my career, the physicians that I work with are very complimentary and expressive about the fact that, Alan, you're one of the few people that really communicates with us about what's going on with their patients. So many times we refer patients to other providers, whether it's another medical provider or it's to some other type of therapy, and we never hear anything. So physicians are very appreciative of when we communicate back with them. And we need to do that in the normal medical protocol of using the SOAP format, subjective objective assessment and plan format. Of giving them the information back so they know exactly what's going on with the patient. And another little pearl I'll give you is that when I do that, because I use a software program that auto generates these communications for me, I go through and it doesn't take two minutes. I go through and actually highlight what is the important stuff. And it may be only three or four highlight points, which again, I've been told by my referring physicians, they appreciate the fact that they don't have to read the whole thing with every little data tidbit in there. They can go straight to what's the important information in my opinion that I think that they know, they need to know about that patient. And I generally like to, at the very end, to take another two minutes and type a personal, hey, this patient is, and I refer to all my sleep physicians by their first name. I consider them colleagues. They consider me a co-equal colleague. I expect for them to call me by my first name. And I just say, hey, let's say Jim, saw this patient today. She seems to be doing great subjectively. Everything seems fine. I'm referring her back to you for your follow-up and any objective testing that you may feel is necessary. But on my end, she seems to be doing great and her bite is very stable. Her appliance is in good shape. Thank you for the referral. So those things are really, even if your physicians don't express that, they're very appreciative of that type of communication. So when you're setting up your communication and we do this too, not every physician's the same. So some physicians like things in certain information, others may like other types. I've pretty much trained my referral network of this is how my format is. You know, it's like when you get a lot of different sleep studies from a lot of different centers and you're going through and you're trying to figure out, okay, where's the information that I need? Where can I find the information that I'm looking for that's important for me to have in my records? I try to be very standardized in the way that I get information back to my sleep physicians. And what that requires is, you know, not routinely, but on a regular basis, making contact with your physician, excuse me, your referral physician network and saying, hey, is the way I'm presenting the information to you acceptable to you? Is there something you want me to do different? Is there other information? And as we may tweak and adjust, I don't, I can't remember the last time I tweaked or adjusted anything. I pretty much got them trained as, hey, this is the information you're gonna get. I'm gonna highlight the important stuff. They know this is what they're gonna get back from me. But those things need to be customized. And it's a good idea, particularly initially, to find out is that the physicians, what their preferences are and what data that they're interested in. And all this stuff can be designated to a team member to do so that you're not like me, so anal retentive where I want to generate my own letters and then go back through and tweak. And I get crazy too, because this is all I do now. I have the time to do it. I'm checking for typos and it's nuts. I can't seem to turn that loose, but hopefully you realize that your time can be better spent and is more valuable and turn that over to a team member. I could learn a lot in this area. And then you document that that letter's been sent. So you know what's going on and who's got what. Again, there are samples on the website. You can make your own through Word where you insert the information and make them very personalized. But you want to be sure and let the patients know, I mean, not the patients, but where you want to copy patients on your letters that you send to your medical professionals. But you want to document things like failing to return for follow-up, discontinuing, that they discontinued use of the oral appliance, if they're not being adherent or compliant with the therapy, or if you suspect that, hey, I don't think the appliance is really getting it for them. Now we need to be talking about either combination therapy or getting the patient on pap therapy, because we're just not making it with the oral appliance. You want to obviously prepare. And one of the things that I will always stress is that before any patient visit, whether it's the consultation visit or the workup visit or a follow-up visit, you want to take the time to review the patient information, the notes and things, so that you don't walk into the operatory to talk to the patient and you're trying to read while the patient's talking with you. It's always a great thing to prepare and be ready and know what the team roles are. Some of the tools that you use, we've talked about the recall system, the correspondence, screeners that you may want to use, whether it's for the initial screening for sleep disorder breathing, or if it's for TMD and oral facial pain concerns. Want to be sure that you're charting all of these things, that you may be in a situation and a state where you're comfortable using pulse oximetry or home studies to give you some more objective readings on patients and their oral appliance therapy use. Photos are critical, I think, because there are so many times, especially when you start to see a lot of patients, patients will come in where they're having some discomfort because a tooth is out of line, the appliance initially is putting pressure on that tooth, they're more aware. Patients are not as aware of their teeth as dentists are, obviously. And so many times patients will come in and say, I think that the appliance has made that tooth crooked. It's very simple and easy to go back and say, well, let's look at that. And to pull up the original photos that you took prior to any treatment with an oral appliance and say, you know, no, that tooth was that way when we started. The problem is it's putting a little pressure on that tooth and now you're aware of that tooth, but, and it can save your rear end a lot of times with a patient and the patient says, oh, well, gosh, I never realized that before, but yeah, it was, it was out of line. So those kinds of things are really important. The way you document things in your notes and in communications with the medical world is using the SOAP format, like I said, the subjective observations, objective data, making the assessment of what's going on with the patient and then coming up with a plan to address those. Subjective history includes these things, the symptoms, the chief complaints, the social history, the goals of the treatment, medical history, prescription history. Objective findings are more about what you're actually seeing in the patient, the data that you're collecting of the patient themselves, as well as the results of the testing that has been done on the patient. Assessment is making comments about the general patient condition and the treatment results, determining the recall interval. And again, those things are pretty much outlined for you in the protocols that have been established, identifying any areas of concern that we might need to be aware of and monitor. And then the plan is how do we address those areas of concern? What do we want to reevaluate at the next follow-up appointment? And then any correspondence that we're going to do with the medical team. When we look at the elements for long-term follow-up appointments and what we need to be addressing, we'll look at what the four pillars or the four areas. And these areas closely follow the four areas of data accumulation, the subjective objective assessment and plan. So we're going to look at patient evaluation and management, the cranio-mandibular complex itself, the oral appliance and how effective the therapy is with each patient. So it's a good way to organize the follow-up visit and any conversations and record keeping that you do. So if we look at the first pillar, the patient evaluation and management, we're looking at those subjective things. We're following the history, any changes to the symptoms that the patient first presented with, the general quality of life assessment, any sleep history changes, any changes in what their initial sleepiness, unrestorative sleep may have improved since we initiated therapy. We're also going to look at any medical history updates that the patient has, have things changed for them? Have conditions changed? Have they developed any new conditions? Have they changed medications or dosages? Is there a new, any history surgically? Have they had a hip replacement? Have they had any cancer diagnosed, any nasal surgeries, any problems with their lungs, anything that may have changed? It's a review of their medical history and any changes. And then we also look at anticipated changes. Are you trying to get pregnant or are you pregnant now where you weren't before? You're approaching menopause. Are you noticing changes to your overall health because of that? You're getting older. Do you see changes there? And what are you noticing? Subjectively, maybe a mental and cognitive status update. Some patients, particularly as the older patients are starting to lose their cognitive abilities a little bit. Are they having any tremors? Are things starting to change for them? Are there any problems from long-term medications? I'm sorry, my dogs are not supposed to be in here, but my wife just walked out and left them in here. Are they using any SSRIs? Have they been diagnosed with depression? Are they using any antipsychotics? Those kinds of things. Objectively, we're gonna look at, is their weight changing? Is it going down? Is it going up? Their blood pressure, we wanna monitor that. Any nasal resistance that we're picking up on, those kinds of things we're looking at. Are they starting to have declining health issues? Are they starting to suffer from, like I am, from any kind of degenerative joints that are causing some problems with them? When you see them coming to the room, are there things that you noticed from the last time that you saw them? You wanna evaluate those things. The next thing you wanna look at, initially the patient as a whole, but now you wanna concentrate on cranial mandibular complex. How are things for them? Have they had dental work done? Are they having problems now that having some periodontal problems? Any problems joint-wise or oral facial muscular problems? You wanna evaluate those. Have those changed? You wanna definitely evaluate the occlusion. Every patient that we see on a follow-up visit, we're going to check with Shemstock to make sure they've still got their bite there. Pretty routine. You're gonna check all these things, any changes in the occlusion, the contacts, those kinds of things, any evidence of wear. Again, photos are great. We take photos both initially and at the long-term follow-ups to have a record of any changes that are going on. This patient that I just saw, I changed, I added one slide today because she had come in this week and we took, she's been a patient of mine since like 2014, so 10 years. We started our first appliance. She's now started in her third appliance. And the top row of pictures were her occlusion initially. When we started 10 years ago, occlusion was solid. We gave her, her occlusion had stayed solid all the way through her first appliance and her second appliance. We put her in the third appliance earlier this year and she came back in for a six month follow-up. And this is the second row is what I saw, this opening and shifting of the bite to where she's almost in the end on the anterior and has a posterior open bite. Those pictures now up on the top row and the bottom row is that she came back this week and I threw these in because we've gotten her to start doing some exercises and some thinker man poses to try to stretch out those lateral pterygoids and she's reestablishing her bite. So it can happen at any point. Generally, you see these kinds of changes early in therapy, but just be aware that it could be the third appliance that you start to see changes because the patient gets a little lazy with their morning occlusal guide to reestablish their bites in the morning. But we can do things to get it back and we'll continue to work with her and hopefully the next time I see her, she will be even better. Want to change, want to establish, are there any symptom changes, sound change, you know, that we've now picked up sounds, any changes in meds that are affecting any nighttime bruxism, those kinds of things when you're looking at that, any shifting of bite overall, you know, the dental work, are they anticipating any future restorative work? Those kinds of things. Are they looking at some cosmetic dental work now? I've got a patient, we just started in oral appliance therapy less than a year ago, who now her daughter's wedding is coming up. I referred her to a friend of mine who's getting ready to do a lot of anterior restorative work on her, you know, veneers and things, which she understands the appliance that I made for her less than a year ago is no longer going to fit right. And we're going to be redoing an appliance and she understands that, but she doesn't want to go through her daughter's wedding without having this cosmetic work done. So those kinds of things you look at. We want to evaluate the oral appliance itself. Is it still effective? Is it still fitting well? Is it staying retentive? Are they wearing elastics and cracking? Does it need to be replaced? How are they doing with their cleaning and all? Is everything working well? Are any components to the appliance still functioning well? Has the restorative dentist or the primary dentist done any modifications to the appliance without you not being knowledgeable of that? And make sure that we check and make sure that the position and symmetry of any advancement we've done is still there. We start to see wear and tear on appliances. Some things we can do to correct as far as their cleaning habits, but it's sometimes when we'll say an appliance starts to delaminate or has got a number of years wear on it we may be looking at replacing that. So does it need to be replaced? What's the warranty on the appliance? What is the insurance allowance on that? And can we do something in our office with our ultrasonic to help with the patient in cleaning it up? And then we will want to look at our effectiveness evaluation and plan, which is the fourth pillar. Looking at any physical issues and necessitating titration for the patient, gathering whatever objective reports we might do in our office, whether it's either pulse oximetry or home study and make sure that we're reconnecting with the referring physician for any refinement or reassessment and plan. Does the patient need to be retested because of changes in weight, health, whatever? Consider the external influences, if the insurance changed, are they now on Medicare? Are we monitoring their compliance? Is the patient doing good monitoring of how long they're doing the therapy? There are wearables that may be considered, apps on phones like SnoreLab, those kinds of things that may be helpful in seeing how things, just remember that you can't run a race effectively with shoelaces, just like you can't, an appliance can't be effective if it's not stable in the patient's mouth. So you look at those kinds of things. You make therapeutic decisions based on the subjective history, the objective findings of, any objective findings of concern, you assess where you are with the patient and make a plan going forward. So in summary, be prepared for the patients that you're gonna see on follow-up by reviewing the patient history before the appointment, what was established at the last follow-up appointment. As far as your practice is concerned, come up with a workflow and assessment plan that improves how the patient moves through the practice and through the follow-up so that you're gathering the data you need, make it something that's efficient for you and your practice. You communicate with both the patient and the physician, both to increase the patient confidence and to increase your credibility with the medical providers. It's always about educating and informing the patients about what's changing in the field of mental sleep medicine. Patients, particularly when they're looking at new appliance for them, so many changes that have occurred in the technology over the years, you always wanna make patients aware of that and informed. And then understand that as you continue to be that proactive with the patients that they really appreciate that personalized care. So Rubina, that's it. Dr. Wynn, that's all I got. All right. Well, thank you. We have lots of questions. If I guess we are doing very good with the time. Let's, let me see if there are any questions that were upvoted. All right, here's one. During COVID, I made my wife a MyTap. She developed a posterior open bite. How do you handle this? You gotta understand what is probably occurring with, she developed an anterior open bite? Posterior. Posterior, okay. What's probably occurring there is that she is not, and then when you see this in patients, we probably got a shortening of the muscle fibers of the lateral pterygoid muscles in most instances. The lateral pterygoid is the muscle when you contract, it protrudes the jaw. If we brought a patient forward during the night for seven, eight hours, those muscles are shortened. And if we don't stretch those muscles back out, much like stretching a hamstring, if you don't stretch those muscle fibers all the way back and get them back in their established posterior bite, over a short period of time in some individuals, those muscle fibers will shorten a little bit, which will produce a shifting anteriorly of the entire lower jaw and the bite and produce an open posterior bite. So it's all about trying to get those muscles stretched out. There are good videos from the ADSM on exercises you can do to stretch those back out. I have patients chew gum, manipulate the jaw. The best, most effective seems to be getting in the thinker position where you're relaxing and pushing that lower jaw complex posteriorly, which stretches out those lateral pterygoids and having the patient maintain kind of isometrically in that position. But they gotta be sure that they're forcing the jaw, not forcing, they're allowing the jaw to go back, straight back and not up towards their head, but back towards below their ear. Okay. So the next question is, do you have any trouble getting patients to come for follow-up visits? And what do you charge? Or rather, how do you charge it? Maybe that might be easier to answer. Do you? Yeah. Once, I wanna be careful here. Once we have gone through the 90 days of initial adjustment and accommodation with the patient, every follow-up appointment after there is a charged visit. And we charge it as an office visit, a follow-up. It is a reasonable fee that covers my expenses. It's, I don't know if Trish is still on what I can say about that. I need direction, but you do need to be charged. You do need to charge the patient for your time. And we, if the patient directs us, we file that with their insurance, but they pay the amount. We're a fee-for-service practice. We'll file their insurance all day long. And a lot of times they'll get reimbursed directly. We don't accept assignment, but, you know, what's a, I don't know what to relate it to in general dentistry. I've been at it for a while. I don't remember what, I don't remember what we charge for a, for an exam fee, but that's, I don't want to get into price fixing, but it's a reason. It's kind of hard to answer that. Yeah, it's a reason. It's a very reasonable charge, plus patients don't care. But how do you get them to come back? You establish that at the very beginning and say, look, this is a chronic, progressive, potentially fatal disorder. And if this is not, I mean, if you want something that you just, we give you an appliance and we don't ever see you again, there are plenty of things you can get online. You can get at the drug store. That's not what we're providing for you. We're providing something that we need to see you back and follow up with because things change. Generally things get worse and we need to monitor that, know when we need to make adjustments and changes in order to provide you the best health. And we're going to do that and follow up visits. I'm going to see you after this initial period. I'm going to see you six months after delivery. I'm going to see you six months after that, which is year after delivery. Then I'm going to want to see you back yearly after that. Perfect. Well, thank you, Dr. Blanton. That was an excellent presentation. Very informative.

oral appliance therapy

obstructive sleep apnea

long-term management

patient compliance

healthcare collaboration

treatment efficacy

follow-up protocols

side effects monitoring

oral appliance evaluation