Bruxism and OSA Dental Sleep Medicine in Practice Informed Consent JournaCALIFORNIA DENTAL ASSOCIATION Pediatric OSA

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departments

177 The Editor/Bluetooth and Mondegreens

181 Impressions

225 RM Matters/Workers’ Compensation: Quick Reporting Required With Employee Injuries

231 Regulatory Compliance/Texting Patients? Collecting Patient Information on a Website? Know the Rules

235 Ethics/What Would You Do If Your Patient Cheated on You? 238 Tech Trends 181

f e at u r e s

185 The Dentist’s Role in Sleep-Related Breathing Disorders: Impact, Implications and Implementation An introduction to the issue. Jamison R. Spencer, DMD, MS

189 What Every Dentist Should Know About Sleep-Related Breathing Disorders This essay helps the dental team understand the details about what they should be doing to make the biggest difference for their practice’s and community’s health. Steve Carstensen, DDS

195 Bruxism, Obstructive Sleep Apnea and This article discusses how the dental professional can be an integral part in working with the medical community to identify and manage patients with obstructive sleep apnea. Cameron A. Kuehne, DMD, MS

199 Incorporating Dental Sleep Medicine Into Your Practice: S.E.T.U.P. for Success in Sleep This article provides insight into systems for incorporating or improving a dental sleep medicine program into the dental practice. Marty R. Lipsey, DDS, MS

205 Informed Consent for Dental Sleep Medicine This article explains how taking the time to obtain an informed consent can reduce clinician liability and result in a more motivated patient. Ken Berley, DDS, JD

213 Pediatric Obstructive Sleep Apnea: An Interdisciplinary Approach to Treatment This manuscript highlights the opportunities medical and dental professionals have to collaboratively manage obstructive sleep apnea in children and teens. Thomas Stark, DDS, LTC(P); Peter O’Connor MD, COL; and Tracey Fischer, MA, MA, CCC-SLP

Cover apnea illustration: Habib M’henni/Wikimedia Commons

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Volume 48 Number 4 April 2020 JournaCALIFORNIA DENTAL ASSOCIATION

published by the Management Blake Ellington Manuscript Journal of the California Dental Association California Peter A. DuBois Tech Trends Editor Submissions Editorial Board Dental Association Executive Director Jack F. Conley, DDS www.editorialmanager. Charles N. Bertolami, DDS, DMedSc, Herman Robert 1201 K St., 14th Floor com/jcaldentassoc Fox dean, NYU College of Dentistry, New York Carrie E. Gordon Editor Emeritus Sacramento, CA 95814 Chief Strategy Officer 800.232.7645 Robert E. Horseman, DDS Letters to the Editor Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental cda.org Kristine Allington Humorist Emeritus www.editorialmanager. Medicine, Pomona, Calif. Chief Marketing Officer com/jcaldentassoc Production CDA Officers Mina Habibian, DMD, MSc, PhD, associate professor Alicia Malaby Richard J. Nagy, DDS Randi Taylor Subscriptions of clinical dentistry, Herman Ostrow School of Dentistry Communications Director President Senior Visual Designer Annual subscriptions are of USC, Los Angeles [email protected] Editorial available to association Upcoming Topics members at a rate of $36. Robert Handysides, DDS, dean and associate professor, Judee Tippett-Whyte, DDS Kerry K. Carney, DDS, CDE May/TDSC To manage your printed department of endodontics, Loma Linda University School President-Elect Editor-in-Chief June/Health Literacy Journal subscription of Dentistry, Loma Linda, Calif. [email protected] [email protected] July/Licensure online, log in to your cda. Bradley Henson, DDS, PhD, associate dean for research org account or email Ariane R. Terlet, DDS Ruchi K. Sahota, DDS, CDE and biomedical sciences and associate professor, Western Advertising [email protected] Vice President Associate Editor University of Health Sciences College of Dental Medicine, Sue Gardner for assistance. View the [email protected] Pomona, Calif. Brian K. Shue, DDS, CDE Advertising Sales publication online at John L. Blake, DDS Associate Editor [email protected] cda.org/journal. Paul Krebsbach, DDS, PhD, dean and professor, section Secretary 916.554.4952 of periodontics, University of California, Los Angeles, Gayle Mathe, RDH [email protected] School of Dentistry Senior Editor Permission and Steven J. Kend, DDS Jayanth Kumar, DDS, MPH, state dental director, Jamison R. Spencer, Reprints Treasurer Sacramento, Calif. DMD, MS [email protected] Andrea LaMattina, CDE Guest Editor publications manager Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral Debra S. Finney, MS, DDS [email protected] health education, University of the Pacific, Arthur A. Dugoni Andrea LaMattina, CDE Speaker of the House 916.554.5950 School of Dentistry, San Francisco Publications Manager [email protected] Nader A. Nadershahi, DDS, MBA, EdD, dean, Kristi Parker Johnson R. Del Brunner, DDS University of the Pacific, Arthur A. Dugoni School of Senior Communications Immediate Past President Dentistry, San Francisco Specialist [email protected] Francisco Ramos-Gomez, DDS, MS, MPH, professor, section of pediatric dentistry and director, UCLA Center for Children’s Oral Health, University of California, Los Angeles, School of Dentistry The Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. Periodicals postage paid at Sacramento, Calif. Postmaster: Michael Reddy, DMD, DMSc, dean, University of Send address changes to Journal of the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814. California, San Francisco, School of Dentistry The California Dental Association holds the copyright for all articles and artwork published herein. Avishai Sadan, DMD, dean, Herman Ostrow School of The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial Dentistry of USC, Los Angeles staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or Harold Slavkin, dean and professor emeritus, division of reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the biomedical sciences, Center for Craniofacial Molecular Biology, Journal of the California Dental Association. The association does not assume liability for the content of advertisements, nor Herman Ostrow School of Dentistry of USC, Los Angeles do advertisements constitute endorsement or approval of advertised products or services. Brian J. Swann, DDS, MPH, chief, oral health services, Copyright 2020 by the California Dental Association. All rights reserved. Cambridge Health Alliance; assistant professor, oral health policy and epidemiology, Harvard School of Visit cda.org/journal for the Journal of the California Dental Association’s policies and procedures, author Dental Medicine, Boston instructions and aims and scope statement. Richard W. Valachovic, DMD, MPH, president emeritus, American Dental Education Association, Washington, D.C. Connect to the CDA community by following and sharing on social channels

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176 APRIL 2 0 2 0 Editor CDA JOURNAL, VOL 48, Nº4

Bluetooth and Mondegreens

Kerry K. Carney, DDS, CDE

y brother, a retired network administrator, As dentists, how can we not pause and wonder likes to tell me that his hearing loss is just an about this blue tooth? Most of us use Bluetooth “undocumented feature” every day, but why is it blue and what does it Mof aging. But sometimes, conversations have to do with dentition? seem more interesting and surprising as our auditory function declines and the brain substitutes for words that are misheard. This auditory accommodation But what about the reverse? Two engineers working on the is sometimes called a mondegreen. What about when we hear a word project to unify devices attended a The term was coined in 1954 by or words that are so familiar that conference in the summer of 1997 and a writer who had misheard the lyric we do not think twice about their then went out for drinks afterward.1,2 in a Scottish ballad about a knight meaning, even when they make In addition to discussing the project, and substituted words that made no sense in their new context. they talked about their mutual interest sense to her. What should have been Take the word Bluetooth. This word in Vikings. One of the engineers was “they killed him and laid him on the is made up of two very common reading about a 10th century Danish green” became “they killed him and and easily understood words, but king, Harald Bluetooth, who unified Lady Mondegreen” for the writer. understanding each word provides Denmark, conquered Norway and Surely, everyone has had the no clue as to what Bluetooth really converted the Danes and Norwegians experience of singing gayly along with a means. Our brain just accepts it to Christianity. Harald Bluetooth’s popular song only to have someone else as a new term without any logical history reads a lot like a backstory bemusedly correct their mondegreen. connection to the meanings for the popular TV series “Game My favorite example was a friend of the words blue and tooth. of Thrones.” It contains plenty of who energetically sang John Fogerty’s As dentists, how can we not pause battles, blood and betrayals. Harald “Bad Moon Rising” refrain “there’s and wonder about this blue tooth? Bluetooth’s ability to unite the a bad moon on the rise” as if it were Most of us use Bluetooth every day, divided Nordic peoples reminded “there’s a bathroom on the right.” but why is it blue and what does it the engineer of the battle to unite It was years into our marriage have to do with dentition? The story fixed and mobile devices through before I realized that my husband and I of the origin of Bluetooth is a tale of standardized data exchange. He had the same mondegreen for lines in technology, history and endodontics. decided that the working code name Longfellow’s “Paul Revere’s Ride.” For In the mid-1990s, there was a for the system should be “Bluetooth” both of us, the signal from the North move to unite all the individual as a salute to this Nordic unifier. Church tower sounded like “one-ith companies’ efforts to develop a It was not uncommon for rulers to by land and two-ith by sea.” We both short-range radio technology and have an epithet – a descriptive phrase thought some old English vernacular produce a single wireless standard expressing a quality or characteristic was responsible for what we heard. that would link local devices. The of the person (Bluebeard, the Red, Mondegreens are a tribute to idea was seamless communication the Great, the Terrible, Greycloak, the brain’s attempt to make sense between mobile personal computers etc.) Harald’s epithet, Bluetooth, out of nonsense. The brain offers up and cellphones. This is the Bluetooth was probably due to an endodontic a logical substitute for words that technology we take for granted in problem that produced a noticeably are misheard or unrecognized. It is today’s world. It is how your car or darker blue or black tooth. Though the a charming undocumented feature your laptop computer knows your depictions of Harald on the internet of perception and cognition. smartphone is close at hand. never show him with a toothy smile,

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CDA JOURNAL, VOL 48, Nº4

it seems plausible that a dead tooth The technology was launched as So, the next time you see someone was the origin of the epithet. Bluetooth with the idea that it could be apparently talking to themselves As far as the origin of the changed based upon future market research. with their Bluetooth-connected Bluetooth logo, it is the combination The rest is history. The name stuck, and AirPods, remember a Danish king or an overlaying of the two runes we all use Bluetooth to connect to our over 11 centuries ago who had an that symbolize Harald Bluetooth’s cars, our phones, our earbuds, our watches endodontic problem that resulted in name on a blue field. There were and many of life’s other technological a less than optimal cosmetic outcome other suggested names for the conveniences. All our devices are and appreciate the connection system. One alternate name was connected through the unifier, Bluetooth. between our profession and a FLIRT, which derived from the According to one online authority, ubiquitous bit of technology today. n idea that the devices could connect “… Bluetooth has evolved from a wireless without touching. PAN, for personal replacement for old RS-232 cables to [Editor’s Note: Many thanks to area network, was a top choice, a fully fledged, far-reaching standard my friend David, a survivor of the but it pulled up too many hits in its own right. It caters to everything Paradise Camp Fire, who brought this when googled and that had the from file sharing and device pairing, to interesting connection to my attention.] potential for trademark problems. wireless music and accessories ….”3 1. Estes AC. Bluetooth is named after a medieval king who may have had a blue tooth. gizmodo.com/bluetooth-is-named-after- a-medieval-king-who-may-have-h-1671450657. 2. Kardach J. Tech history: How Bluetooth got its name. www. eetimes.com/document.asp?doc_id=1269737. 3. Triggs R. A quick history of Bluetooth. www.androidauthority. com/history-bluetooth-explained-846345. Live a Better Life Open Door is hiring dentists, pedodontists, We are an NHSC Loan Repayment Site The Journal welcomes letters and registered dental hygienists. Located with a dental health HPSA score of 21. We reserve the right to edit all communications. Letters should discuss an item on the beautiful North Coast, we offer: You can get up to $50K to repay your published in the Journal within the last two months • Competitive salary dental school loans in exchange for two or matters of general interest to our readership. • Relocation assistance years of service. Or, through CalHealth- Letters must be no more than 500 words and cite no more than five references. No illustrations • Childcare program Cares, you can get up to $300K to will be accepted. Letters should be submitted at • Full health benefits repay your loans in exchange for a five- editorialmanager.com/jcaldentassoc. By sending • Great team year commitment. the letter, the author certifies that neither the letter nor one with substantially similar content Open Door has 29 operatories across under the writer’s authorship has been published Please contact Recruitment three of our 12 health centers. In 2018 we or is being considered for publication elsewhere, Director Angela Mendes at opened our newest center in Fortuna. and the author acknowledges and agrees that [email protected] the letter and all rights with regard to the letter or (707) 496-5465 Join us and work near rivers, redwoods, become the property of CDA. and the ocean.

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SINCE 1870

Join in as CDA celebrates 150 years of innovation and growth. Explore limitless member benefits and exciting new ways to connect through the year. See how you can be a part of what’s next at cda.org/150. Impressions CDA JOURNAL, VOL 48, Nº4

Treating Obesity May Impact Periodontitis

Obesity and periodontal disease are among the most common diseases in the United States, and studies show these chronic conditions may be related. But according to a study published in the British Dental Journal, the connection between obesity and gum disease isn’t as simple as cause-and-effect; instead, the relationship centers on what both diseases have in common: inflammation. A research team, led by Andres Pinto, PhD, professor of oral and maxillofacial medicine and diagnostic sciences at the Case Western Reserve University School of Dental Medicine in Ohio, set out to explore the effect of obesity on nonsurgical periodontal care and to evaluate potential pathways that illustrate the connection between the two conditions. The team examined a plethora of existing studies, most of which analyzed data from population subsets at one point in time, as opposed to studying the same population over a longer period. Researchers found data showing that increased body mass index, waist circumference and percentage of subcutaneous body SINCE 1870 fat and serum lipid levels are associated with an increased risk to develop periodontitis. The underlying biological mechanisms of this association involve adipose tissue-derived cytokines, such as tumor necrosis factor-α and interleukin-6, which affect whole-body metabolism and contribute to the development of a low-grade systemic inflammation, according to the study. The research team concluded that changes in body chemistry affect metabolism, which in turn causes inflammation — something present in both obesity and periodontitis. “Periodontal disease occurs in patients more susceptible to inflammation — who are also more susceptible to obesity,” Dr. Pinto said. This information can inform how health care professionals plan treatments for patients suffering from obesity and periodontal disease. “Oral health care professionals need to be aware of the complexity of obesity to counsel their patients about the importance of an appropriate body weight and maintaining good oral hygiene,” Dr. Pinto said. Further research on the relationship between gum disease and obesity is needed, as there is, at this point, limited evidence to Join in as CDA celebrates 150 years of recommend changes in treatment planning, according to the study. innovation and growth. Explore limitless “There is a thought, from the clinical perspective, that member benefits and exciting new ways to if you treat one of the issues, it may impact the other,” Dr. connect through the year. See how you can Pinto said. “This is the big question. For example, if we treat be a part of what’s next at cda.org/150. obesity successfully, will this impact periodontal disease to the point of being of clinical relevance compared to the control population. The jury is still out given the paucity of controlled, well-designed, clinical trials on this issue.” Learn more about this study in the British Dental Journal (2019); doi.org/10.1038/s41415-019-0611-1. n

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CDA JOURNAL, VOL 48, Nº4

The multicollector, inductively coupled plasma mass spectrometer allows high-accuracy isotope ratios to be collected. (Credit: John Samuelsen, Periodontitis Affects Pregnancy Outcomes University of Arkansas) A recent study has linked periodontal disease during pregnancy to worse Lead Isotypes in Ancient health outcomes for mothers and their children. The study was published in the November 2019 issue of the journal PLOS One. Human Teeth Identify Researchers from the pediatrics department at the Botucatu Medical Geographic Origin School in Brazil studied the potential health consequences of periodontal diseases during pregnancy on maternal and infant health. Their study included Working with lead isotopes taken 138 pregnant women who gave birth at a hospital in Botucatu and were all in from tooth enamel of prehistoric animals, good general health in the second trimester of pregnancy. researchers at the University of Arkansas The study found that women who had severe periodontal disease during have developed a new method for assessing pregnancy were more likely to experience premature membrane rupture and the geographic origins of ancient humans. inflammation of the vulva and vagina. Their offspring also were more likely to The new method allowed the experience fetal growth restriction. researchers to compare the ancient human teeth to those of prehistoric animals, as well About two-thirds of the women experienced periodontal disease during as to rocks and soil samples, taken from the their pregnancy and 18% had severe periodontal disease. Experiencing same area. The research, sponsored in part severe periodontal disease proved to have negative consequences for both by the National Science Foundation, was maternal and newborn health. published online in February ahead of print The odds of fetal growth restriction were 11 times higher in women with severe in the Journal of Archaeological Science. periodontal disease than those without periodontal disease. In addition, women John Samuelsen, doctoral candidate with severe periodontal disease were 5.6 times more likely to experience premature in anthropology and research assistant rupture of the membrane and 3.5 times more likely to have vulvovaginitis. at the Arkansas Archeological Survey, The authors noted two key limitations of their research. First, the study included analyzed linear patterning of lead isotopes a relatively small sample size, which resulted in a low occurrence of some negative on teeth from a 600- to 800-year-old health outcomes known to occur with periodontal disease. skull and mandible cemetery at the In addition, the authors could not determine whether the Crenshaw site in southwest Arkansas. women received dental treatment following a diagnosis of The ongoing study is being conducted periodontal disease. in collaboration with the Caddo Nation The authors intend to take what they learned from the of Oklahoma to help answer questions study and promote more oral health care for pregnant women. the tribe has about the cultural affiliation Learn more about this study in PLOS One (2019); and origin of the remains. The Crenshaw doi.org/10.1371/journal.pone.0225036. site along the Red River is a culturally significant multiple-mound ceremonial center of the Caddo Indians. Lead is a toxic trace metal that affects the health of biological organisms, but contained isotopic signatures consistent other geographical areas, those isotopes it is useful for determining geographic with those found in the teeth of prehistoric taken from nearby rocks were far too origins. Its isotopic content within human animals from several sites in the area. variable to be useful for the same purpose, and animal tooth enamel, via food chain Moreover, their isotopic signatures were Samuelsen said. He emphasized that a pathways, reflects the geology of the inconsistent with isotopes from humans full evaluation of the human remains region in which an organism grew up. and animals from other regions. will be addressed in a future study. Samuelsen and his colleagues found While the lead isotopes from animal Learn more about this study in the that teeth of five of the 352 individuals teeth were successful at identifying Journal of Archaeological Science (2020); tested with the new assessment method local human remains, versus those from doi.org/10.1016/j.jas.2020.105079.

182 APRIL 2 0 2 0 CDA JOURNAL, VOL 48, Nº4

Better Method Devised for Treating Periodontitis New biodegradable rods developed attacks or pneumonia, said Karsten Mäder, by researchers will provide better PhD, head of the Institute of Pharmacy treatment for periodontal disease and at Martin Luther University Halle- Flexible, biodegradable rods containing antibiotics could spare patients from the many Wittenberg, Germany (MLU). Therefore, for periodontitis treatment. (Credit: MLU/faculty side effects associated with antibiotic mechanical cleaning procedures are marceting NF1) treatment, according to a study often followed by antibiotics. These published in the International Journal are usually administered in pill form, itching. The possible development of of Pharmaceutics in December 2019. which puts a strain on the entire body. resistance to common antibiotics is also The inflammation of periodontal Common side effects are diarrhea, a major factor in this form of treatment. disease affects the entire body and is often abdominal pain and nausea as well Ideally, the antibiotic would only the cause of other diseases such as heart as skin reactions such as redness and act locally in the mouth rather than throughout the entire body. Dr. Mäder’s research group therefore combined a proven antibiotic (minocycline) with an equally proven pharmaceutical New Bioactive Peptide Helps Prevent, excipient (magnesium stearate). “The complex is just as effective, Heal Cavities in Lab Experiments but more stable. It slowly releases Researchers have discovered a bioactive peptide that coats tooth the antibiotic on the spot,” said surfaces, helping prevent new cavities and heal existing ones in lab Dr. Mäder. “In addition to the experiments. The research was published in the journal ACS Applied continuous and sustained release Materials & Interfaces in December 2019. of the antibiotic, we needed to find The peptide was discovered by Hai Ming Wong, DDS, PhD, and colleagues an easy way of administering it.” from the University of Hong Kong and the Prince Philip Dental Hospital in Hong The research group found a Kong when they wanted to develop a two-pronged strategy to prevent and treat practical solution to this problem by tooth decay: prevent colonization of the tooth surface by the plaque-forming utilizing pharma-grade polymers to bacteria that cause cavities and reduce demineralization while increasing produce flexible, biodegradable rods remineralization. They based their anticavity coating on a natural antimicrobial containing the antibiotic. The small peptide called H5. Produced by human salivary glands, H5 can adsorb onto rods can be easily inserted into the tooth enamel and destroy a broad range of bacteria and fungi. gingival pocket. Because they are To promote remineralization, the team added a phosphoserine group to one broken down by the body, they do not end of H5, which they thought could help attract more calcium ions to repair the have to be removed after treatment. enamel than natural H5. They then tested the modified peptide on slices of A patent for the complex active human molars. Compared with natural H5, the new peptide adsorbed more ingredient and its formulation has been applied for, according to the study, which strongly to the tooth surface, killed more bacteria and inhibited their adhesion also stated that rapid implementation and protected teeth from demineralization, according to the study. Surprisingly, in clinical studies is possible because all however, both peptides promoted remineralization to a similar degree. of the pharmaceutical-grade ingredients Researchers say that someday people could are already available on the market. apply the modified peptide to their teeth, after The rods can also be produced using brushing, as a varnish or gel to protect against proven techniques, so they can be tooth decay. Learn more about this study in ACS market ready in just a few years’ time. Applied Materials & Interfaces (2019); doi. Learn more about this study org/10.1021/acsami.9b19745. in the International Journal of Pharmaceutics (2019); doi.org/ 10.1016/j.ijpharm.2019.118794.

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CDA JOURNAL, VOL 48, Nº4

The Dentist’s Role in Sleep-Related Breathing Disorders: Impact, Implications and Implementation

Jamison R. Spencer, DMD, MS

GUEST EDITOR

Jamison R. Spencer, In fall 2017, the ADA House moderate obstructive sleep apnea, DMD, MS, is the director of Delegates approved a policy which is considered a medical disorder. of dental sleep medicine statement on the role of dentistry Hundreds of thousands of people for the Center for Sleep Apnea and TMJ in Boise, in the treatment of sleep-related who were not able to tolerate the Idaho, and Salt Lake City. breathing disorders (SRBDs). use of continuous positive airway He received a master’s Included in that policy statement are pressure (CPAP) are now effectively degree from Tufts University guidelines related to the screening, treated with oral appliance therapy with a focus on craniofacial referral and treatment of adults and around the world, and dentists are pain and dental sleep medicine. Dr. Spencer is children with possible SRBDs. now looking to help children and lead faculty for dental sleep Over the past 20 years, it has adults avoid development of SRBDs medicine miniresidencies at become increasingly common for or reduce the likelihood of mild University of the Pacific and dentists to be involved with SRBDs. problems becoming more severe. Tufts and lead faculty for Lectures related to sleep apnea are Dentists are in a unique position the U.S. Army short course in dental sleep medicine. included at every large dental meeting to participate in the care of people He is a diplomate of the and at local dental societies and with potential SRBDs. Dentists board of Dental Sleep study clubs. Long-held paradigms in are also familiar with screening for Medicine and the board restorative dentistry and conditions that we don’t necessarily of Craniofacial Pain. are being reconsidered and sometimes diagnose, like cancer for example. Conflict of Interest Disclosure: None reported. modified as dentists “look beyond the Whether or not a dentist wishes teeth” and consider the upper airway in to actively be involved with the their diagnosis and treatment planning. treatment of patients with SRBDs, the These changes have been caring dentist will certainly wish to supported by over 40 years of research acquire the necessary skills to be able and clinical experience. Medicare to identify possible SRBDs in their recognizes oral appliance therapy patients and refer those patients to provided by a licensed dentist as their medical and dental colleagues a first-line treatment for mild to for further diagnosis and treatment.

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CDA JOURNAL, VOL 48, Nº4

As dentists, we have a special largest stumbling block for dentists evaluation and treatment of patients focus on prevention. We screen trying to help their patients with with or with potential SRBDs. We asymptomatic people and often SRBDs — the billing of medical have not addressed newer techniques discover underlying problems that insurance. As a California resident such as hypoglossal nerve stimulation have the potential to result in pain and owner of a medical billing service, or gone into great detail on other and dysfunction if not addressed. Dr. Lipsey is intimately aware of the surgical and nonsurgical approaches We have the ability to help our issues in this area. Because money to the treatment of sleep apnea. We patients understand such issues and matters are typically of significant have also not provided a step-by-step encourage them to make well-informed consideration for our patients, this guide to providing oral appliance decisions to protect their overall is also an important area for dentists therapy. It is my hope that this issue health. We see these patients on a to at least be familiar with. of the CDA Journal will inspire you regular basis and build relationships Ken Berley, DDS, JD, takes into to immediately start screening your with them based on caring and consideration the informed consent patients for potential SRBDs, that trust. Helping these same patients of our patients. As a practicing you will review the ADA policy understand a possible sleep issue, dentist and attorney, Dr. Berley statement with your team and discuss even when it is not related directly deals extensively with cases where how you will proceed in your practice to their dental health, can literally proper consent was unfortunately not and that you will then take the next be life altering or even lifesaving. obtained. In dental sleep medicine, steps toward acquiring additional In this issue, we present five as in other areas of dentistry, proper knowledge and skill in this area. articles written by esteemed dentists informed consent protects the patient Dentistry’s role in the diagnosis, who are directly involved in the as well as the dentist. Our goal is treatment and perhaps even prevention screening, evaluation and treatment to communicate these sometimes of SRBDs is significant, and I believe it of SRBDs and cover these issues difficult and complicated issues will become more significant and more in both adults and children. in a way that allows our patient widespread in years to come. As we Steve Carstensen, DDS, addresses to make a well-informed decision. look beyond the teeth to potentially the critical points that all practicing Because the treatment of SRBDs alter the current health path of our dentists need to know in order crosses over between dentistry and patients in a positive direction, to effectively help their patients medicine, there are unique aspects working hand in hand with our medical who are or may be suffering with to the informed consent process. colleagues, we and those we serve SRBDs. One does not need to be And lastly, Thomas Stark, DDS, will be rewarded for our efforts. n an expert in sleep apnea in order LTC(P), reviews how obstructive to immediately start helping their sleep apnea is evaluated and treated patients, and the impact on your in children using an interdisciplinary patients cannot be understated. approach. The opportunity for Cameron A. Kuehne, DMD, MS, prevention-oriented dentists, working discusses the potential connections with skilled dental and medical between the scourge of restorative specialists, to make potentially dentistry, bruxism and obstructive major and extensive impacts on the sleep apnea. Dr. Kuehne takes a highly current and future health and well- practical and clinically relevant being of their pediatric patients approach to this topic. Unfortunately, is incredibly exciting. In his well- not all bruxism is related to SRBDs, referenced article, Dr. Stark highlights but recognizing when it might be the current state of the art and could improve the odds of a successful, science in helping our children. long-term clinical outcome. This CDA Journal issue is meant to In his article, Marty R. Lipsey, be an overview of our role as dental DDS, MS, takes on perhaps the professionals in the screening, referral,

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CDA JOURNAL, VOL 48, Nº4

What Every Dentist Should Know About Sleep-Related Breathing Disorders

Steve Carstensen, DDS

a b s t r ac t Dentists have the opportunity to attend to more of their patient’s health than what is found in the oral cavity. The American Dental Association has prompted members to embrace a larger scope of practice, obligating every dentist to become aware of sleep-related breathing disorders and seek additional training for all team members. Collaboration with other medical providers will become a part of everyday dental practice and airway health will become a component of every treatment plan.

AUTHOR

Steve Carstensen, o one can survive without In 2017, the American Dental DDS, started treating breathing. Everyone can Association adopted the Policy Statement sleep problems in 1998 survive while breathing on the Role of Dentistry in the Treatment and practices at Premier 1 Sleep in Bellevue, Wash. badly — but there’s a price of Sleep-Related Breathing Disorders. He completed UCLA’s to pay for compromising That document encourages dentists miniresidency in sleep Nrespiration. When the body is denied to screen for SRBDs and outlines and is a diplomate of essential nutrients, such as oxygen, appropriate actions for them to take when the American Board of normal physiologic responses like they participate in the treatment and Dental Sleep Medicine. He lectures internationally, inflammation are enhanced and there are management of airway problems. The directs sleep education at always consequences. The dentist is the first step in understanding the dentist’s the Pankey Institute and is a best medical provider to identify those role, then, is to obtain and study this guest lecturer at the Spear problems early in life and to help people landmark document, available at ada.org. Education, University of the redirect their choices toward health. Early in the establishment of sleep Pacific, and Louisiana State University dental schools. Indeed, of all the medical providers in medicine as a subspecialty of medical He was editor-in-chief of most people’s lives, they spend more practice, positive air pressure (PAP) Dental Sleep Practice time with the dental hygienist than machines came to dominate physicians’ Magazine from 2014 any other. Including awareness of sleep- treatment choices.2 This was supported to 2019. Along with a related breathing disorders (SRBD) in by the rapid development of sophisticated co-author, Dr. Carstensen wrote The Clinician’s everyday dental practice is straightforward, PAP machines, improved masks and Handbook for Dental Sleep rewarding and mandatory. This essay widespread enthusiasm among physicians Medicine published by helps the dental team understand the for having an alternative to surgery. As Quintessence in 2019. details about what they should be doing early as 1982, papers were published Conflict of Interest today to make the biggest difference for about dentists fitting patients with oral Disclosure: None reported. their practice’s and community’s health. appliances to support the airway against

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collapse.3 This was only a year after Colin hygienists on typical dental diseases majority of those patients have not been Sullivan, PhD, BSc, MB, published his first such as caries, periodontal disease, tested for the disease. Of those tested, paper on the development of continuous occlusion and temporomandibular most diagnosed patients are prescribed positive airway pressure (CPAP).4 Dentists disorders. While other pathologies, PAP devices. Data compiled for World have been collaborating with sleep such as oral cancer, are also part of the Sleep Day 2019 by Philips Respironics, physicians for nearly four decades to treat curriculum, the typical dental practice one of the major PAP providers, shows SRBDs, including obstructive sleep apnea is occupied with surgical and preventive that 65% of people with sleep apnea syndrome (OSAS), but oral appliances procedures. This pattern is supported have never used or are no longer using have never had the research and corporate by a coding system for record-keeping therapy to treat their disease.8 One study support that PAP therapy has had. The and insurance benefits that is procedure of VA patients showed 90-day adherence American Academy of Sleep Medicine based without the explicit requirement of 2.5 hours per night.9 Considering (AASM) produces policy statements for to document the diagnosis or medical these statistics, it is reasonable to say the specialty; in 2015, the AASM and decision-making procedures routinely that dentists are treating many adults the American Academy of Dental Sleep found in medical encounter notes. with underdiagnosed and undertreated Medicine (AADSM) jointly published sleep-related breathing disorders. a guideline that lists oral appliances Dental practices emphasize regular alongside PAP devices as key therapy preventive visits for their patients and choices for all levels of OSAS diagnosis.5 Dentists have been each encounter provides an opportunity Every licensed dentist is legally collaborating with sleep to update the patient’s medical history supported in placing oral appliances physicians for nearly four and inquire about new symptoms. The for treating SRBDs, although the lack airway-aware dental team can use these of training in most dental education decades to treat SRBDs, visits to create meaningful conversations programs requires dentists to acquire including obstructive sleep about SRBDs. Simple screening tools additional education to include oral apnea syndrome (OSAS). such as the Epworth Sleepiness Scale and appliance therapy (OAT) within their the STOP-BANG are each comprised scope of practice. Training choices vary of eight questions that produce a score from lectures at dental meetings to online to determine risk of medically defined training to multiple-session events hosted There are many dental conditions obstructive sleep apnea (OSA). Even by dental colleges. Like other areas of commonly seen that have connections simpler is the Elbow Test — if a person practice, dentists are free to decide for to airway-related problems. One example has been told they snore and have been themselves whether they are sufficiently is periodontal disease; a study published prompted to change sleep position to trained. The trade organization AADSM in 2016 noted that OSA correlates with stop snoring and/or resume breathing, has a “qualified dentist” category that increasing periodontal disease severity.6 there is a 90% positive predictive value is earned with certain C.E. programs, The prevalence of SRBDs in for SRBDs.10 These questionnaires but that and other self-designated the population is difficult to declare are readily obtainable via any search accreditations have not been adopted with certainty. A study in Lausanne, engine. Screening tools are effectively into any regulation of dentistry. There Switzerland, reported that 49% of men incorporated into the dental encounter are professional peer-reviewed journals, and 23% of women had moderate to only when every member of the clinic textbooks, blogs and trade magazines severe sleep-disordered breathing.7 The team understands them and why they are for expanding the dentist’s scope. most commonly cited percentage of the included in the office visit. Patients will During the course of ordinary dental at-risk population that has been diagnosed wonder why the dental office is inquiring practice, patients present with a variety for SRBDs is 15%, and that number has about sleep habits and observed breathing of clinical conditions for the dentist to not changed in the 20-plus years this patterns until the connection between assess and to apply medical decision- author has been involved in treating oral and whole-body health is presented making skills, diagnose and create a airway problems. It is safe to say that by the trained dental team member. treatment plan to address. Professional every dental practice has many patients Technology is a tempting tool to use training focuses dentists and dental at risk for SRBDs and that the vast as a screening device. One instrument

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commonly found is cone beam computed by a medical doctor. After diagnosis, jaws to achieve dental goals like a fine tomography (CBCT). These devices they can fully manage therapy for a occlusion and pleasing arrangement create accurate images of 3D structures large segment of patients who have of teeth. If the scope is limited to and allow the radiologist or trained mild OSA without serious medical those laudable benchmarks, a major dentist the ability to assess the airway. comorbidities such as cardiovascular potential health contribution is left out: Because the vast majority of the scans disease. By collaborating with medical establishment of maximum health for are obtained while the subject is upright colleagues, the airway-aware dentist the airway associated with those growing and awake, however, there has been no can be a critical part of the treatment structures. After all, the American Dental consensus about the use of CBCT data of this large number of at-risk adults. Association House of Delegates adopted for identifying patients at risk for SRBDs. SRBDs in children are different in a definition of dentistry in 1997 that says, One meta-analysis concludes that people nearly every way from adults. Children in part, that “dentistry is the evaluation, diagnosed with OSA have a smaller (for the purposes of this essay, defined diagnosis and treatment of the oral cavity, minimum cross-sectional airway than that as preadolescent and before growth of maxillofacial area and adjacent and found on unaffected controls, but it does the maxilla and mandible is complete) associated structures and their impact not provide a clinically useful scale to on the human body.” That means that compare with the patient in the chair.11 dentists must assess the nasal cavity, Consumer-level devices and airway and oropharynx to determine if smartphone apps are also widely used Dentists are not there are compromises that affect the to gauge various parameters of sleep, currently licensed to health of the rest of the body. A child with claims by the commercial entities treat patients for SRBDs with poor breathing, whether through bad ranging from measuring snoring to daytime habits such as assessment of sleep quality. These if those patients have or nighttime restrictions in respiration devices, while very useful for patient not been diagnosed by from SRBDs, will not be providing the communication, are not validated against a medical doctor. rest of their body the ability to grow scientifically established testing cleared and develop to maximum potential. by the FDA for use in medicine. These The maxilla is the common structure apps and devices can be an excellent defining the oral and nasal cavities and way to alert undiagnosed people to are assessed for SRBDs by observation the position of the relative to the seek expert advice and for patients to of behavior common to a compromised posterior wall of the oropharynx. As such, gain some confidence in prescribed airway, primarily mouth breathing and the three-dimensional position of the therapy as they watch scores improve. poor sleep quality. In common use maxilla is key to whether the airway is Screening is used in medicine to are the Pediatric Sleep Questionnaire optimized during growth. Patients with identify who should be recommended to and the BEARS questionnaire; these a hypoplastic maxilla or one that has the next test. If a person completes an and others are imperfect but can been misshapen by muscle forces and air Epworth Sleepiness Scale, for example, serve well to begin the conversation pressure compromises will suffer from and it results in a score of 12 (out of a with families.12 Those children found an underdeveloped airway.14 Dentists, possible 24), this indicates someone who at risk are still recommended to be to be able to assess their child patients has excessive daytime sleepiness. This is seen by a pediatric sleep specialist for for a properly developing craniofacial- not specific for SRBDs, but it does mean testing in a child-friendly sleep lab.13 respiratory complex, must learn to that the person should be tested further There are, unfortunately, very few of evaluate the three-dimensional position to understand the reason behind the these facilities or trained sleep doctors of the maxilla during each exam while the sleepiness. Very often this is an SRBD, available compared to the number of child is growing. If the child shows signs so that sleepy patient should be sent children at risk, so, again, it falls to of airway-related problems, intervention for evaluation by a sleep specialist. the dentist to identify those patients during this period can often establish a Dentists are not currently licensed in their everyday dental practice. more open airway while simultaneously to treat patients for SRBDs if those Dentists are trained to assess and encouraging alveolar growth, creating patients have not been diagnosed manage growth and development of the room for all the permanent teeth.

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It’s not just structure that draws the abnormalities, longer electrical recovery axis. The HPA axis regulates cortisol attention of the airway-aware dentist, time of the sinoatrial node and atrial production; when that system is out however, because early problems such as enlargement compared to people without of sync with the circadian rhythm, - and/or -tie, allergies and simple SRBDs; this disruption to the homeostasis all body systems are affected.18 bad habits can result in the mouth being of the heart leads to atrial fibrillation.16 the primary respiratory portal. Christian Cardiomyopathy, atherosclerosis, Conclusion Guilleminault, MD, DSc, who defined hypertension and a host of other heart Dentists have long had the obligation the term “obstructive sleep apnea” and is diseases accompany chronic SRBDs as well. to consider whole-person health in their among the world’s leading clinicians and The limbic system, a complex group practices. General medicine is relatively researchers, declared that “nasal breathing, of brain structures, can be simplistically unconcerned with the necessity to treat 24/7, is the only possible finish line for considered as the connection between readily observable oral disease. Most children’s airway.”15 Dentists and their purely autonomic brain stem functions dentists, therefore, lack the need to team members are ideally positioned to and the highly evolved cortical regions. regularly interact with other medical recognize and offer help to families to Signals from sensory input are filtered in professionals to provide this care, resulting get their children on the right path for in the separation of dentistry from daytime as well as nighttime breathing. medical practice. The growing awareness By encouraging healthy habits of keeping of SRBDs as a factor affecting every their together, breathing through the The trained dental team cell in the human body requires every nose and posturing the tongue in the roof member can help children medical provider to consider SRBDs when of the mouth during a properly coordinated grow their craniofacial- assessing and diagnosing each patient. swallow, the trained dental team member Thus, dentists must learn how airway can help children grow their craniofacial- respiratory complex to maximum disruptions possibly explain clinical respiratory complex to maximum advantage advantage while there is time findings, consider the airway during while there is time to shape that maxilla. to shape that maxilla. evaluation and treatment planning and SRBDs affect more than blood oxygen interact with other medical providers in levels and mechanical problems in the managing chronic disease. Bridging the upper airway. For two examples, let’s divide between dentistry and medicine consider heart rhythm regulation and the thalamus to reduce cortical activity will result in higher levels of patient care the balance between the sympathetic during sleep. The autonomic nervous and a reduction in health care burden for and parasympathetic divisions of the system cycles between parasympathetic entire populations. Little of this expanded autonomic nervous system. Dentists are (rest and restore) and sympathetic connection requires medical providers often surprised to learn that snoring might (fight or flight) predominance based to learn much about oral homeostasis have effects on the heart and brain; if this on the body’s needs second by second, but it does demand dental professionals essay prompts professional curiosity and while maintaining enteric nervous expand their scope to embrace many the reader seeks deeper understanding, system functions such as respiration.17 aspects of primary care. What does the one of the writer’s goals is accomplished. Because the limbic system is the center dentist need to know about SRBDs The thorax expands when the of the body’s regulatory processes, it is today? That every service provided in diaphragm is activated, creating low highly sensitive to outside input. An a dental office must consider airway pressure in the chest cavity, normally often overlooked part of the limbic health as a necessary part of the care. n resolved with air flowing through respiratory system is embedded in cranial nerve 1, channels. If the airway is blocked, the the olfactory bulb. Mechanoreceptors REFERENCES pressure gradient pulls more blood into the there send airflow signals to the 1. The role of dentistry in sleep related breathing disorders. heart, overfilling the right atrium. The walls limbic system to aid homeostatic www.ada.org/en/~/media/ADA/Member%20Center/FIles/ The-Role-of-Dentistry-in-Sleep-Related-Breathing-Disorders. of the atrium expand, stretching beyond regulation. Disruption to the normal 2. Kryger MH ed. Principles and Practice of Sleep Medicine. normal shape. Embedded in the atrial wall is pattern of pressure change during 6th ed. Philadelphia: Elsevier; 2017:13. the sinoatrial node, the pacemaker for heart respiration yields imbalances to the 3. Cartwright RD, Samelson CF. The effects of a nonsurgical treatment for obstructive sleep apnea. The tongue-retaining rhythm. People with OSA have conduction hypothalamic-pituitary-adrenal or HPA device. JAMA 1982 Aug 13;248(6):705–9.

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4. Sullivan CE, Issa FG, Berthon-Jones M, et al. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet 1981 Apr PEMPHIGUS / PEMPHIGOID AWARENESS 18;1(8225):862–5. 5. Clinical practice guideline for the treatment of obstructive Pemphigus and pemphigoid are rare, autoimmune, skin and mucosal sleep apnea and snoring with oral appliance therapy: An update for 2015. aadsm.org/docs/CPG_OAT.pdf. blistering diseases. Patients often experience delayed diagnosis 6. Nizam N, Basoglu OK, Tasbakan MS, et al. Is there an association between obstructive sleep apnea syndrome and they commonly present with oral symptoms first. These include and periodontal inflammation? Clin Oral Investig 2016 blisters, lesions, pain when brushing or eating, and the peeling of oral May;20(4):659–68. doi: 10.1007/s00784-015-1544-y. Epub 2015 Aug 2. tissue with simple pressure. 7. Heinzer R, Vat S, Marques-Vidal P, et al. Prevalence of sleep- disordered breathing in the general population: The HypnoLaus You can accelerate diagnosis times! study. Lancet Respir Med 2015 Apr;3(4):310–8. doi: 10.1016/S2213-2600(15)00043-0. Epub 2015 Feb 12. 8. World Sleep Day 2019. www.philips.com/worldsleepday. 9. Scharf MT, Keenan BT, Pack AI, Kuna ST. Mask Refills as a Measure of PAP Adherence. J Clin Sleep Med 2017 Nov ASK YOUR PATIENTS: 15;13(11):1337–1344. doi: 10.5664/jcsm.6810. 10. Fenton ME, Heathcote K, Bryce R, Skomro R, Reid JK, Gjevre J, Cotton D. The utility of the elbow sign in the diagnosis Do you have more than one blister of OSA. Chest 2014 Mar 1;145(3):518–524. doi: 10.1378/ 1 chest.13-1046. or lesion in your mouth? 11. Chen H, Aarab G, de Ruiter MH, de Lange J, Lobbezoo F, van der Stelt PF. Three-dimensional imaging of the upper airway anatomy in obstructive sleep apnea: A systematic Have your blisters or lesions lasted review. Sleep Med 2016 May;21:19–27. doi: 10.1016/j. 2 for more than a week? sleep.2016.01.022. Epub 2016 Apr 5. 12. Ahmed S, Hasani S, Koone M, Thirumuruganathan S, Diaz-Abad M, Mitchell R, Isaiah A, Das G. An empirical study Have you continually had blisters of questionnaires for the diagnosis of pediatric obstructive 3 sleep apnea. Conf Proc IEEE Eng Med Biol Soc 2018 or lesions that don’t heal? Jul;2018:4097–4100. doi: 10.1109/EMBC.2018.8513389. 13. Marcus CL, Brooks LJ, Draper KA, Gozal D, et al. Diagnosis and management of childhood obstructive sleep Do you have blisters or lesions in apnea syndrome. Pediatrics 2012 Sep;130(3):e714–55. doi: 4 10.1542/peds.2012-1672. Epub 2012 Aug 27. any locations outside the mouth? 14. Oltramari-Navarro PV, de Almeida RR, Conti AC, Navarro Rde L, de Almeida MR, Fernandes LS. Early treatment protocol for skeletal Class III . If your patient answers YES to 3 or MORE of these questions, Braz Dent J 2013;24(2):167–73. doi: 10.1590/0103- a biopsy should be considered. Both conventional H&E histology 6440201301588. 15. Guilleminault C, Quo SD. Sleep-disordered breathing. A (in formalin) and DIF (in Michel’s/Zeus) are needed for a diagnosis. view at the beginning of the new millennium. Dent Clin North Am 2001 Oct;45(4):643–56. Specimens must contain intact epithelium over the underlying 16. Dimitri H, Ng M, Brooks AG, et al. Atrial remodeling in connective tissue. obstructive sleep apnea: Implications for atrial fibrillation. Heart Rhythm 2012 Mar;9(3):321–7. doi: 10.1016/j. hrthm.2011.10.017. Epub 2011 Oct 19. More info and photos at https://pemphig.us/cal 17. Wehrwein EA, Orer HS, Barman SM. Overview of the anatomy, physiology and pharmacology of the autonomic nervous system. Compr Physiol 2016 Jun 13;6(3):1239–78. doi: 10.1002/cphy.c150037. 18. Amdo T, Hasaneen N, Gold MS, Gold AR. Somatic syndromes, insomnia, anxiety and stress among sleep disordered breathing patients. Sleep Breath 2016 May;20(2):759–68. doi: 10.1007/s11325-015-1296-6. Epub 2016 Jan 21. The IPPF Awareness Program is generously funded by the Sy Syms Foundation and the Unger family. THE AUTHOR, Steve Carstensen, DDS, can be reached at [email protected].

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TOGETHER WE ARE LIMITLESS obstructive sleep apnea

CDA JOURNAL, VOL 48, Nº4

Bruxism, Obstructive Sleep Apnea and Dentistry

Cameron A. Kuehne, DMD, MS

a b s t r ac t There are many recent studies pointing to a connection between bruxism and obstructive sleep apnea (OSA). Due to the potential for adverse health effects related to untreated or improperly treated OSA, dental professionals have a key role in helping to identify and manage OSA.

AUTHOR

Cameron A. Kuehne, bstructive sleep apnea for their OSA. Finding these untreated DMD, MS, has been (OSA) is a serious health or incorrectly treated people is medically mentored by world- problem that affects at necessary due to the increased risk of the renowned experts in the fields of TMJ disorders and least 9% of women and at health concerns associated with OSA. dental sleep medicine. least 24% of men aged 30 OSA has been implicated with He is a graduate of the Oto 60,1 and many clinicians feel that these many different health concerns such Temple University School numbers may be an underestimation of the as hypertension, stroke and congestive of Dentistry and the Tufts prevalence of OSA. Many physicians and heart failure.6,7 Obstructive sleep apnea University School of Dental Medicine where researchers believe that as the incidence has also been linked to Type 2 diabetes, he obtained a master’s of obesity continues to rise, the prevalence and it is thought that up to 83% of Type degree in craniofacial of OSA increases. However, it is now 2 diabetics suffer from unrecognized pain and dental sleep understood that OSA may affect anybody, OSA.8 Most of these studies agree that medicine. Dr. Kuehne is a not just the elderly or the obese. Healthy the exact mechanism by which OSA is diplomate of the American Board of Craniofacial men, women and children may also be at linked to different medical problems is not Pain, the American Board risk for OSA. Thus, it is not possible to fully understood. However, the literature of Dental Sleep Medicine rule out sleep apnea in anyone based on available that shows the connection and the American Board of their physical attributes alone. Multiple between OSA and multiple medical Craniofacial Dental Sleep studies have shown that an anatomically comorbidities is immense. The medical Medicine. He is a fellow of the American Academy small airway increases risk for OSA and is community is beginning to understand of Craniofacial Pain. He is comparable to the increased risk for OSA the consequences of untreated OSA and also adjunct faculty at the that obesity and age cause.2–5 If there is any realizes the importance of early diagnosis University of Utah and the suspicion that a person may be at risk for and treatment of this serious issue. The University of the Pacific, OSA, they should be evaluated medically dental community needs to follow suit. Arthur A. Dugoni School of Dentistry where he is due to the vast complications associated Through correct intervention, OSA co-director of dental sleep with OSA. Diagnosis of this problem is is a treatable problem and there are miniresidency programs. the key to receiving proper treatment. Due multiple different treatments for OSA. Conflict of Interest to the underdiagnosis of this problem, it Dental oral appliance therapy is one of Disclosure: None reported. is possible that many people are currently the most common forms of treatment untreated or are being treated incorrectly for OSA. A dental oral appliance is a

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device that fits within the oral cavity and devices and soft palate lifts have not.10 oral activity characterized by teeth prevents upper airway collapse in patients Tongue-retaining devices and soft grinding or clenching during sleep.19,20 with OSA. Dental oral appliances have palate lifts tend to be poorly tolerated One study suggested that upwards of been shown to be a valid alternative by patients.10 Mandibular advancement 15% of children grind their teeth at to continuous positive airway pressure devices are usually tolerated the best night.21 Most studies agree that around (CPAP).9,10 Dental oral appliance therapy of any dental oral appliances used for 8% to 9% of adults brux at night.22 has been effective in reducing blood the treatment of OSA.10 Of the MADs, There have been many different forms pressure.11 A study published in 2011 by there are titratable versions that have of treatment for bruxism in the past; Holley et al. is one of the largest studies been shown to be more effective than however, the most accepted treatment ever done comparing the effectiveness fixed versions.14 Titratable dental oral for bruxism is the dental nightguard of adjustable dental oral appliance to appliances give a better range to fine-tune (NG).23,24 While most research has CPAP for the treatment of OSA.12 This the appliance to the most therapeutic shown that an NG does not necessarily study, with 497 subjects, showed a vast position possible. It has also been shown stop the muscle contractions responsible improvement in OSA levels in both that custom MADs are more effective for bruxism, an NG does help to protect groups, especially when comparing the teeth from wearing down.19 In one subjects with mild OSA. No statistically study, though, short-term relaxation significant difference was seen between of the muscles associated with bruxism 24 the treatments of dental oral appliances There are many dental occurred. The pathophysiologic reasons and CPAP when looking at subjects with for why some people brux at night are not mild to moderate OSA. There was a oral appliances used to completely understood at this point; it is statistically significant difference when treat OSA, but not all possible that bruxism may be due to an comparing the two treatments in subjects dental oral appliances underlying OSA problem.22 There have with severe OSA, with the CPAP group also been studies showing a correlation showing a better result. However, the are as effective as others. between sleep apnea symptoms and subjects with severe OSA still showed temporomandibular disorders.25 considerable improvement when treated The literature has shown that bruxism with the dental oral appliance. This may be caused in part by a narrowing study showed the best improvement of than boil-and-bite MADs.15 Boil-and-bite of the airway due to OSA. Transient OSA with a dental oral appliance than type dental oral appliances are usually arousals, as seen in OSA, have been any other past study. The method used bulky and less retentive than a custom- experimentally shown to cause bruxism.26 in the treatment of OSA is important made dental oral appliance. Research has Arousals are a change in sleep cycles to ensure the patient’s compliance with shown that protrusion of the mandible, from a deeper to lighter stage of sleep or therapy. Compliance has also been shown not the vertical dimension of occlusion, from REM stage sleep to awake. Also, to be high with dental oral appliance is the key to relief of OSA.16,17 Vertical a rise in sympathetic activity, as seen therapy as patients prefer the treatment dimension of occlusion is usually during an apneic event, can induce of OSA with a dental oral appliance over increased or decreased for comfort issues bruxism.27 Studies have shown that other forms of OSA treatment.13 The and not as a way of correcting OSA. A as an MAD is applied at therapeutic type of dental oral appliance used for the correctly fit custom MAD fabricated and levels for the treatment of OSA, treatment of OSA needs to be chosen adjusted by trained dental personnel is a nocturnal bruxism tends to lessen.28 The wisely to aid in patient compliance. viable treatment for patients with OSA. implication is that the dentist who is There are many dental oral appliances Many patients with OSA also fabricating an MAD for the treatment used to treat OSA, but not all dental oral suffer from bruxism, although current of OSA may be actually helping to treat appliances are as effective as others. A literature would suggest that the an underlying cause of bruxism instead mandibular advancement device (MAD) relationship between bruxism and OSA of just helping to protect the teeth. has been shown to be an effective dental is not yet fully understood.18 Bruxism The dentist is a key part in the oral appliance for the treatment of is the third most frequent parasomnia treatment of both OSA and bruxism. OSA,10 while certain tongue-retaining disorder and has been defined as an The dentist also should be instrumental

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in the process of screening patients for Summary Comparison of adjustable and fixed oral appliances for the treatment of obstructive sleep apnea. J Clin Sleep Med 2011 Oct OSA. A patient who presents with a Due to the life-threating nature of 15;7(5):439–445. doi: 10.5664/JCSM.1300. chief complaint of bruxism should be OSA, all dental patients should ideally 15. Vanderveken OM, Devolder A, Marklund M, et al. screened for OSA due to the association be screened for OSA, especially before Comparison of a custom-made and a thermoplastic oral appliance for the treatment of mild sleep apnea. Am J Respir Crit Care Med between OSA and bruxism. Before a a nightguard for bruxism is fit. The 2008 Jul 15;178(2):197–202. Epub 2007 Aug 2. dental NG is fit to help protect the teeth dental professional can and should 16. Nikolopoulou M, Naeije M, Aarab G, Hamburger HL, Visscher from bruxism, OSA needs to be ruled be an integral part in working with CM, Lobbezoo F. The effect of raising the bite without mandibular protrusion on obstructive sleep apnoea. J Oral Rehabil 2011 out. Recent studies have shown that the medical community to identify Sep;38(9):643–647. doi: 10.1111/j.1365-2842.2011.02221.x. NG treatment may actually aggravate and manage patients with OSA. n Epub 2011 Apr 5. the patient’s OSA problem. One such 17. Aarab G, Lobbezoo F, Hamburger HL, Naeije M. Effects of an REFERENCES oral appliance with different mandibular protrusion positions at a study showed that an NG with a vertical 1. Ferini-Strambi L, Fantini ML, Castronovo C. Epidemiology constant vertical dimension on obstructive sleep apnea. Clin Oral dimension of occlusion that was too of obstructive sleep apnea syndrome. Minerva Med 2004 Investig 2010 Jun;14(3):339–345. doi: 10.1007/s00784-009- extreme aggravated OSA.16 Another Jun;95(3):187–202. 0298-9. Epub 2009 Jun 18. 2. Friedman M, Tanyeri H, La Rosa M, et al. Clinical 18. Balasubramaniam R, Klasser G, et al. The link between sleep study of interest was a pilot study predictors of obstructive sleep apnea. Laryngoscope 1999 bruxism, sleep disordered breathing and temporomandibular 29 done by Gagnon that showed 50% of Dec;109(12):1901–1907. disorders: An evidence-based review. J Dent Sleep Med patients with OSA who wore a dental 3. Li KK, Kushida C, Powell NB, Riley RW, Guilleminault C. 2014;1(1):27–37. doi: 10.15331/jdsm.3736. Obstructive sleep apnea syndrome: A comparison between Far- 19. Macedo CR, Silva AB, Machado MA, Saconato H, Prado NG had an aggravation of their apnea- East Asian and white men. Laryngoscope 2000 Oct;110(10 Pt GF. Occlusal splints for treating sleep bruxism (tooth grinding). hypopnea index (AHI, which is classified 1):1689–1693. Cochrane Database Syst Rev 2007 Oct 17;(4):CD005514. as mild when the AHI is between five 4. Schellenberg JB, Maislin G, Schwab RJ. Physical findings and the 20. Ohayon MM, Li KK, Guilleminault C. Risk factors for sleep risk for obstructive sleep apnea. The importance of oropharyngeal bruxism in the general population. Chest 2001 Jan;119(1):53–61. and 15, moderate between 15 and 30 and structures. Am J Respir Crit Care Med 2000 Aug;162(2 Pt 21. Thompson BA, Blount BW, Krumholz TS. Treatment approaches severe when greater than 30). In this 1):740–748. doi: 10.1097/00005537-199912000-00007. to bruxism. Am Fam Physician 1994 May 15;49(7):1617–1622. study, 10 patients slept three nights at 5. Schwab RJ. Pro: Sleep apnea is an anatomic disorder. 22. Behr M, Hahnel S, Faltermeier A, et al. The two main theories Am J Respir Crit Care Med 2003;168(3):270–271. doi. on dental bruxism. Ann Anat 2012 Mar 20;194(2):216–219. a sleep lab: one night as a baseline, one org/10.1164/rccm.2305014. doi: 10.1016/j.aanat.2011.09.002. Epub 2011 Oct 5. night with an NG (maxillary, flat-plane, 6. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The 23. Sheikholeslam A, Holmgren K, Riise C. Therapeutic hard) and one night with no guard in occurrence of sleep-disordered breathing among middle-aged effects of the plane occlusal splint on signs and symptoms of adults. N Engl J Med 1993 Apr 29;328(17):1230–1235. craniomandibular disorders in patients with nocturnal bruxism. J place. The study showed that there was 7. Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Oral Rehabil 1993 Sep;20(5):473–482. no statistically significant difference Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and 24. Harada T, Ichiki R, Tsukiyama Y, Koyano K. The effect of oral in the AHI between the night with death. N Engl J Med 2005 Nov 10;353(19):2034–2041. splint devices on sleep bruxism: A six-week observation with an 8. Pamidi S, Aronsohn RS, Tasali E. Obstructive sleep apnea: ambulatory electromyographic recording device. J Oral Rehabil the NG versus the night without the Role in the risk and severity of diabetes. Best Pract Res Clin 2006 Jul;33(7):482–488. NG, but that five of the 10 patients Endocrinol Metab 2010 Oct;24(5):703–715. doi: 10.1016/j. 25. Sanders AE, Essick GK, et al. Sleep apnea symptoms and risk had an aggravation of their AHI. An beem.2010.08.009. of temporomandibular disorder: OPPERA cohort. J Dent Res 2013 9. Barnes M, McEvoy RD, Banks S, et al. Efficacy of positive airway Jul;92(7 Suppl):70S–7S. doi: 10.1177/0022034513488140. interesting note was that patients had pressure and oral appliance in mild to moderate obstructive sleep Epub 2013 May 20. the most increase in AHI while wearing apnea. Am J Respir Crit Care Med 2004 Sep;170(6):656–664. 26. Kato T, Montplaisir JY, Guitard F, Sessle BJ, Lund JP, Lavigne the NG on their sides and stomachs, Epub 2004 Jun 16. GJ. Evidence that experimentally induced sleep bruxism 10. Barthlena G, Browna L, Wiland M, Sadeha J, Patwaria J, is a consequence of transient arousal. J Dent Res 2003 not in the supine position. The authors Zimmerman M. Comparison of three oral appliances for treatment Apr;82(4):284–288. suggested that dental clinicians should of severe obstructive sleep apnea syndrome. Sleep Med 2000 Oct 27. Huynh N, Kato T, Rompre PH, et al. Sleep bruxism is associated be aware that manipulating spaces 1;1(4):299–305. to micro-arousals and an increase in cardiac sympathetic activity. J 11. Gotsopoulos H, Kelly JJ, Cistulli PA. Oral appliance therapy Sleep Res 2006 Sep;15(3):339–346. within the mouth can reduce tongue reduces blood pressure in obstructive sleep apnea: A randomized, 28. Landry ML, Rompre PH, Manzini C, Guitard F, de Grandmont space and possibly cause aggravation controlled trial. Sleep 2004 Aug 1;27(5):934–941. P, Lavigne GJ. Reduction of sleep bruxism using a mandibular of sleep disturbances such as OSA 12. Holley AB, Lettieri CJ, Shah AA. Efficacy of an adjustable oral advancement device: An experimental controlled study. Int J appliance and comparison with continuous positive airway pressure Prosthodont 2006 Nov–Dec;19(6):549–556. and snoring. As such, screening of all for the treatment of obstructive sleep apnea syndrome. Chest 2011 29. Gagnon Y, Mayer P, Morisson F, Rompre PH, Lavigne GJ. dental patients before a dental NG Dec;140(6):1511–1516. doi: 10.1378/chest.10-2851. Epub Aggravation of respiratory disturbances by the use of an occlusal for bruxism is fabricated needs to be 2011 Jun 2. splint in apneic patients: A pilot study. Int J Prosthodont 2004 Jul– 13. Ferguson KA, Ono T, Lowe AA, Keenan SP, Fleetham Aug;17(4):447–453. a priority. Dentists have the unique JA. A randomized crossover study of an oral appliance vs opportunity to see their patients on a nasal-continuous positive airway pressure in the treatment THE AUTHOR, Cameron A. Kuehne, DMD, MS, can be six-month basis and have the chance to of mild-moderate obstructive sleep apnea. Chest 1996 reached at [email protected]. May;109(5):1269–1275. recognize a potential issue with OSA. 14. Lettieri CJ, Paolino N, Eliasson AH, Shah AA, Holley AB.

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CDA JOURNAL, VOL 48, Nº4

Incorporating Dental Sleep Medicine Into Your Practice: S.E.T.U.P. for Success in Sleep

Marty R. Lipsey, DDS, MS

a b s t r ac t This article provides insight into systems for incorporating or improving a dental sleep medicine program into the dental practice.

AUTHOR

Marty R. Lipsey, DDS, hy should I get independent of and apply regardless of MS, is a consultant, started? How do I the dentist’s choice of bite registration lecturer and medical get started? How technique or appliance. These protocols billing expert in the area of dental sleep medicine. do I screen my are comprehensive and will benefit the Conflict of Interest patients? What entire dental team. The good news, right Disclosure: Dr. Lipsey is the Wabout sleep testing and diagnosis? What from the start, is that the protocols do not president of Medical Billing documents do I need in my records? require the purchase of any new software or for Dentists. How do I deal with medical insurance? expensive instrumentation to incorporate As a practitioner, lecturer, consultant dental sleep medicine into your practice. and medical billing expert, I will provide A significant number of patients insight into these and more commonly who walk through our doors every day asked questions. Clinical procedures and present with life-threatening and life- appliances will not be discussed in this shortening risk factors for sleep-related article. It is my goal to present easily breathing disorders. Furthermore, the duplicated, tried-and-true systems that entryways to the nasal and oropharyngeal have been developed and fine-tuned airways are constantly in our field of for more than 16 years. This is a system view during every clinical procedure that my team and I have successfully throughout our day. Dentists can play implemented in practice and that we a major role in the recognition of the have used to help hundreds of dentists signs and symptoms and the overall implement or improve the dental sleep management of obstructive sleep apnea medicine area of their dental practices. (OSA).1 Levendowski et al.2 found that This is a step-by-step process for successful the high prevalence of undiagnosed implementation of a dental sleep medicine sleep apnea in dental patients suggests program, which I will outline below that dentists could provide a valuable as a “S.E.T.U.P. for Success in Sleep” service to their patients by incorporating protocol. The steps in that protocol are sleep apnea screening and treatment

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TABLE Screening Protocol Patient category Suggested education action Not at risk and never tested No action for this patient. Explain why the practice has implemented a sleep health awareness program. into their practice. In their study of two At risk and never tested Review risk factors and educate as to benefits of diagnostic sleep testing. dental practices, 28% of female patients Diagnosed and compliant Encourage patient to continue CPAP usage. and 67% of male patients were shown to with CPAP have a high pretest probability of having Diagnosed and noncompliant Review prior findings with patient in an effort to find a medically at least mild sleep apnea. Al-Jewair et with CPAP recommended treatment option that patient can be compliant with. al.3 found in a total of 200 consecutive Diagnosed and OA compliant Review history of treatment and continued care. female and male dental patients that Diagnosed and noncompliant Review prior findings with patient in an effort to find a medically 21.75% of the females and 78.3% of with OA recommended treatment option that patient can be compliant with. the males were at high risk of OSA. In 2017, the ADA’s House of Delegates adopted the “Policy Statement for the STOP, STOP-BANG (SB), Epworth awareness of our patients. As was Role of Dentistry in the Treatment of Sleepiness Scale (ESS) and four-variable mentioned previously, screening and Sleep-Related Breathing Disorders.” This screening tool (4-V). The bottom line is education go hand in hand. This is a should be deemed as setting the current that each practice should find an organized value-added service for the practice standard of practice. In that policy, way to screen and discuss sleep health and the educational and health lessons dentists are encouraged to screen patients with every patient. A point person or sleep extend to other family members. for sleep-related breathing disorders coordinator should be tasked to assure It is important to understand that the and refer as needed to the appropriate that these forms are reviewed and that sole purpose of screening is to identify physicians for proper diagnosis. The conversations take place so at-risk patients patients who are at risk for sleep-related policy also clearly states that oral clearly understand the life-threatening breathing disorders. It is the first step appliance therapy is an appropriate and life-shortening nature of this disease. in an overall process. Comparing to treatment for mild and moderate sleep In most dental practices, the flow for our usual dental world, it would be apnea and for severe sleep apnea when new patients is different as compared to inappropriate to discuss possible root continuous positive airway pressure the flow for patients of record. Likewise, canals and crowns with a patient before (CPAP) is not tolerated by the patient. the flow of these screening processes a complete dental examination. During The steps for “S.E.T.U.P. for may differ as well. Including a sleep that dental examination, we would Success in Sleep” are screen, educate, health screening form with new patient utilize all appropriate diagnostic tools and test, understand and present. paperwork will help gather information imaging. Only after a complete analysis for an initial sleep health conversation would we then discuss treatment options. Screen with each new patient. For patients Likewise, sleep health screening is not While screen is the first step of record, each practice should decide the appropriate time to discuss treatment. in the acronym and also in actual whether it is easier and more efficient There is usually no medical diagnosis at implementation, keep in mind that we to have patients complete a sleep this step in the process. With that said, are actually educating our patients during health questionnaire at their recare this is a very common mistake made by screening. Screen and educate are truly appointment or if the hygienist or sleep many dental teams. During the screening combined cornerstones of the process. coordinator should accomplish this task process, if you are asked, “What might For practitioners desiring to act in a conversation with the patient. be wrong?” or “What treatment might I in accordance with the ADA policy During screening, all patients in need?” the only answer is, “I don’t know statement and to have a successful dental the practice will fall into one of the and that’s why we are going through sleep medicine program in their practice, categories shown in the TABLE. A this screening process.” The screening step one is to screen 100% of your patients suggested action for each category process is the first step in an effort to for sleep-related breathing disorders. There is proposed. Beyond any suggested identify patients at risk and increase our are a number of recognized screening action (and even when no action is patients’ sleep health awareness. We then forms that are commonly used in medical necessary for a particular patient), keep move on to educate about the risks of practice to screen for OSA. Singh et al4 in mind that the underlying principle the disease and the benefits for those at found that four screening tools are widely of this program is that we are always risk to complete a diagnostic sleep study recognized as being easy to administer: striving to increase the sleep health that will be reviewed and interpreted by

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Dentist

Sleep Educate the initial steps in education. It is through coordinator Education is the most critical part of these steps that each office can identify the process and probably the “make it or the responsibilities and delineate the break it” for the success of implementing duties of the sleep coordinator. Those Team Patient a dental sleep program. As you read responsibilities and duties will also become through the articles in the CDA Journal, easier to enumerate and define as we go you are increasing your own sleep health through the remainder of the steps in FIGURE. The educational triangle. awareness, which is certainly a key the S.E.T.U.P. process. Dentists should component of what we will introduce as become the captain of their teams to the educational triangle (FIGURE). Sleep assure that they and the entire team have a board-certified sleep physician. Only health education begins with educating had an appropriate level of sleep health then might we be able to talk about what’s ourselves and our entire team so we are education. The sleep health education wrong and what might be needed to fix it. then able to educate our patients to help and awareness level of the dentist should If we find that a patient has had a them understand what may previously help to determine if team education is prior sleep study, we should obtain a have been out of the scope of usual best accomplished in house or if the team copy before we begin to speculate on conversation at the dental office. should seek outside education in areas that what to recommend or not recommend. The sleep coordinator and the dental may include learning sleep health terms During the overall screening process, we team should not assume that the patient and terminology, sleep pathophysiology, will also undoubtedly identify patients has a thorough understanding of this diagnostic sleep testing and oral appliance who were previously told by a physician disease and all appropriate treatment therapy. Most of what we are dealing that they should undergo a diagnostic options even if they have previously gone with in incorporating dental sleep into sleep study and did not. Screening is through diagnostic sleep testing. The the practice is new and different, but it also where we will identify untreated reality of the medical practice world often certainly does not need to be difficult if patients previously diagnosed with OSA may not have allowed sufficient time for the dentist assures that the educational as well as noncompliant CPAP patients. patients to fully understand the diagnosis targets are appropriate and have been Any and all of these situations require and the ramifications of their diagnosis. achieved by the different members of our further assessment of the diagnostic Education encompasses a tripartite the team. The sleep coordinator can and treatment history before we jump in effort for dentist, team and patient. In be tasked with assuring that front- and with recommendations. These situations most cases, sleep health is not an area back-office members understand their would only then warrant further patient of practice where the dentist received responsibilities and have the knowledge education and direction to the next any or very little clinical education necessary to accomplish these tasks. appropriate step. Even when patients in the dental school curriculum. The dentist must establish a flow for have had prior sleep tests, it is not For the dentist and the dental the sleep program and assure that the appropriate to discuss treatment until team, educating themselves in sleep sleep coordinator is familiar with and we have reviewed medical history and health must be coupled with educating able to guide staff and patients through prior diagnostic sleep study reports. themselves in a process that informs the program. Safeguards must be put in The S.E.T.U.P. process is the most and educates patients. The entire place so that the dental sleep program is patient-, practice- and physician- team must be onboard. The team must not derailed before it ever gets started. friendly when you don’t jump ahead. understand the process that they will It might be one of the oldest clichés in Lastly, but equally as important to all carry out for implementation and life, but in the dental office, new habits mention, is that screening is not the follow-through of a step-by-step dental are hard to make and easy to break. The appropriate time to discuss cost or sleep medicine program for the practice. sleep coordinator’s prime responsibility medical insurance or appliances. We’ll The sleep coordinator is responsible is to keep the integrity of a routine sleep get there, but we have to first educate for maintaining the integrity of the health screening process and to assure that ourselves and then the patient on the educational triangle. Without a point patients are receiving the direction and specifics of their individual risk factors person other than the dentist, the program education that is necessary to predictably and the appropriate next step to take. is more often miss than hit. Let’s review and successfully move on to the next step.

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Test might be practical in building any referral When oral appliance therapy is a Up to this point, the documentation relationship, a face-to-face meeting with recommended treatment option and that should be in your clinical records the sleep physician should be helpful the patient chooses to proceed in that is detailed notes of the sleep health and informational. It is important to direction, their medical insurance review with the patient as well as discuss the sleep physician’s feelings company will usually require a patient- detailed notes regarding any relevant about treatment options for patients signed CPAP Intolerance or Refusal comorbidities. A copy of any screener/ you might refer to their practice. We are form in order to provide coverage for oral questionnaire should be in the record. A looking for a physician partner who will appliance therapy. Getting this document copy of the patient’s medical insurance make treatment recommendations in should become normal practice and a card should be obtained, as it will be the best interest of the patient. We are responsibility of the sleep coordinator. necessary for upcoming verification looking for a physician partner who will of medical insurance benefits. recommend oral appliance therapy as a Understand Diagnostic sleep testing can be treatment option when it is appropriate There are, at minimum, three people accomplished with polysomnography according to the guidelines of the involved in the understand portion of (PSG) during an overnight stay in a lab or the process. The first two are the dentist at home with a home sleep testing device and the sleep coordinator. The third (HST). In all cases, the results must be is the patient and perhaps additionally read and interpreted by a medical doctor In all cases, the results the bed partner or a family member who will also provide a medical diagnosis must be read and interpreted of the patient. The dentist and sleep and treatment recommendations. It is by a medical doctor who coordinator must review and understand within the scope of dental practice to all findings, including but not limited to provide oral appliance therapy. Only a will also provide a medical the sleep study report. Understanding physician can review the sleep study data, diagnosis and treatment the patient’s personal and family medical provide the diagnosis and recommend recommendations. history as well as a thorough evaluation the appropriate treatment options. of the patient’s intraoral health is If the patient has previously critical to this stage of the process. undergone a diagnostic sleep study, a The dentist and sleep coordinator copy should be easy to obtain by having American Academy of Sleep Medicine. should review the sleep study so they can the patient sign a medical records We are also looking for someone we can prepare themselves to present the findings release form. This can be faxed to respect and learn from as we enter the to the patient and help the patient to the facility or to the physician’s office medical sleep world of our dental practice. understand the most important and where the study was completed. Understanding when a particular sleep relevant findings during case presentation. If the patient is at risk and has not physician will and will not recommend The dentist and sleep coordinator should undergone a diagnostic sleep study, testing oral appliance therapy can help the understand the technical data in the sleep is the next step in the process. The results dentist make the best referral choices. study report. They should also understand of the sleep study will dictate how to It is equally important to determine how to communicate these findings in a proceed and will frame the conversation what the sleep physician expects of the simple and illustrative way to the patient. and case presentation with the patient. dentist as a referrer to the sleep practice. Items that may be critical to the patient’s The availability of sleep physicians and When the patient has completed understanding may include: How many testing facilities will vary depending the diagnostic sleep study, the sleep times does the patient choke and suffocate on the geographic location. In most study report becomes the key document per hour/per night, how long is the longest metropolitan areas, patients and practices in the clinical record and is critical for choking and suffocating event, how much will have many options. This article medical insurance purposes. When oral oxygen desaturation is the patient going deals with incorporating dental sleep appliance therapy is listed as one of through as a result of their choking and medicine into the dental practice, and we the recommended treatment options, suffocating during sleep? How might therefore will assume that most readers that report provides the physician’s the sleep health findings be related to are near the beginning of this process. As directive for the dentist to proceed. medications that the patient is taking,

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to impending life-shortening or life- ■ Use visual words in your case REFERENCES threatening medical issues, to excessive presentation. Don’t assume that 1. Bailey DR, Attanasio R. Dentistry’s role in the management of sleep disorders. Recognition and management. Dent Clin daytime sleepiness/drowsiness? What is the your patient understands the life- North Am 2001 Oct;45(4):619–630. board-certified sleep doctor recommending shortening and life-threatening 2. Levendowski DJ, Morgan T, Montague J, Melzer V, Berka for treatment? The list of considerations nature of this disease. Paint an C, Westbrook PR. Prevalence of probable obstructive sleep apnea risk and severity in a population of dental patients. goes on and on, but there is a personalized easy to understand picture. If you Sleep Breath 2008 Nov;12(4):303–309. doi: 10.1007/ story to tell from the data collected in shortcut patient education, you s11325-008-0180-z. Epub 2008 Apr 9. each case. We must understand how to shortcut the formula to success. 3. Al-Jewair TS, Nazir MA, Al-Masoud NN, Alqahtani ND. Prevalence and risks of habitual snoring and obstructive be good educators and communicators ■ Review all treatment options sleep apnea symptoms in adult dental patients. Saudi during this part of the process, so we are from the sleep study report. Don’t Med J 2016 Feb;37(2):183–90. doi: 10.15537/ prepared for the case presentation. be negative about CPAP. It is the smj.2016.2.12852. 4. Singh J, Mims N. Screening Tools for the Obstructive This is the appropriate time to gather gold standard medical treatment Sleep Apnea for the Cardiovascular Clinician. medical insurance benefit information. and is the most appropriate American College of Cardiology Latest in Cardiology. The patient is almost certainly going to treatment for severe cases. If a July 14, 2015. www.acc.org/latest-in-cardiology/ articles/2015/07/14/11/04/screeing-tools-for-the- ask the “how much” question at the case patient is CPAP intolerant or obstructive-sleep-apnea-for-the-cardiovascular-clinician. presentation. Reach out for competent refuses CPAP and you have a help in this process. An expert third-party physician’s recommendation THE AUTHOR, Marty R. Lipsey, DDS, MS, can be reached at [email protected]. medical billing team can assist in not for oral appliance therapy, you only obtaining all the necessary details should point out the benefits of benefit verification but in completing of this treatment option. medical insurance authorization, ■ Lean on the board-certified sleep which is often necessary for third-party physician’s written report in reimbursement. This part of the process is your case presentation. Their not dental business as usual. It is different, expertise, findings and treatment but not difficult if you outsource the recommendations carry a lot process through a competent partner. of weight for the patient. The dental team should understand that ■ Don’t guarantee success of assisting with medical insurance is a treatment. That’s not the win-win process and more cases will be standard in the medical accepted when we implement a patient- world. Guarantee and provide friendly medical insurance protocol. your best effort to control this life-shortening and Present life-threatening disease. The case presentation is a combined ■ Present an all-inclusive fee for effort by the dentist and sleep coordinator. an all-inclusive initial course Each practice will develop their own of therapy. This is easier for the approach and personality for successfully patient to understand and accept. accomplishing this part of the process. The ■ Be patient-, practice- and previous section outlined what the dentist physician- friendly when it and sleep coordinator should review and comes to working with medical understand so that they, in turn, can help insurance. Working with a the patient to understand the details of partner to outsource verification the findings and the recommendations of medical benefits, medical for treatment. Here are a few additional authorizations and medical pearls that are positive for both patient billing will help you to help more and practice and will help your case patients by getting more yeses to presentations be most successful: treatment that you present. n

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CDA JOURNAL, VOL 48, Nº4

Informed Consent for Dental Sleep Medicine

Ken Berley, DDS, JD

a b s t r ac t Informed consent for dental sleep medicine is a process of obtaining permission before conducting health care intervention or for disclosing personal information. An informed consent is given based upon a clear appreciation and understanding of the facts, implications and consequences of an action. Adequate informed consent is rooted in respecting a person’s dignity.

AUTHOR

Ken Berley, DDS, JD, has nformed consent for dental disclosures should be made by the practiced general, implant sleep medicine (DSM) is a physician (dentist) to their patient and cosmetic dentistry process of obtaining permission and not through use of consent forms for more than 35 years and completed extensive before conducting health care that are not particular to individual training in the field of dental intervention or for disclosing patients. To minimize any subsequent sleep medicine. He is also Ipersonal information. An informed claim by the patient that there was an attorney and teaches consent is given based on a clear a lack of adequate disclosures, the other dentists how to appreciation and understanding of the physician (dentist) should record in effectively treat patients with obstructive sleep apnea. facts, implications and consequences the patient’s chart the circumstances Dr. Berley is a diplomate of an action. Adequate informed of the patient’s consent and should of the American Board of consent is rooted in respecting a not rely on the patient’s unreliable Dental Sleep Medicine and person’s dignity.1 Informed consent ability to recall those circumstances.2,3 a member of the American is collected according to guidelines To legally provide any service or Academy of Dental Sleep Medicine, the American from the fields of medical ethics and medical procedure for a patient, the Dental Association and research ethics. Informed consent patient must give permission for the the Academy of General is a legal obligation due from a treatment. The permission is only Dentistry. physician (dentist) to their patient, valid if it is given with full knowledge Conflict of Interest an obligation that may not be met of the possible risks and benefits of Disclosure: None reported. by the physician’s (dentist’s) skillful the treatment. Therefore, appropriate treatment of their patient. It may informed consent is mandatory only be met by the treating physician for oral appliance therapy (OAT). (dentist) obtaining from their patient While significant complications have knowing authorization for carrying been rare, tooth and jaw movement out the intended medical procedure. secondary to mandibular advancement The physician (dentist) is required to device (MAD) usage is a common disclose whatever would be material to long-term result. To practice dental their patient’s decision, including the sleep medicine and minimize risk, nature and purpose of the procedure patients must be adequately informed and the risks and alternatives. The before treatment is initiated.4

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Elements of Informed Consent procedures. Rather, each of the 50 states which a doctor must disclose risks inherent Appropriate informed consent is has one or more informed-consent statutes in a contemplated method of treatment.8 composed of three elements:5,6 disclosure (California Informed Consent Statute 22 Common elements that should be of information, capacity to consent and CCR § 72528), each of which is subject included in all consent forms are: voluntary consent. Each element must be to amendment during each session of the ■ The diagnosis. satisfied to achieve adequate permission states’ legislatures. Furthermore, a state’s ■ The nature and purpose of to perform any medical procedure. statutes addressing informed consent the procedure(s) for which The patient must be presented may be supplemented by common-law consent is sought. with adequate information to make (judicially enacted) concepts. This ■ All material risks and the decision to proceed or decline the manuscript summarizes “best practices” consequences of the procedures. treatment. The information that must as they can be gleaned from a review of ■ An assessment of the likelihood be disclosed is unique to each patient. the California informed-consent laws, that the procedures will accomplish The information must be presented in a ethical standards and accreditation the desired objectives. way that the patient can understand and, standards in the health care industry.7 ■ Any reasonably feasible alternatives ideally, presented in the native language for treatment, with the same of the patient. Likewise, the method supporting information as is required of disclosing pertinent information regarding the proposed procedures. must be unique to the patient, such as The patient must have the ■ The prognosis if no treatment for a patient with hearing problems. is provided.9,10 The patient must have the mental mental capacity and be of capacity and be of legal age to consent. legal age to consent. Disclosure Mental capacity is a real concern for Mental capacity is a real Disclosure requires the physician DSM practitioners. OSA has been (dentist) to supply each prospective closely linked to dementia. Frequently, concern for DSM practitioners. patient with the information necessary our patients present with obvious to make an autonomous decision and neurological deficiency. It is certainly also to ensure that the patient adequately advisable to have a family member present understands the information provided. during the consent process. Having the General Components of Consent This latter requirement implies that a family member co-sign (witness) the In the absence of special written consent form be written in lay consent document will minimize the circumstances, a physician (dentist) language suited for the comprehension risk associated with providing treatment may not treat a patient without first skills of subject population as well as on a patient who presents for treatment obtaining their consent. Courts in many assessing the level of understanding with obvious neurocognitive deficits. jurisdictions, however, have questioned through conversation. In order to Additionally, severe sleep deprivation can whether consent should be binding where ensure that informed consent is properly make the consent process problematic. the patient does not, at least in some obtained, the physician (dentist) should The patient must be free to voluntarily measure, consciously weigh the risks of actually discuss with the patient each of consent. While this may not seem to be undergoing treatment against the risks the procedures to be performed, detailing a problem, male patients are frequently of foregoing treatment. A decision to their nature, risks and alternatives. This under pressure from their partners to undergo treatment despite such risks is conversation should take place before receive treatment for their snoring the product of “informed consent.” But the patient is under the influence of or obstructive sleep apnea (OSA). If the average patient’s ignorance of medical preoperative medications. Thus, the in doubt, ask the partner to leave the science very likely makes him or her consent form should provide blanks for room and have a frank conversation unaware of particular risks inherent in a the date and precise time of signature by with the patient in private.4 proposed treatment, and hence prevents both the patient or their responsible party The United States currently has no him or her from giving the informed and the physician (dentist). The patient federal statute that comprehensively consent that the law requires. Informed should also be given an opportunity to addresses informed consent to health care consent, therefore, concerns the extent to ask questions concerning the proposed

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treatment and the written consent should with the therapeutic alternatives and to undertake treatment is vested in the confirm that the opportunity has been their hazards becomes essential. party most directly affected: the patient.16 given. The consent should be signed The court in Cobbs held that “as an The scope of the disclosure required of by the patient or responsible party in integral part of the physician’s overall physicians defies simple definition. Some the presence of an attesting witness.11 obligation to the patient there is a duty courts have spoken of “full disclosure”17 There is always concern regarding of reasonable disclosure of the available and others refer to “full and complete” the amount of information that must choices with respect to proposed therapy disclosure,18 but such facile expressions be disclosed for a patient to make an and of the dangers inherently and obscure common practicalities. Two informed decision about any therapy. potentially involved in each.”12 A medical qualifications to a requirement of “full The court in Cobbs7 employed several doctor, being the expert, appreciates disclosure” need little explication. First, postulates. The first is that patients the risks inherent in the procedure he the patient’s interest in information does are generally persons unlearned in the is prescribing, the risks of a decision not extend to a lengthy polysyllabic medical sciences, and therefore, except not to undergo the treatment and the discourse on all possible complications. in rare cases, courts may safely assume probability of a successful outcome of A minicourse in medical science is not that the knowledge of patient and required; the patient is concerned with physician (dentist) are not in parity. the risk of death or bodily harm and The second is that a person of adult problems of recuperation. Second, it years and in sound mind has the right, In all cases, the decision is not a physician’s duty to discuss the in the exercise of control over their relatively minor risks inherent in common own body, to determine whether or not whether or not to undertake procedures when it is common knowledge to submit to lawful medical treatment. treatment is vested in the that such risks inherent in the procedure The third is that the patient’s consent to party most directly affected: are of very low incidence. In a medical- treatment must be an informed consent malpractice action based on the doctrine to be effective. And the fourth is that the patient. of informed consent, an objective standard the patient, being unlearned in medical applies and the question is whether a sciences, has an abject dependence upon reasonably prudent patient, fully advised and trust in their physician (dentist) for of material known risks would have the information upon which he relies the treatment. But once this information consented to the suggested treatment.19 during the decisional process, thus raising has been disclosed, that aspect of the When there is a common procedure, an obligation in the physician (dentist) doctor’s expert function has been a doctor must, of course, make such that transcends arms-length transactions. performed. The weighing of these risks inquiries as are required to determine if From the foregoing axiomatic against the individual subjective fears for the particular patient the treatment ingredients emerges a necessity, and a and hopes of the patient is not an expert under consideration is contraindicated — resultant requirement, for divulgence by skill.13 Such evaluation and decision is for example, to determine if the patient the physician (dentist) to their patient of a nonmedical judgment reserved to the has had adverse reactions to medication; all information relevant to a meaningful patient alone. A patient should be denied but no warning beyond such inquiries decisional process. In many instances, to the opportunity to weigh the risks only is required as to the remote possibility the physician (dentist) whose training where it is evident; the patient cannot of death or serious bodily harm. When and experience enable a self-satisfying evaluate the data, as, for example, where there is a more complicated procedure, evaluation, the particular treatment there is an emergency or the patient is the jury should be instructed that when that should be undertaken may seem a child or incompetent. For this reason, a given procedure inherently involves evident, but it is the prerogative of the the law provides that in an emergency, a known risk of death or serious bodily patient, not the physician (dentist), to consent is implied.14 If the patient is a harm, a medical doctor has a duty to determine for himself the direction in minor or incompetent, the authority to disclose to his/her patient the potential which he believes their interests lie. To consent is transferred to the patient’s legal of death or serious harm and to explain enable the patient to chart their course guardian or closest available relative.15 in lay terms the complications that might knowledgeably, reasonable familiarity In all cases, the decision whether or not possibly occur. Beyond the foregoing

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minimal disclosure, a doctor must also been produced, then the burden of is the result of neuroanatomical factors reveal to their patient such additional going forward with evidence pertaining and pathophysiological processes that information as a skilled practitioner to justification for failure to disclose either singularly or collectively fail to of good standing would provide under shifts to the physician.22 Defenses are maintain the patency or opening of the similar circumstances. The patient’s available when a doctor who has failed upper airway. Patient education should right of self-decision is the measure of to make a disclosure required by law; include the role of these processes as the physician’s duty to reveal. That right for example, a medical doctor need not well as highlighting demographic, ethnic can be effectively exercised only if the make disclosure of risks when the patient and gender risk factors. Additionally, patient possesses adequate information to requests that they not be so informed.23 patients should be informed about enable an intelligent choice. The scope Such a disclosure need not be made if disease processes including comorbid of the physician’s communications to the the procedure is simple and the danger conditions arising from or associated patient, then, must be measured by the remote and commonly appreciated to be with OSA. The patient undergoing patient’s need, and that need is whatever remote. A disclosure need not be made OAT should be informed of their SRBD information is material to the decision. beyond that required within the medical severity including an understanding of Thus, the test for determining whether the resulting apnea-hypopnea index a potential peril must be divulged is its (AHI), respiratory disturbance index materiality to the patient’s decision.20 (RDI) or respiratory event index (REI) 26 There must be a causal relationship The test for determining from objective sleep-apnea testing. between the physician’s failure to inform Initiating OAT includes obtaining and the injury to the plaintiff. Such causal whether a potential peril informed consent and a letter of connection arises only if it is established must be divulged is its medical necessity and should allow for that had revelation been made consent materiality to the modification of the treatment plan as to treatment would not have been needed to obtain the desired therapeutic given. At trial, the record must disclose patient’s decision. result. Informed consent is the process testimony that had the plaintiff been by which the treating dentist discloses informed of the risks of surgery they would appropriate information to a competent not have consented to the operation.21 patient so that the patient may make The patient-plaintiff may testify on this community when a doctor can prove by a voluntary choice to accept or refuse subject, but the issue extends beyond a preponderance of the evidence that he treatment. The qualified dentist should their credibility. Because at the time of relied on facts that would demonstrate provide the patient an opportunity to ask trial when the uncommunicated hazard to a reasonable man that the disclosure questions about the risks of treatment as has materialized, it would be surprising would have so seriously upset the patient well as educate the patient as to the risks if the patient-plaintiff did not claim that that the patient would not have been associated with no treatment. Informed had they been informed of the dangers able to dispassionately weigh the risks of consent also requires that the qualified they would have declined treatment. refusing to undergo the recommended dentist informs the patient as to alternate Subjectively, they may believe so, treatment.24 Any defense, of course, therapies to OAT, such as positive airway with the 20/20 vision of hindsight, but must be consistent with what has been pressure therapy, positional therapy, justice cannot be served by placing the termed the “fiducial qualities” of the maxillofacial surgery or otolaryngologic physician in jeopardy of the patient’s physician-patient relationship.25 surgery. Upon agreement to a plan of bitterness and disillusionment. Thus, treatment, the patient should sign the an objective test is preferable, i.e., what Disclosure in Dental Sleep Medicine informed consent in front of the qualified would a prudent person in the patient’s The effective management of a dentist or other dental staff. The qualified position have decided if adequately sleep-related breathing disorder (SRBD) dentist should then countersign and date informed of all significant perils.16 requires the qualified dentist to provide the document, which should be kept as The burden of going forward with the patient with an overview of the part of the patient’s record of care.26 evidence of nondisclosure rests on disease process as well as an understanding The patient should also be informed the plaintiff. Once such evidence has of how oral appliances treat SRBDs. OSA that OAT success may be impacted by

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fragmented sleep, oxygen desaturation Additionally, OSA is an unusual disease and make judgments.29 To give informed and other coexisting sleep disorders. because it has been associated with many consent, the individual concerned must Additionally, the qualified dentist comorbid medical conditions. The law of have adequate reasoning faculties and should explain risk modifiers that informed refusal requires that a patient be in possession of all relevant facts. may mitigate disease severity. The be informed of the risk associated with Impairments to reasoning and judgment patient should be advised that the refusing treatment. As a result of OSA or as that may prevent informed consent risk of disease severity or treatment a complication of OSA treatment, patients include basic intellectual or emotional success may be negatively influenced may develop any or all of the following immaturity, high levels of stress such as by using tobacco, alcohol, caffeine or temporary or permanent comorbid post-traumatic stress disorder or a severe recreational substances.27 The impact diseases: coronary artery disease, high intellectual disability, severe mental of both weight loss and weight gain blood pressure, diabetes, cerebrovascular disorder, intoxication, severe sleep should be discussed with the patient. disease, stroke, heart problems, heart deprivation, Alzheimer’s disease or being The educated and informed patient attack, atrial fibrillation, depression, mood in a coma. When the patient lacks the may choose to reduce disease impact disorders, vivid dreams, anxiety, feeling requisite capacity to consent, another by modifying behaviors that increase person is generally authorized to give SRBD risk or severity. Additionally, consent on their behalf, e.g., parents patients should be educated about the or legal guardians of a child (though importance of sleep hygiene. The patient The law of informed in this circumstance the child may be should understand the impact of ambient required to provide informed assent) and room lighting, temperature, the use of refusal requires that a conservators for the mentally disordered electronics in bed, animals on the bed as patient be informed of the or consent can be assumed through the well as the importance of regular sleep risk associated with doctrine of implied consent, e.g., when schedules. While these considerations an unconscious person will die without may not directly affect OA efficacy, refusing treatment. immediate medical treatment.26 they can collectively fragment sleep In dental sleep medicine, practitioners and aggravate daytime sleepiness routinely treat patients with “severe sleep concerns. Improper sleep hygiene can deprivation” who have difficulty following also indirectly reduce patient perception suffocated, sexual dysfunction, weight gain, conversations or who may fall asleep of oral appliance benefit in terms of obesity, dementia, Alzheimer’s disease, during consent discussions. If a dentist is sleep quality and daytime function.26 gastroesophageal reflux (GERD), chronic unsure of the patient’s ability to consent, The complications that could obstructive pulmonary disease (COPD), it is always advisable to have a family occur over a lifetime of MAD wear congestive heart failure, cancer, excessive member witness the consent and sign the are numerous. It would be difficult to daytime sleepiness, increased work-related informed-consent document. As a practice include a complete list of all possible and traffic-related accidents and death.4 tip, patients who present excessively issues that could arise. However, some sleepy need a driver and may need to be of the possible issues include tooth Capacity To Consent referred back to their sleep physician for movement, jaw movement, TMD, Capacity pertains to the ability control of the patient’s excessive daytime injury secondary to appliance breakage, of the patient to both understand sleepiness until the MAD is effective.4 dry mouth, excessive saliva, sore teeth, the information provided and form dental decay, periodontal disease, a reasonable judgment based on Voluntariness of Consent mobile teeth, fractured teeth and dental the potential consequences of their Voluntariness refers to the patient’s restorations, popping and noise in the decision. In general, it is the dentist’s right to freely exercise their decision- jaw, acrylic or other (material) allergies, role to provide the necessary medical making without being subjected to posterior open bite, difficulty chewing, facts and the patient’s role to make the external pressure such as coercion, residual sleepiness and symptoms subjective treatment decision based on manipulation or undue influence. after treatment and increased AHI/ their understanding of those facts.28 The A patient’s decision to proceed with RDI during a follow-up sleep study.4 patient must have the capacity to reason any medical procedure must be voluntary

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and without coercion and the patient the common complications inherent risk of tooth movement. Patients with must have a clear understanding of in OAT. Included in the discussion is a minimum number of teeth require a the risks and benefits of the proposed a time for questions to be answered. directed discussion that may include a treatment alternatives or nontreatment, Once the discussion is completed, the discussion of implants to help secure along with a full understanding of the written consent is presented for signature. the MAD. Patients with a history of nature of the disease and the prognosis.30 Remember, a well-written and executed periodontal disease and attachment loss informed-consent document is your most must be informed of any additional risk.4 Informed Refusal valuable defense tool if your records are Patients can be allergic to the The legal principals of informed ever reviewed by a plaintiff’s attorney. material contained in the MADs. Acrylic consent also apply to the doctrine of With a well-written, signed informed allergies and metal allergies are not informed refusal. Any adult patient consent most lawsuits never happen.4 uncommon. This possibility should be who has the requisite capacity has discussed. Additionally, appliances can the legal right to refuse any medical Concerns break or parts may become dislodged. treatment.26 The patient’s ability to The practice of dental sleep medicine Appropriate warnings are necessary.4 control their bodily integrity through presents some unusual risks. The most Each patient is unique. Informed- informed consent is significant only common risk of providing a mandibular consent discussions must be specific when one recognizes that their right also advancement device is occlusion issues to the clinical presentation of the encompasses a right to informed refusal.31 that develop as a result of the persistent patient, the severity of OSA, the In obtaining an informed refusal, forces placed on the teeth and jaws. capacity of the patient to understand the health care provider is required to MADs can cause the maxillary teeth to tilt the risks of treatment, the existence of fulfill the same steps as in an informed posteriorly and the mandibular teeth to extenuating circumstances (arthritis consent. The patient must be provided tilt anteriorly. This action will result in a making insertion and removal an issue) the diagnosis, a layman’s description of posterior open bite in a significant portion and the patient’s ability to understand the procedure, the likelihood of success of OAT patients. It is imperative for all English. Each of these clinical situations (prognosis), alternatives and the risks practitioners to inform their patients of and patient peculiarities necessitates associated with no treatment. This the risk. At each appointment, occlusion a different consent discussion.31 discussion must include MI, hypertension, should be examined and morning However, a fully informed patient is strokes, diabetes and automobile/ repositioner wear should be encouraged. more engaged in the therapy and more industrial accidents. The final step of Patients with a history of TMD committed to the process. The time the informed refusal is to document the must be informed of the possibility of spent in obtaining an informed consent discussion and the refusal. It is ideal if muscle pain, capsulitis, dysfunction reduces clinician liability and results the dentist has an informed-refusal form and difficulty chewing with MAD use. in a more motivated patient.4 n that is specific to this discussion. If no Fortunately, MAD appliance wear will NOTE such document exists, detailed notes generally improve TMD symptoms with This information is not intended to constitute legal advice should be made in the patient’s record time; however, initially this may not and should not be relied upon in lieu of consultation with fully memorializing the discussion.4 be the case. Appropriate consent will appropriate legal advisors in your own jurisdiction. It may not be current as the laws in the area of informed consent include a frank discussion of TMD risks. change frequently. Written Consent MADs place significant amounts Most practitioners believe that of pressure on the teeth and existing REFERENCES a written signed consent is legally dental restorations. Ill-fitting crowns 1. Elsayyad A. Informed Consent for Comparative Effectiveness required. This is not the case. A written and bridges or other restorations can be Trials. N Engl J Med 2014 May 15;370(20):1959–60. doi: consent is only for documentation. Oral dislodged or fractured as a result of oral 10.1056/NEJMc1403310. 2. Smith v. Shannon, 666 P.2d 351 (Wash. 1983). Noting consent is legally binding but proving appliance therapy. Failing endodontic that the doctrine of informed consent is premised upon what information was presented in procedures can be compromised as a patient sovereignty and the patient’s ability to intelligently order to obtain consent is difficult. result of the pressure placed on these govern the treatment of his/her body. The doctrine of informed consent refers to the requirement that a physician, Typically, practitioners are wise to have teeth by a MAD appliance. Adult before obtaining the consent of his/her or her patient to a discussion with the patient outlining patients with recent orthodontics are at treatment, inform the patient of the treatment’s attendant

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risks. The doctrine is premised on the fundamental principle disclose the risk to the patient “where the statistical risk is 18. See: Stafford v. Shultz (1954) 42 Cal. 2d 767, 777 [270 that “[e]very human being of adult years and sound mind remote and the severity not great.” 2 D. Louisell H. Williams, P.2d 1]; Pashley v. Pacific Elec. Ry. Co. (1944) 25 Cal. 2d has a right to determine what shall be done with his/her own supra § 22.13, at 22–34. 226, 235 [153 P.2d 325]. body.” Schloendorff v. Society of N.Y. Hosp., 211 N.Y. 125, 11. Performing a medical procedure without consent constitutes 19. Reikes v. Martin 471 So. 2d 385 (Miss. 1985). 129, 105 N.E. 92 (1914) (Cardozo, J.), overruled on other battery. The California Case law has rejected this argument 20. Canterbury v. Spence, 464 F.2d 772, 786. grounds, Bing v. Thunig, 2 N.Y.2d 656, 667, 143 N.E.2d 3, and relied on the law of negligence. 21. Shetter v. Rochelle (1965) 2 Ariz.App. 358 [409 P.2d 74]; 163 N.Y.S.2d 3 (1957). A necessary corollary to this/her See: Cobbs v. Grant. [S.F. Supreme Court of California. Oct. Sharpe v. Pugh (1967) 270 N.C. 598 [155 S.E.2d 108]; cf. principle is that the individual be given sufficient information 27, 1972] In Bank. (Opinion be Mosk, J) [8 Cal. 3d 230] Aiken v. Clary (Mo. 1965) supra, 396 S.W.2d 668. to make an intelligent decision. See Canterbury v. Spence, In giving its instruction the trial court relied upon Berkey v. 22. Cobb, Supra. 464 F.2d 772, 783 (D.C. Cir. 1972). Anderson (1969) 1 Cal. App. 3d 790, 803 [82 Cal. Rptr. 67], 23. See discussion of waiver: Hagman, The Medical Patient’s 3. Fine A. Informed Consent in California — Latent Liability a case in which it was held that if the defendant failed to make Right to Know. 17 UCLA L. Rev. 758–785. Without Negligence. West J Med 1977 Aug; 127(2):158–162. a sufficient disclosure of the risks inherent in the operation, 24. See discussion of informing the dying patient: Hagman, 4. Berley K, Carstensen S. The Clinician’s Handbook for Dental he was guilty of a “technical battery” (also see Pedesky v. The Medical Patient’s Right to Know, supra. 17 UCLA L. Rev. Sleep Medicine. Batavia, Ill.: Quintessence Publishing USA; Bleiberg (1967) 251 Cal. App. 2d 119, 123 [59 Cal. Rptr. 758–778. 2019. 294]; Hundley v. St. Francis Hospital (1958) 161 Cal. App. 25. Emmett v. Eastern Dispensary and Casualty Hospital 5. Myers MJ. Informed Consent in Medical Malpractice, 55 2d 800, 802 [327 P.2d 131]).While a battery instruction may (1967) 396 F.2d 931, 935 [130 App.D.C. 50]. Calif. L. Rev. 1396 (1967). doi.org/10.15779/Z385X89. have been warranted under the facts alleged in Berkey, in the 26. Levine M, Bennett K, Cantwell M, Postol K, Schwartz D. 6. Faden RR, Beauchamp TL. A History and Theory of Informed case before us the instruction should have been framed in terms Dental Sleep Medicine Standards for Screening, Treating and Consent. New York: Oxford University Press; 1986. of negligence. Managing Adults With Sleep-Related Breathing Disorders. 7. 22 CCR § 72528 Informed Consent Requirements. govt. 12. See Cobbs: 8 Cal. 3d 243. J Dent Sleep Med 2018;5(3):XXX. dx.doi.org/10.15331/ westlaw.com/calregs/Document/I4C2C6C005F7B11DFBF8 13. Perna v. Pirozzi. 457 A.2d 431 (N.J. 1983) Discussing the jdsm.7030. 4F211BF18441D?contextData=%28sc.Default%29&transitio doctrine of informed consent in medical malpractice context. 27. Peppard PE, Austin D, Brown RL. Association of alcohol nType=Default. Informed consent is a negligence concept predicated on the consumption and sleep disordered breathing in men and 8. Myers MJ, Informed Consent in Medical Malpractice, 55 duty of a physician to disclose to a patient information that will women. J Clin Sleep Med 2007;3(3):265–70. Calif. L. Rev. 1396 (1967). enable him to “evaluate knowledgeably the options available 28. Hilfiker, supra, 308 New Eng. J. Med. at 718 9. In Roberts v. Wood, 206 F. Supp. 579 (S.D. Ala. 1962), and the risks attendant upon each” before subjecting that (acknowledging that “our ability [as doctors] to phrase the doctor performed a second thyroidectomy without patient to a course of treatment. Canterbury v. Spence, 464 options, stress information and present our own advice gives us informing the patient of the second operation’s greater F.2d 772, 780 (D.C. Cir.), cert. den., 409 U.S. 1064, 93 S.Ct. tremendous power”). risk or suggesting the preferable radioiodine method of 560, 34 L.Ed.2d 518 (1972); see Calabrese v. Trenton State 29. Matter of Conroy. 486 A.2d 1209 (N.J. 1986). treatment, and the patient lost the use of her true vocal College, 162 N.J. Super. 145, 156 (App.Div. 1978), aff’d, 302. Ermoian v. Desert Hospital. 152 Cal. App. 4th 475 (Cal. cords. In Patrick v. Sedwick, 391 P.2d 453 (Alaska 1964), 82 N.J. 321 (1980) (summary judgment for defendant-doctors Ct. App. 2007). a referring physician told plaintiff it was nothing more than reversed because of fact question whether they disclosed 31. Matter of Conroy, Supra. a . Plaintiff’s consultation with the surgeon was dangerous side effects of drugs); Kaplan v. Haines, 96 N.J. limited to an exchange of greetings. After the operation, Super. 242, 255-58 (App.Div. 1967), aff’d o.b., 51 N.J. THE AUTHOR, Ken Berley, DDS, JD, can be reached at one vocal cord was paralyzed and plaintiff’s soft, feminine 404 (1968) (not error, in light of complete charge, to instruct [email protected]. voice became harsh and hoarse. In DiFilippo v. Preston, 53 jury that it should return verdict for defendants if patient “fully Del. 539, 173 A.2d 333 (1961), the doctor did not warn appreciated the danger involved in the operation”). See the patient of the risk, and now the patient cannot speak generally Natanson v. Kline, 186 Kan. 393, 350 P.2d 1093 above a hoarse whisper and will breathe through a tracheal (1960); M. Victor, “Informed Consent” 1981 Med. Trial Tech. tube for the rest of her life. In Watson v. Clutts, 262 N.C. Q. 138. Under the doctrine, the patient who consents to an 153, 136 S.E.2d 617 (1964), the doctor told the patient operation is given the opportunity to show that the surgeon she would have to stay in the hospital for a week before the withheld information concerning “the inherent and potential serious operation. She suffered paralysis of both vocal cords hazards of the proposed treatment, the alternatives to that and had to have a tracheotomy. Plaintiff in each of these treatment, if any, and the results likely if the patient remains cases lost on the informed consent theory. The plaintiff in untreated.” Canterbury v. Spence, supra, 464 F.2d at 787-88. Patrick v. Sedwick, supra, recovered on a negligence theory. If the patient succeeds in proving that the surgeon did not 10. Hook v. Rothstein. 316 S.E.2d 690 (S.C. Ct. App. comply with the applicable standard for disclosure, the consent 1984). Noting the under the doctrine of informed consent, is vitiated. See Canterbury v. Spence, supra, 464 F.2d at a physician has a duty to disclose “(1) the diagnosis, (2) 782; 2 Louiselle and Williams, Medical Malpractice § 22.08 the general nature of the contemplated procedure, (3) the (1982). material risks involved in the procedure, (4) the probability 14. Wheeler v. Barker (1949) 92 Cal. App. 2d 776, 785 of success associated with the procedure, (5) the prognosis if [208 P.2d 68]; Preston v. Hubbell (1948) 87 Cal. App. 2d 53, the procedure is not carried out, and (6) the existence of any 57-58 [196 P.2d [8 Cal. 3d 244] 113]. alternatives to the procedure.” 15. Ballard v. Anderson (1971) 4 Cal. 3d 873, 883 [95 Cal. The extent of disclosure is ordinarily a medical judgment. Rptr. 1, 484 P.2d 1345, 42 A.L.R.3d 1392]; Doyle v. Giuliucci Stauffer v. Karabin, 30 Colo. App. 357, 492 P.2d 862, (1965) 62 Cal. 2d 606 43 Cal. Rptr. 697, 401 P.2d 1]; 865 (1971); Starnes v. Taylor, 158 S.E.2d at 344. “[T]he Bonner v. Moran (1941) 126 F.2d 121 [75 App.D.C. 156, doctrine of informed consent does not require the physician 139 A.L.R. 1366]). to risk frightening the patient away from treatment which 16. See Cobb. Supra. sound medical judgment indicates is necessary. . . .” 61 17. See: Berkey v. Anderson, supra, 1 Cal. App. 3d 790, 804; Am. Jur.2d Physicians, Surgeons, and Other Healers § 190, Salgo v. Leland Stanford etc. Bd. Trustees, supra, 154 Cal. at 321 (1981). The physician is not ordinarily required to App. 2d 560, 578.

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CDA JOURNAL, VOL 48, Nº4

Pediatric Obstructive Sleep Apnea: An Interdisciplinary Approach to Treatment

Thomas Stark, DDS, LTC(P); Peter O’Connor, MD, COL; and Tracey Fischer, MA, MA, CCC-SLP

a b s t r ac t Dentists have an important partnership with the medical community in the recognition and management of obstructive sleep apnea (OSA) in children. OSA negatively impacts the overall health and well-being of children, and an interdisciplinary approach to management may optimize care. Sleep medicine physicians, dentists, otolaryngologists, pediatricians, orofacial myologists and other health care providers have a role in the management of pediatric OSA.

AUTHORS

Thomas Stark, DDS, bstructive sleep apnea for recognition and management.7 LTC(P), is a pediatric dentist Tracey Fischer, MA, MA, (OSA) is a leading cause Structural factors play a significant and orofacial pain specialist CCC-SLP, is a speech- of sleep disturbance role in the etiology of pediatric OSA; at Uniformed Services language pathologist at 1 University of the Health Landstuhl Regional Medical in children. Despite however, the underlying causes of sleep- Sciences, Dental Health Center in Landstuhl, respiratory effort, disordered breathing are complex and the Activity Rheinland Pfalz in Germany. Ochildren with OSA experience recurring pathophysiology is not fully understood.8,9 Wiesbaden, Germany. Conflict of Interest episodes of upper airway obstruction For instance, the upper airway lacks Conflict of Interest Disclosure: None reported. that disrupt ventilation and sleep rigid support and is vulnerable to periods Disclosure: None reported. patterns during sleep.2 According to of complete obstruction (apnea) or Peter O’Connor, MD, epidemiologic studies, the prevalence partial obstruction (hypopnea) during COL, is an otolaryngologist of OSA in children is approximately sleep.2 In addition to being smaller in and sleep medicine 1% to 5%.3,4 Although OSA can occur size, the airway is more collapsible in physician and chief, from infancy through adolescence, children than adults.10 The smallest division of surgery at Landstuhl Regional Medical the peak incidence of pediatric OSA cross-sectional region of the pharyngeal 5 Center in Landstuhl, is between the ages of 2 and 8. OSA airway is the retropalatal area where Germany. His is a faculty occurs equally in preadolescent males the tonsils and adenoids overlap.11 This member of Uniformed and females but becomes more common circumferential area of lymphoid tissue Services University of the in males over time.5 Although OSA is a known as Waldeyer’s ring is an anatomic Health Sciences. Conflict of Interest chronic disease in adults, it often remits focus in pediatric OSA. Adenotonsillar Disclosure: None reported. without intervention during certain hypertrophy is the primary structural factor phases of growth and development in linked with OSA.11,12 However, many children.6 However, some pediatric children with adenotonsillar hypertrophy patients will not “outgrow” this disorder do not have OSA.11 Furthermore, and will rely on health care teams OSA can persist despite addressing the

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TABLE 1 Screening for OSA in Nonsyndromic Children Sleep questions Medical history Orthodontic features Other clinical features Snoring or noisy breathing? Attention deficit hyperactivity disorder Maxillary constriction Tonsillar hypertrophy Mouth breathing? (ADHD) Posterior Long soft palate (modified Sweating? Learning difficulties “V”-shaped maxillary arch Mallampati classification of 3–4) Fitful sleep? Behavioral problems Retrognathic profile Unusual sleep position (seated Hypertension Excess overjet Dry lips position/neck hyperextension)? Gastroesophageal reflux disorder Class II malocclusion Erythematous maxillary gingiva (GERD) Sleep bruxism? Class III malocclusion Hypernasal speech Excessive daytime sleepiness? Nocturnal enuresis (bed wetting) (maxillary deficiency) Small nares Hyperactivity? Headaches Long lower one-third of face Dental attrition (secondary to Failure to thrive Adenoid facies sleep bruxism) Obesity Lip incompetence

Screening questions, medical history and clinical features that suggest a child may be at risk for OSA. adenotonsillar hypertrophy, therefore neurologic, neurocognitive and motor skills are also common in children other areas and elements contributing inflammatory disorders have been with OSA.14,23 Studies suggest academic to the disease must be considered.13 associated with pediatric OSA.5,14–19 performance, quality of life and behavior Neuromuscular factors also influence Furthermore, consequences of OSA may tend to improve with treatment.24,25 airway size, shape, coordination and persist into adulthood.20 Fortunately, many An important concept is the compliance.9 Pharyngeal dilator muscles of the negative effects of OSA resolve with recognition of different observable traits or offset airway collapse in response to medical treatment.1,21 Early recognition phenotypes in patients with OSA.26 While hypercapnia and negative luminal of signs and symptoms of OSA enables the phenotyping focus has primarily been pressure.9 Pharyngeal collapse may be children to receive appropriate medical investigated in adults, the same conceptual more common in children with OSA due attention and avoid irreversible damage.1 overlay can be applied to children. All to a decrease in upper airway dynamic Recognizing the signs and symptoms patients with OSA are not the same neuromotor response.10 Sleep arousals of pediatric OSA is an important and several phenotypes for pediatric lead to ventilatory instability and competency for health care providers, OSA likely exist.27 Furthermore, the obstructive cycling because ventilation including dentists. Most children and management of OSA in one population is regulated by feedback loops.9 In adolescents with OSA have a history or phenotype may differ from another.27 addition to a reduction in ventilatory of loud snoring or labored breathing Predisposing factors for OSA may drive, control of muscle tone is different during sleep.2 Restless sleep, paradoxical include conditions associated with during wakefulness and sleep.2 Volitional breathing, thoracic retractions, airway inflammation (poorly controlled muscle tone is most inhibited during hyperextension of the neck, unusual sleep asthma, gastroesophageal reflux disease, rapid eye movement (REM) sleep.2 positions, sweating, nocturnal enuresis mucopolysaccharidosis, cystic fibrosis and Consequently, the majority of obstructive (bedwetting) and morning headaches also environmental exposure to secondhand events occur during REM sleep.2 may occur.2,22 Young children may exhibit smoke or pollution); craniofacial Children are vulnerable to the hyperactive behavior while older children anomalies and malocclusion (craniofacial negative consequences of OSA. When and adolescents demonstrate somnolence synostoses, Pierre Robin sequence, compared with adults, children have a and excessive daytime sleepiness.19 High- midface retrognathia, mandibular greater metabolic need for oxygen, higher resolution brain imaging in children hypoplasia, palatal constriction, long and respiratory rate, lower oxygen stores and with OSA demonstrates tissue damage in narrow faces, narrow and deep palate, smaller functional residual capacity.2 the prefrontal cortex and other regions steep mandibular plane angle, anterior Moreover, hypoxemia and hypercapnia of the brain responsible for executive open bite and conditions associated may occur more rapidly even during brief functioning and learning.14,15 OSA-related with macroglossia or nasal obstruction); periods of airway obstruction if their reserve deficits in executive function lead to conditions associated with decreased is low.2 Untreated OSA in children leads to irritability, moodiness, disorganization, neuromotor tone (trisomy 21, Prader-Willi somatic growth deficiency and multisystem poor judgement, rigid thinking syndrome and neuromuscular disease); disease.16 Metabolic, pulmonary, and impulsivity.14,23 Poor academic and conditions influencing breathing cardiovascular, gastroenterological, performance and impaired visual fine compliance or airway collapsibility

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FIGURE 1. The top half of the page shows the EEG and eye movement tracings over a one-minute section. The video picture shows the child sleeping prone. The bottom half of the page shows a five-minute section of the study. The green box outlines the abdominal and thoracic belts showing effort to breath with repeated variability. The red arrows show the decreased flow amplitude in the nasal pressure channel and total airflow with corresponding label of an obstructive apnea. The yellow box corresponds to a sudden increase in airflow when the obstruction is finished and airflow briefly returns before the next obstruction. The blue box highlights the oxygen saturation showing repetitive decreases in oxygen that corresponds to the obstructive events.

(Marfan syndrome, Ehlers-Danlos Screening for OSA in Children (heart rate, rhythm) and movements (eye, syndrome, laryngomalacia).2,11 Family Various screening aids and clinical limb, tooth bruxing) and cortical activity history of OSA, African American exam features (TABLE 1) have been used during sleep. PSG differentiates OSA from ethnicity, premature birth and obesity also to help identify children who are at primary snoring, defines severity of OSA increase the risk for developing OSA.28,29 risk for OSA.36 Keating and colleagues and evaluates success of interventions. Treatment of OSA in children is often described screening and practices among Utilization of home sleep apnea testing directed by physicians with expertise in practicing pediatric dentists in the U.S. (HSAT) has increased in uncomplicated pediatrics, pulmonology, otolaryngology and and found that 41% of respondents adult patients with a high pretest sleep medicine.30 Adenotonsillectomy is were uncomfortable screening for OSA probability for OSA,40 but has been used typically considered first-line treatment for and 61% received no formal training sparingly in pediatrics.41 At present, the children with OSA.30 Unfortunately, OSA in OSA during residency.37 Some data American Academy of Sleep Medicine persists in many children following surgery.30 suggest screening tools tend to have (AASM) and the American Academy Furthermore, parents may decline surgical acceptable sensitivity (in determining of Pediatrics (AAP) do not recommend procedures because they are not willing those who have the condition) but low HSAT for pediatric patients.1,41 to accept risks associated with surgery or specificity indicating a high number of The AASM Manual for Scoring of general anesthesia.30 Nonadherence to false positives.38,39 Patel and colleagues Sleep and Associated Events outlines traditional therapies for OSA, such as evaluated different pediatric sleep diagnostic criteria for OSA in children.42 positive airway pressure therapy (PAP), screening tools and determined that Pediatric OSA applies to patients younger has driven advances in the understanding current screeners do not accurately predict than age 18.2 However, adult diagnostic and pathophysiology of upper airway a diagnosis of OSA.38 Additionally, criteria for OSA may be used for patients collapse.31–33 Management protocols for Overland found that neither clinical aged 13–18.42 Pediatric OSA occurs with improving outcomes in children with poor features nor questionnaires were sensitive greater than one obstructive event per compliance with medical recommendations enough to detect the prevalence or hour of sleep as determined by the apnea or persistent OSA following surgical severity of OSA in a population of hypopnea index (AHI).2,42 Additionally, interventions are evolving.34 As a result, children referred for adenotonsillectomy.12 pediatric OSA may be diagnosed if a single treatment modality option has obstructive hypoventilation is present been increasingly abandoned toward Diagnosis and Polysomnography (more than 25% of total sleep time with a more personalized approach.34 Sleep-related breathing disorders are hypocapnia [paCO2 > 50 mm Hg]) Due to the complexity of pediatric on a continuum ranging from occasional along with one of the following: snoring, OSA, optimal treatment may involve snoring to severe OSA.2 Polysomnography flattening of inspiratory waveform or collaboration with several disciplines, (PSG) is the gold standard for diagnosis of paradoxical breathing.2,42 Apneas tend including dentists.35 The aim of this pediatric OSA.2 (FIGURE 1). PSG evaluates to be measured consistently; however, informational paper is to evaluate respiratory parameters (respiratory scoring of hypopneas is not homogenous treatment options for the interdisciplinary effort, apneas and hypopneas, oxygen across studies, leaving some children with management of pediatric OSA. saturations), cardiovascular parameters undiagnosed OSA.43 Similar to adults,

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CDA JOURNAL, VOL 48, Nº4

TABLE 2 Severity of Adult and Pediatric OSA Based on the Apnea Hypopnea Index Adult AHI Pediatric AHI Mild 5 to 15 1 to 5 Moderate 15 to 30 > 5 to < 10 posture, tongue position and breathing.27,48 Severe > 30 10+ Both skeletal and soft tissue changes that occur during normal growth and the severity of OSA is established by the development result in a remarkable 2 AHI. Because children have a lower increase in size of the upper airway from FIGURE 2. Example of an orthodontic appliance 46,48 threshold for OSA, the corresponding childhood through adolescence. used for rapid maxillary expansion. values for mild, moderate and severe This fact highlights the importance of OSA are much lower2 (TABLE 2). matched control groups when evaluating correct posterior crossbites, palatal Making definitive conclusions interventions for OSA in the pediatric constriction and growth asymmetries.55 and defining successful treatment for population. A comprehensive review of RME appliances are well-tolerated and pediatric OSA is challenging due to a craniofacial growth and development increasingly utilized as an early treatment lack of consistency across studies.32,44 is beyond the scope of this manuscript option for children with OSA and AHI less than 1 is considered resolution and may be reviewed elsewhere.47,48,52 transverse maxillary deficiencies.48 RME of OSA; yet, reductions in SPO2 nadir is an example of distraction osteogenesis or AHI by a specific percentage or Interdisciplinary Treatment and facilitates skeletal expansion, benchmark are common measures which is typically complete within a of success in the literature.45 There Dental Management (General Dentists, few weeks after 0.025 mm to 0.50 mm is also a lack of consensus regarding Pediatric Dentists, Orthodontists) of expansion per day (FIGURE 2). As the use of PSGs within in the AAP, Recognizing the consequences of a rule, RME should be performed prior AASM and the American Academy untreated OSA, the American Academy to the fusion of the midpalatal suture, of Otolaryngology-Head and Neck of Pediatric Dentistry (AAPD) recently which generally occurs near the onset Surgery.45 Furthermore, among pediatric created an oral health policy on OSA.53 of puberty (12 years in females, 14 years otolaryngologists, there is a discrepancy The AAPD policy states that nonsurgical in males).48,54,55 Timing of expansion on who and when PSG is required.45 intraoral appliances may be considered is critical as the mature suture has after a complete orthodontic/craniofacial increased interdigitation making skeletal Growth and Development of the assessment of the patient’s growth and separation unlikely without surgical Pediatric Airway development as part of a multidisciplinary intervention.48 Although the target Over time, normal facial growth approach.53 The American Association of expansion is the midpalatal suture, increases the dimensions of the pediatric of Orthodontists (AAO) also addressed circummaxillary sutures may also be airway.46 Facial growth in children OSA in a parallel white paper.46 The affected.56,57 Furthermore, dentoalveolar involves bone surface remodeling and white paper states that the primary expansion may occur, especially with translation of the nasomaxillary complex outcome of orthodontic and dental a slow expansion protocol or when a and midface in an anterior and inferior therapy is to improve occlusion and spring-type expander is used.58 In slow direction relative to the cranium.47,48 address underlying skeletal discrepancies. protocols, transverse deficiencies take The mandible translates downward and However, benefits such as increasing longer to correct and more dentoalveolar forward and grows upward and backward, volume of the nasopharynx and nasal than skeletal expansion is anticipated.58,59 maintaining its contact with the skull.47 cavity, reducing nasal resistance and Several studies have demonstrated a The larynx also descends caudally away improving respiratory parameters reduction in the AHI and lowest oxygen from the skull base, which in turn lends during sleep may also be achieved.46,48 saturation following orthopedic expansion to a more collapsible and therefore of the maxilla.60–63 Two systematic reviews unstable airway.49 Lymphoid tissue mass Orthodontic Expansion and meta-analyses found an overall occupying the airway decreases over Orthodontic appliances may be reduction in the AHI with the use of time.49 Growth of the tongue closely used to expand the skeletal boundaries RME in pediatric patients.64,65 Of note, follows that of the mandible in an of the maxilla and nasal floor.54,55 randomized controlled trials (RCTs) are anterior direction.50,51 Furthermore, Rapid maxillary expansion (RME) is lacking and would help determine the postnatal development of the oral airway commonly used to exert lateral forces effect of expansion versus spontaneous is influenced by oral function, oral resting at the immature midpalatal suture to resolution of OSA with growth.65

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The impact of RME on airway dimensions and nasal resistance has been How Much Sleep Is Recommended for Children? extensively reviewed.66–68 Challenges exist standardizing longitudinal airway A consensus statement by the American Academy of Sleep Medicine volume measurements as well as comparing described the amount of sleep required for children of all ages (table below). standing upright airway volume with the Infants, children and teens routinely sleeping the recommended hours reap airway during sleep.67,69 Because OSA is many benefits including improvements in attention, behavior, learning, complex, a clear link between enlarged memory, emotional regulation, quality of life and mental and physical health. awake, upright airway dimension in Conversely, children regularly sleeping fewer than the recommended hours children and sleep-related breathing face a multitude of problems, such as problems with attention, behavior and 46,48 parameters has yet to be defined. learning, increased risk for accidents, injuries, hypertension, obesity, diabetes Fastuca evaluated 15 pediatric patients and depression. Teens with insufficient sleep are also at risk for self-harm, with posterior crossbite and found increases suicidal thoughts and suicide attempts. Sleep quantity is clearly important; in total airway volume and respiratory however, sleep quality is also critical. Both cortical arousal and autonomic performance verified by CBCT and PSG activation occur during sleep disruption. Although children with OSA may get following expansion.70 A recent systematic enough hours of sleep, the quality and architecture may not be ideal. Both the review found RME was associated with short- and long-term increases in nasal quantity of sleep and the quality of sleep are important to consider. airway volume.71 Conversely, Abdalla and others demonstrated that the narrowest Amount of Sleep Required for Children cross-sectional area and pharyngeal airway Age Amount of sleep (hours) per day volume did not differ statistically between Infants (4 to 12 months) 12 to 16, including naps 66 RME and matched control groups. Children (1 to 2 years) 11 to 14, including naps Children (3 to 5 years) 10 to 13, including naps Functional or Mandibular Advancement Appliances Children (6 to 12 years) 9 to 12 Functional appliances (FA) alter the Teens (13 to 18 years) 8 to 10 position and growth of the maxilla and Paruthi S, Brooks LJ, D’Ambrosio C, et al. Recommended amount of sleep for pediatric populations: A mandible.72 FA are meant to be worn full consensus statement of the American Academy of Sleep Medicine. J Clin Sleep Med 2016;12(6):785–786. time to correct sagittal discrepancies.72 doi: 10.5664/jcsm.5866. Since the early 1900s, FA have been used with much controversy regarding their long-term influence on skeletal growth.74 Sheats describes FA as “tooth movers” The mandibular advancement device supported nor refuted the use of MADs that tip mandibular incisors labially (MAD) is endorsed by the AASM and in a pediatric population.76 The review and maxillary teeth posteriorly and the American Academy of Dental Sleep included results from a single trial of cautioned against widespread use without Medicine (AADSM) as a valuable 23 children and the outcome measure an orthodontic reason.56 Evidence for treatment option for adult OSA but is was reduction of AHI to less than one compliance and efficacy of FA for OSA in not commonly used in children because event per hour.76 Another systematic children is limited.73 A systematic review of the potential to alter growth.75 MADs review with limited evidence suggests including two studies found customized bypass airway obstructions during sleep by that MADs could provide short-term FA to reduce the AHI in a small sample of protruding the mandible.75 Although not improvement in AHI scores in children; children with mandibular retrognathia.73 intended to alter permanent occlusion, however, the authors could not conclude Data suggest a case-by-case approach MADs are essentially class II functional that MADs are effective to treat pediatric with close monitoring and coordination appliances only worn at nighttime.75 A OSA.77 The most recent systematic with a physician when using FA to 2016 Cochrane Review revealed very review and meta-analysis to date suggests treat OSA in growing children.46,53,74 low quality of evidence and neither appliance therapy may be effective

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TABLE 3 Weight Status Category Based on Body Mass Index (BMI)* Percentile Range in Children103 Weight status category Percentile range Underweight Less than 5th percentile Normal or healthy weight 5th percentile to less than 85th percentile Although preliminary data is promising, Overweight 85th to less than 95th percentile further RCTs demonstrating efficacy Obese 95th percentile or greater and stability of results are necessary.82

* BMI is age and sex specific in children and teens and is calculated by dividing the patient’s weight in kilograms by the square Furthermore, no longitudinal data exists of height in meters. documenting the effect of noncustom appliances on growth and development. for children with OSA.78 The meta- there is a lack of data supporting the Medical Management (Sleep analysis demonstrated that MADs were use of RME for treating OSA in the Physician, Primary Care Physician) beneficial at reducing AHI in prepubertal absence of a transverse discrepancy.64 children across severity levels.78 As with In a similar manner, a physician may Watchful Waiting adults, MADs may not resolve OSA for prescribe a MAD for a child or teen According to some sources, watchful several reasons including anatomical with OSA in the absence of a sagittal waiting up to six months may be variance and poor compliance.76 discrepancy (class II skeletal relationship). appropriate for children with mild to In this case, the goal of therapy would be moderate OSA.83,84 OSA may also Considerations for Appliance Therapy in airway maintenance instead of correction improve with changing sleep position.85 Children or Adolescents With OSA of a malocclusion.46 The device may A retrospective case study with chart It is important for the individual improve sleep respiratory parameters review evaluated 101 patients aged 2 to provider to recognize that dental for children even without mandibular 18 opting for nonsurgical management and orthodontic therapy may not be retrognathia; however, studies on the use and watchful waiting.86 Nonsurgical appropriate for all patients with OSA. of MADs in children are scarce.76 Off- management included intranasal steroids, Furthermore, appliances may not improve label, short-term use of MADs could be montelukast, nasal rinses and humidified OSA to an acceptable level even when a treatment alternative; however, this air.86 Based on follow-up PSG data, there the clinical presentation seems favorable. treatment requires coordination with were no significant differences in the Patients may be referred by medical medical professionals and close monitoring proportion of patients with resolution colleagues for consideration of RME. of occlusion, facial growth and development of OSA between those treated with Palatal constriction appears to be an and sleep-related breathing parameters.46 medications and watchful waiting.86 important prerequisite for expansion Furthermore, the authors concluded that in children with OSA.64 To that point Passive, Noncustom Appliances mild OSA in children has a roughly equal in a systematic review by Vale, all but Passive, noncustom appliances chance of worsening or improving over two of the 137 patients experiencing a have been marketed for continuous time without surgical intervention.86 significant reduction in AHI after RME wear to encourage oropharyngeal had a posterior crossbite.64 Interestingly, movements similar to exercises used for Medications Quo and colleagues conducted the only myofunctional therapy.80 The intent Intranasal or systemic medications study to date involving bimaxillary of these devices is to facilitate nasal may be appropriate for some children expansion in young children without breathing, mobilize oral musculature and with OSA. Medications may decrease posterior crossbites.79 In this study, reduce maxillary incisor proclination.80 swelling and inflammation of the airway bimaxillary expansion (expansion of both These appliances may be designed for and/or decrease tonsillar hypertrophy. maxillary and mandibular arches using use in the primary, mixed and young Therefore, in some patients OSA may jackscrew appliances) was performed.79 permanent dentitions and are classified as also resolve after treating comorbidities Although the sample size was small, AHI functional appliances because they have such as asthma and allergic rhinitis.86 actually worsened in 15 of 45 patients the potential to alter occlusion and facial Intranasal fluticasone and budesonide following bimaxillary expansion.79 growth.72 Huang and colleagues refer to have been shown to decrease OSA in Patients with more severe OSA (AHI > this practice as passive myofunctional children with mild OSA.87,88 Montelukast, 10) were more likely to improve while therapy or passive MFT.81 A few studies a systemic leukotriene modifier, may those with mild OSA were less likely to have evaluated the use of noncustom also reduce severity of OSA in children benefit from expansion.79 At this time, appliances in children with OSA.81,82 and improve quality of life.89,90

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Positive airway pressure (PAP) airway soft tissues in adults are not Continuous positive airway pressure common in pediatric patients with OSA, (CPAP) is a common therapy for OSA that but select applications may be necessary delivers pressurized air through an oral or along with other adjunctive therapies as a nasal interface.91 CPAP acts as a pneumatic more targeted approach is considered.97 stent that maintains patency of the upper airway.91 PAP can be very beneficial when Orthognathic Surgery FIGURE 3. A child performing oral motor exercises utilized,1 but problems with adherence is an Maxillomandibular advancement under the direction of a speech-language pathologist. issue requiring consideration for different (MMA) is the most common orthognathic treatment modalities.31–33,92 Nasal masks surgery used to treat adults with OSA.98 Orofacial Myofunctional Therapy tend to apply a retrusive molding pressure Orthognathic surgery is performed in Anatomic airway narrowing or to the maxilla.48 Prolonged use may be some children with craniofacial anomalies obstruction and deficits in the musculature associated with negative consequences on and comorbid OSA.99 Unless medically within the upper airway contribute to the developing facial structures of children.48 necessary, surgeons may prefer to wait the pathophysiology of OSA.106–108 Nasal until late teen years for girls and early 20s breathing, suctioning, mastication and Surgical Management for boys due to growth concerns.99,100 swallowing are examples of functional (Otolaryngologist, Oral and activities that engage orofacial and Maxillofacial Surgeon) Adjunct Management (Dietitians, oropharyngeal muscles.109–112 Atypical Behavioral Health Providers, or maladapted patterns of the oral/ Soft Tissue Surgery Orofacial Myologists) orofacial musculature that emerge in Adenotonsillectomy (T&A) is widely the absence of normalized patterns considered an effective first-line treatment Weight Loss and lead to abnormal facial growth for OSA in children.1 It remains an Obesity in young patients is a growing and function constitute an orofacial important consideration for many pediatric public health concern and may lead to OSA myofunctional disorder.113 Atypical patients but should not be the sole focus in children.101 Fatty infiltration into the patterns (e.g., mouth breathing, tongue of anatomic assessment or treatment neck and upper airway has been associated thrusting, dysfunctional swallowing, target.21 Hypertrophy of the tonsils and with OSA and obesity in adolescents.102 improper lip seal, parafunctional and/ adenoid tissue is thought to be the most Obesity is defined differently in children or nonnutritive sucking habits) may common cause of OSA in children.93 versus adults because body composition impact upper airway patency and Objective and subjective improvements varies by age and sex.102 Childhood obesity contribute to the emergence of sleep- in sleep, behavior and quality of life have is defined as a body mass index at or above disordered breathing patterns or OSA.114 improved following T&A.94 According the 95th percentile for peers of the same Orofacial myofunctional therapy to a Cochrane Review, there is moderate age and sex (TABLE 3). The Centers for (oral exercises, oropharyngeal exercises, quality evidence that T&A is beneficial Disease Control and Prevention developed myofunctional therapy) (OMT) has been for behavior, symptoms and quality of life an online calculator to establish the weight reviewed as adjunct therapy in both adults in nonsyndromic children.93 However, status of children and adolescents.103 and children with OSA.106–108 The goal a meta-analysis by Brietzke showed Weight loss improves OSA in of myofunctional therapy for children effective response from T&A was far overweight children and adolescents; with OSA is to provide functional below 100% and emerging data suggests however, the degree of weight loss is neuromuscular reeducation to correct that T&A may not be curative.95 To that unknown.102,104 Health care providers trained abnormal breathing patterns and muscular point, in some studies up to one-third in prevention and treatment of obesity have dysfunctions that impair upper airway of pediatric patients continue to have a welcome role on an interdisciplinary OSA patency, especially during sleep.107,111,115,116 residual OSA as demonstrated by PSG.96 team.104 Registered dietitians and behavioral Typically, professionals with a speech- As such, there is an increased focus on health providers offer nutritional and language pathology or dental/dental alternate or adjunctive treatments that behavioral guidance respectively.104 Bariatric hygiene background who are certified can improve durability of treatment.13 surgery to assist with weight loss in morbidly in OMT assist with this adjunctive and Reconstructive techniques of the upper obese adolescents has also been described.105 noninvasive treatment.107,111,113 Principles

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TABLE 4 Sample Oral Motor Exercises Target Exercise Frequency Jaw Graded closure/bite _____ reps each Place _____ (#) stacked tongue depressors on the lower molars at the left and right. Have your child bite down gently _____ x per day and hold for _____ seconds. Chewing _____ reps each Place a semisoft food item (e.g., string cheese) or soft teething toy on the right lower molars. Have your child bite up and _____ x per day down on it _____ times. Switch sides, repeat. Tongue Tongue base retraction _____ reps each Have your child lightly anchor the tongue between the teeth and swallow without letting go of the tongue. Repeat. _____ x per day Tongue Tongue tip _____ reps each elevation Have your child place the tongue tip on the alveolar ridge just behind the upper front teeth. Hold as long as possible, _____ x per day working up to _____ minutes. Your child may swallow as needed but then return the tongue to this position. Place _____ (#) stacked tongue depressors on the lower molars at the left or right. Have your child bite down gently and hold and then move the tongue tip up and down. Tongue surface _____ reps each Have your child suction the tongue on the roof of the mouth. Hold it there for_____ seconds. _____ x per day Do a tongue pop: Have your child suction the full tongue up onto the roof of the mouth and draw down briskly in a “pop.” Work up to _____ times in a row. Tongue Move to one side _____ reps each lateralization Hold a piece of firm candy (e.g., licorice) on the right or left lower molars. Have your child bite down gently onto the _____ x per day candy and then touch the tongue tip to the candy. Switch sides, repeat. Move across midline _____ reps each Starting at the right or left lower molars, have your child bite down gently onto a piece of firm candy (e.g., licorice) and _____ x per day touch the tongue tip to it. Move the candy along the surface of the teeth at four spaced-apart locations until reaching the lower molars on the opposite side. Have your child touch the tongue tip to the candy each time. Switch sides, repeat. Lips Seal _____ reps each Have your child puff out the cheeks while keeping lips sealed. Relax and repeat. _____ x per day Place tongue depressor between your child’s lips. Have your child close the lips and press together. Hold for _____ seconds.

Any oral motor exercise program must be performed under the guidance of a certified orofacial myologist, following a comprehensive evaluation and individualized treatment plan specifically designed to meet the needs of your child. and techniques of treatment generally relatively inexpensive and not associated in tongue function and mobility that may include a series of isometric and isotonic with any major risks.119 Systematic reviews lead to speech and feeding problems.121,122 exercises structured to engage oropharyngeal of the literature support myofunctional Guilleminault described a patient and tongue musculature with the aim to therapy as an adjunct treatment in the phenotype with a short lingual frenum, restore normative function of the lips, interdisciplinary management of sleep- narrow hard palate, speech difficulties early tongue, soft palate and lateral pharyngeal related breathing disorders.117,118 in life and sleep-disordered breathing.27 walls (FIGURE 3 and TABLE 4).106 Cohort studies reported improvement in Similar to any physical therapy program, Lingual Frenectomy articulation and intelligibility following OMT may take several months to solicit The AAO white paper and AAPD oral lingual frenectomy.123 The relationship normalized orofacial behaviors. Intervention health policy on the management of the between tongue mobility as it relates necessitates active parent involvement, and frenulum in pediatric dental patients do not to the pediatric airway during sleep is poor compliance with exercises may limit support lingual frenectomy at this time as an less clear.124,125 Furthermore, the degree outcomes.109 Although children at age 4 approved treatment to prevent development of frenum attachment considered to may be referred for evaluation of consistent of OSA in children.46,120 Lingual frenectomy be a deviation from normal is also nasal breathing, generally OMT is not involves the surgical release of a soft tissue controversial.124 Frenectomy is not a recommended for children under age 7 or band on the underside of the genioglossus recognized intervention for preventing 8. Nonetheless, myofunctional therapy muscle in the midline of the floor of the OSA in children or adults; yet, it is possible has been shown to decrease AHI as well mouth. Recent evidence points to an dentists may receive referrals to perform this as significantly reduce both severity and increase in utilization despite a lack of good procedure. Consideration for any surgical symptoms of sleep-disordered breathing and quality evidence indicating the need.121,122 intervention should be based on best OSA.114,117,118 Treatment is noninvasive, Ankyloglossia is associated with deficits practices with case-by-case consideration.125

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Ribeiro AN, de Paiva JB, Rino-Neto J, Illipronti-Filho E, Lin CH, Guilleminault C. Neutral supporting mandibular maxillary expansion in the promotion of oral and general Trivino T, Fantini SM. Upper airway expansion after rapid advancement device with tongue bead for passive health. Prog Orthod 2015;16:33. doi: 10.1186/s40510- maxillary expansion evaluated with cone beam computed myofunctional therapy: A long-term follow-up study. 015-0105-x. Epub 2015 Oct 7. tomography. Angle Orthod 2012 May;82(3):458–63. doi: Sleep Med 2019 Aug;60:69–74. doi: 10.1016/j. 55. McNamara JA, Brudon WL. Orthodontics and dentofacial 10.2319/030411-157.1. Epub 2011 Oct 17. sleep.2018.09.013. Epub 2018 Sep 29. orthopedics. Ann Arbor, Mich.: Needham Press Inc.; 2001: 69. Obelenis-Ryan DP, Bianchi J, Ignácio J, Wolford LM, 82. Levrini L, Salone GS, Ramirez-Yanez GO. Pre-fabricated 211–31. Gonçalves JR. Cone beam computed tomography airway myofunctional appliance for the treatment of mild to moderate 56. 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duration consensus statement: A step forward. J Clin Sleep 10.1002/lary.25979. Epub 2016 Mar 24. characteristics of oral breathers in different ages: A Med 2016 Dec 15;12(12):1705–1706. doi: 10.5664/ 97. Woodson BT, O’Connor PD. Reconstruction of airway retrospective case-control study. Prog Orthod 2015;16:23. jcsm.6368. soft tissues in obstructive sleep apnea. Oral Maxillofac Surg doi: 10.1186/s40510-015-0092-y. Epub 2015 Jul 15. 84. Chervin RD, Ellenberg SS, Hou X, Marcus CL, et al. Clin North Am 2009 Nov;21(4):435–45. doi: 10.1016/j. 113. Cooper A. Orofacial myology and myofunctional Prognosis for spontaneous resolution of OSA in children. coms.2009.08.005. therapy for sleep related breathing disorders. Sleep Med Chest 2015 Nov;148(5):1204–1213. doi: 10.1378/ 98. John CR, Gandhi S, Sakharia AR, James TT. Clin 2010 Mar 5(1):109–113. doi.org/10.1016/j. chest.14-2873. Maxillomandibular advancement is a successful treatment jsmc.2009.10.002. 85. Verhelst E, Clinck I, Deboutte I, Vanderveken O, Verhulst for obstructive sleep apnoea: A systematic review and meta- 114. Guimaraes KC, Drager LF, et al. Effects of oropharyngeal S, Boudewyns A. Positional obstructive sleep apnea in analysis. Int J Oral Maxillofac Surg 2018 Dec;47(12):1561– exercises on patients with moderate obstructive sleep children: Prevalence and risk factors. Sleep Breath 2019 1571. doi: 10.1016/j.ijom.2018.05.015. Epub 2018 Jun 2. apnea syndrome. Am J Respir Crit Care Med 2009 May Dec;23(4):1323–1330. doi: 10.1007/s11325-019- 99. Bell RB, Turvey TA. Skeletal advancement for the treatment 15;179(10):962–6. doi: 10.1164/rccm.200806-981OC. 01853-z. Epub 2019 May 7. of obstructive sleep apnea in children. Cleft Palate Craniofac J Epub 2009 Feb 20. 86. Kohn JL, Cohen MB, Patel P, Levi JR. Outcomes of children 2001 Mar;38(2):147–54. 115. Guilleminault C, Huang YS, Monteyrol PJ, Sato R, Quo with mild OSA treated nonsurgically: A retrospective review. 100. Conley RS. 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Oct;125:66–70. doi: 10.1016/j.ijporl.2019.06.027. Epub R, Cohen A, Amin R. Obstructive sleep apnea in extremely 120. American Academy of Pediatric Dentistry. Oral Health 2019 Jun 26. overweight adolescents undergoing bariatric surgery. Obes Policy on Management of the Frenulum on Pediatric Dental 91. Friedman N. Positive airway pressure for OSA. In: Kryger Res 2005 Jul;13(7):1175–9. Patients. Pediatr Dent 2019 (official but unformatted). M, Roth T, Dement WC, eds. Principles and Practices of Sleep 106. Huang Y, Hsu S, Guilleminault C, Chuang Y. 121. Walsh J, McKenna Benoit M. Ankyloglossia and Other Medicine. 6th ed. Philadelphia: Elsevier Inc.; 2017:1125– Myofunctional Therapy Role in Pediatric OSA. Sleep Oral Ties. Otolaryngol Clin North Am 2019 Oct;52(5):795– 1137. Med Clin 2019 Mar;14(1):135–142. doi: 10.1016/j. 811. doi: 10.1016/j.otc.2019.06.008. Epub 2019 Jul 25. 92. Rotenberg BW, Vicini C, Pang, EB, Pang KP. Reconsidering jsmc.2018.10.004. Epub 2018 Nov 30. 122. 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Treatment of ankyloglossia disordered breathing in children. Cochrane Database Syst Rev symptoms in children with sleep-disordered breathing? Sleep for reasons other than breastfeeding: A systematic review. 2015 Oct 14;(10):CD011165. doi: 10.1002/14651858. Breath 2017 Dec;21(4):1025–1032. doi: 10.1007/ Pediatrics 2015 Jun;135(6):e1467–74. doi: 10.1542/ CD011165.pub2. s11325-017-1489-2. Epub 2017 Mar 18. peds.2015-0660. Epub 2015 May 4. 94. Garetz SL. Behavior, cognition and quality of life after 109. Huang Y, Guilleminault C. Pediatric OSA: Where 124. Meyer AK. Ankyloglossia and oral ties: What is the adenotonsillectomy for pediatric sleep-disordered breathing: do we stand? Lin HC (ed): Sleep-related breathing evidence. College of Diplomates of the American Board of Summary of the literature. Otolaryngol Head Neck disorders. Adv Otorhinolaryngol 2017;80:136–144. doi: Pediatric Dentistry lecture. May 8, 2019. Surg 2008 Jan;138(1 Suppl):S19–26. doi: 10.1016/j. 10.1159/000470885. 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APRIL 2 0 2 0 223 Specializing in selling and appraising dental practices for over 46 years!

LOS ANGELES & VENTURA COUNTY VENTURA - GP w/ 4 eq ops . PPO & Cash SAN DIEGO COUNTY only. 40 years goodwill. Projection approx. BEVERLY HILLS - Established in 1981. CARLSBAD— This beautiful practice has $470K in 2019. Property ID #5288. Grossed approx. $1M in 2019. Net of over 22 yrs of goodwill. Has 4 eq ops in a $244K. Has 5 eq ops and 1 plmbd not eq op VENTURA (LH) - GP located in a 2 story med 1,800 sq ft suite.SOLD Fee for service office. room for expansion. Property ID #5307. prof. bldg with 2 eq ops. Prop. #5304. Grossed approx. $440K for 2018. Property ID # 5256. CERRITOS— GP with 40 yrs of goodwill in WHITTIER—COMING SOON!! EL CAJON (GP) - Price Reduced! Consists of shopping plaza. Grossed approx. $1.4M in 5 eq ops and equipped with 3D Sirona CBCT ORANGE COUNTY 2019. NET $261K. Property ID #5295. Digital X-ray. Grossed over $1M in the past ANAHEIM— GP located in a small shopping 10 years. Property ID # 5265. DUARTE— GP established in 1964 located center. Has 4 eq ops w/ digital x-ray. Ap- LEMON GROVE— Fee for service general in a 2 story mixed bldg. Grossed approx. prox. 40-45 new patients/mo. Grossed practice with over 48 years of goodwill $350K in 2019. Property ID #5183. approx. $1.35M in 2019. Net $876K. Prop- located in 2 story corner building. Has 4 eq erty ID #5296. GLENDALE—GP w/ 3 eq ops and 1 plmbd ops. Grossed approx. $398K for 2019. Prop- not eq op in a 3 story medical professional CORONA DEL MAR—Well established GP erty ID #5308. bldg. Grossed approx. $544K in 2019. Prop- with walking distance to the ocean. Consists of erty ID #5305. 3 eq ops. Grossed approx. $788K in 2019. RIVERSIDE COUNTY GRANDA HILLS— With 50 yrs of goodwill Property ID #5285. TEMECULA - Pedo and Ortho Practice! It’s this general practice grossed approx. $392K FOUNTAIN VALLEY— GP in strip shopping located in a duplex single story building. in 2019. NET $149K. Property #5276. center w/ great street visibility. Grossed Grossed approx. $1.3M in 2019 with a Has 4 eq ops and 1 plmbd $238K in 2018. Buyer’ net of $557K. PPO/Cash/Denti-cal. LONG BEACH—GP with approx. 60 yrs of not eq. Great staff. Property ID #5293. Has 8 eq ops in a 3,500 sq ft office. Property goodwill. Projecting approx. $373K in 2019. IRVINE—Turn-Key GP in 3 story medical ID # 5243. Property #5303. dental professional building. Has 3 eq ops and 2 plmbd not eq in an approx. 1,562 sq ft LA QUINTA— Price Reduced! Well estab- LONG BEACH—Established in 1985. GP in a suite. Grossed approx. $265K in 2019. lished GP with over 8 years of goodwill. 2 story prof. bldg. w/ 4 eq ops and 2 plmbd Property ID #5311. This modern designed practice has 8 eq ops. not eq on a 1,800 sq ft suite. Grossed ap- LAGUNA NIGUEL—COMING SOON!! On a the busiest major intersection. prox. $718K in 2019. Property ID #5302. Grossed approx. $1.5M for 2019. NET NEWPORT BEACH—Beautiful fee for service ROWLAND HEIGHTS— Estab. in 2009, this GP, located in a corner 2 story med bldg. $344K. Property ID #5130. GP is located in a 1 story free standing bldg. Well established practice with 4 eq op with SAN BERNARDINO - GP established circa Grossed approx. $806K in 2019. NET windows views. Grossed approx. $616K in 1950 located in 2 story bldg. Has 4 eq ops in $314K. Property ID 5278. 2019. Property ID #5310. approx. 1,500 sq ft suite. Grossed approx. WESTMINSTER/FOUNTAIN VALLEY— Es- SAN GABRIEL— GP located n a 2 story $322K in 2019. Seller is retiring . Property tablished in 1978 GP in 2 story free stand- building with 42 yrs of goodwill. Has 11 eq ing bldg. Grossed approx. $763K in 2019. ID #5292. ops. Grossed approx. $1.2M in 2019. NET Has reasonable SOLDrent. Property ID #5291. UPLAND—Beautiful general practice locat- $243K. Property ID#5309. YORBA LINDA—GP in strip shopping center ed in 2 story building with 4 equipped oper- SIMI VALLEY— GP w/ 54 years of goodwill with 33 years of goodwill. Has 3 eq operato- atories. Grossed approx. $920K in 2019. in free standing building. Grossed approx. ries. Grossed approx. $300K in 2019. Buy- Property ID #5237. $575K for 2019. NET $185K. ID #5294. er’s net $113K. Property ID #5299.

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FREE CONSULTATION WWW.CALPRACTICESALES.COM Phone: (800) 697-5656 CA BRE #00283209 CONTACT US FOR A RM Matters CDA JOURNAL, VOL 48, Nº4

Workers’ Compensation: Quick Reporting Required With Employee Injuries

TDIC Risk Management Staff

hether it’s oral health The employee should be directed work-related injuries. This can delay the care or practice to an occupational medical clinic for claims process, the investigation of the management, it’s treatment or a hospital for severe injuries. claim and the benefits that the employee generally better Some states allow employees to pick their may be eligible to receive. Additionally, to be proactive own treating physician, while other states if an employer knows that their employee Wthan reactive. This is certainly the allow employers to direct medical care for was injured at work but the employee case when it comes to maintaining a work-related injuries through a network refuses to follow state-mandated guidelines healthy, happy workplace. And when of approved physicians. Contact your on reporting the injury and where to seek addressing employee injuries, being insurance carrier for guidance on where your treatment, it is recommended that the proactive is not just a recommendation injured employee should seek treatment. dentist contact their workers’ compensation — it’s the law in most states. Unless otherwise predesignated, it is best insurance carrier for advice. Employers The Dentists Insurance Company that an employee avoids seeking treating have a legal obligation to report work- reminds practice owners that employers with their own health care provider for related injuries in a timely manner. are obligated to report workplace injuries immediately. Delaying such occurrences has the potential to not only further an employee’s injury, but to also lead to problems should a claim be filed at a later date. The reasons for delay can be many. In some cases, the employer erroneously believes that reporting an injury will automatically increase their premium. In others, a well-intentioned employer attempts to handle the situation in- answers house. Most commonly, the employer takes a “wait and see” approach, hoping that the injury remains minor. In one case reported to TDIC’S Risk Management Advice Line, an employee injured her back while reaching for something at work. The dentist requested the employee see a doctor, but the employee From one-on-one risk management advice by phone chose to take ibuprofen instead, confident to informed consent forms to expert-led seminars, that this would resolve her back pain. The next day, she was still sore, and the we’re here to help you practice with confidence. dentist again asked if she wanted to see a We are The Dentists Insurance Company. doctor. She declined and said she was fine. Employers are reminded that once Learn more at tdicinsurance.com/rm they become aware of a work-related injury, they should immediately ® contact their workers’ compensation Protecting dentists. It’s all we do. carrier. The carrier will investigate 800.733.0633 | tdicinsurance.com | Insurance Lic. #0652783 the injury to determine liability.

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CDA JOURNAL, VOL 48, Nº4

As part of the reporting process, Workers’ compensation laws vary In other workplace injury cases, it’s important to gather the facts of from state to state, but generally speaking, practice owners are unsure of how to how your employee was injured. Ask an employer must report the incident to handle employees who request time off your employee how they were injured, their carrier within one business day of after becoming injured. TDIC reports a which body parts were injured and becoming aware of an injury. The U.S. case in which an employee was injured the type of injuries they sustained; Department of Labor has state-specific after tripping and falling in the office. for example, was the injury a strain, contacts and guidelines available on During recovery, she had been attending puncture, laceration, etc. This will its website. It should also be noted that two weekly appointments — one visit play a vital role in the investigation of employers are required to authorize to a doctor and the other to a physical the employee’s claim and acceptance appropriate medical treatment and make therapist. The dentist called the Advice for workers’ compensation benefits. medical care available to injured employees, Line for guidance on whether he could ask Your insurance carrier or assigned regardless of whether the employers the employee to take the appointments third-party administrator will need dispute the injury. Workers’ compensation on certain days or times that didn’t this information along with objective claims are considered “no fault,” meaning interfere with his business operations. medical findings to determine the the employee is covered regardless of The Risk Management analyst compensability of a work-related injury. the events that led to the injury. advised the practice owner that yes, he can ask, but he can’t refuse to allow her to attend her appointments if she is unable to schedule them outside of his business hours. However, if the employee fails to give adequate notice to her employer as outlined in the employee manual, she is subject to the same disciplinary actions as any other employee. In any event, everything should be documented, including the time-off requests, approvals or denials and doctors’ notes. This documentation should be maintained in a medical file separate from the employee’s personnel file. It’s also important for practice owners to maintain open lines of communication with all parties involved in injuries — the employee, the carrier and, when applicable and appropriate, the doctor or medical staff. In another case reported to the Advice Line, an employee fell to the ground while walking. She said she didn’t know how she fell, but claimed her arm was hurting and went to the doctor. The doctor confirmed there were no broken bones and gave her a note to return to work. The employee refused to return to work, stating that she was in extreme pain and insisting on obtaining an MRI.

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LDM_CDA_Journal_1.3_Square_LindaBrown_05_23_17.indd 1 5/24/2017 9:21:40 PM Making your transition a reality.

Dr. Thomas Dr. Russell Dr. Rishi Jim Jay Kerri Gina Steve Jaci Kim Thinh Wagner Okihara Salwan Engel Harter McCullough Miller Caudill Hardison Ta Tran LIC #01418359 LIC #01886221 LIC #02085289 LIC #01898522 LIC #01008086 LIC #01382259 LIC #02015193 LIC #00411157 LIC #01927713 LIC #02085576 LIC #01863784 (916) 812-3255 (619) 694-7077 (909) 239-2800 (925) 330-2207 (916) 812-0500 (949) 300-0312 (707) 391-7048 (951) 314-5542 (949) 675-5578 (408) 687-5001 (949) 675-5578 45 Years in Business 38 Years in Business 10 Years in Business 46 Years in Business 36 Years in Business 35 Years in Business 30 Years in Business 30 Years in Business 26 Years in Business 16 Years in Business 11 Years in Business PRACTICE SALES • VALUATIONS/APPRAISALS • TRANSITION PLANNING • PARTNERSHIPS • MERGERS • ASSOCIATESHIPS NORTHERN CALIFORNIA SACRAMENTO: Downtown/Midtown: Hi- MODESTO AREA PERIO PRACTICE: 4 Ops, POMONA: Great potential! Low rent. 4 Op traffic, 4 Ops, under 5% Delta Premier patients. 5th available. 1,600 sf. LANAP Laser and Digital practice. Only open 2 days/wk. Seller is retiring. AUBURN & FOOTHILLS AREA: Fast 2018 GR $607K on 30 Dr. hrs/wk. #CA590 Sensor. 2019 GR $455K on 4 day/wk. Bldg. also 2018 GR $279K. Priced to sell. #CA610 growing practice in 2,500 sf w/ 6 equip. Ops, 1 SACRAMENTO AREA: Price reduced by available. #CA598 SAN FERNANDO VALLEY: New Listing! 10 add’l plumbed. 2019 GR on track to exceed $100K! GP & Specialty HMO/some PPO Practice. $1.2M on 3 avg. Dr. days/wk. #CA632 MODESTO AREA: Established neighborhood Ops, 8 Equip, hi-tech, fantastic location. Digital, 9 Ops, I/O Cam, Digital Pano. 2017 GR $1.1M+, with 60+ yrs Goodwill. 5 Ops, 1,450 sf. 2018 GR Pano, CT Scan. GR $1.1M+. #CA664 CONCORD: East Bay, Contra Costa 2018 Quickbooks (to be verified) GR $680K. 5,000 $1.1M+ on 3 day/wk. Dental Condo also available Community: Digital Practice with 3 Ops, modern/ sf bldg. avail. #CA567 SAN GABRIEL VALLEY: 4 Ops, Digital for purchase or lease. #CA635 X-rays, 65 yrs Goodwill. Most specialty work attractive bldg., PPO, 1,200 sf, and Dentrix. 2018 SACRAMENTO AREA: SELLER MUST SELL! GR $1M+ on 34 avg. Dr. hrs/wk. #CA595 STOCKTON AREA: Great opp to purchase referred out, most PPO plans are accepted. Busy Seller considering all offers. 4 Equip Ops w/1 practice and bldg, 3,000+ sf with 6 Ops, good hyg road with great visibility, open 4 days/wk. Nicely CONTRA COSTA COUNTY: Records for only additional available, 45+ yrs Goodwill in well- recall. 2018 GR $1M+ on avg 37 hrs/wk. #CA616 appointed; excellent opportunity. #CA596 the Pedo and/or Ortho portion of Practice. 11+ yrs established location. 1,403 sf office condo Goodwill. Buyer must be within 15 miles of available for purchase. 2018 GR $574K. #CA603 VISALIA: Practice+Bldg, 5 Ops, 2,000 sf, street SIMI VALLEY: Price Reduced! 3 Ops, 30 yrs Contra Costa County. Asking Price is below frontage, 2019 GR of $353K. Great deal for quick Goodwill, Strip Mall Location. 2018 GR $263K SAN FRANCISCO: Low Rent! 30+ yrs Goodwill. sale, Most Specialty referred out. #CA628 with $77K Adj. Net. #CA626 appraised value. #CA576 Beautiful 4 Op office w/ strong hyg program. 2019 EAST BAY: New Listing! Central beautiful GR $740K+. #CA657 SOUTHERN CALIFORNIA SIMI VALLEY: 6 Ops, 5 Equip. Great location, location with 4 Ops in 1,350 sf. 2019 GR $659K low rent, 45 yrs Goodwill. 2018 GR $297K w/ SAN JOSE: Great cash flow in beautiful retail BAKERSFIELD: New Listing! Well-established, $89K Adj. Net. #CA637 on only 4 doctor days/week. #CA644 space with hi-traffic and visibility. Spacious 3,150 5 Ops, 4 Equip. In-house dental lab. Condo also for SIMI VALLEY: 6 Ops, 39 yrs Goodwill. Strong FAIRFIELD AREA: 4 Ops in 1,500 sf, 30+ yrs sf w/ 10 Ops, 6 Equip. 2018 GR $998K. #CA600 sale. 2019 GR $363K on 3 days/wk. #CA674 Goodwill. Dentrix PMS, I/O Cam, Digital X-ray, hyg. program. Prof. bldg. EagleSoft, Digital, Pano. SAN JOSE: Beautiful practice, very busy retail BAKERSFIELD AREA: 6 Ops, 39 yrs. 2018 GR $783K. #CA617 paperless practice. 2018 GR $840K on 4 day/wk. plaza, luxuriously designed 2,700 sf w/8 Ops. 2019 #CA655 Goodwill, Dentrix, and I/O Cam. 2019 GR $454K. SOUTH ORANGE COUNTY PERIO: 4 Ops, GR $483K on 34 hrs./wk. Priced to sell! #CA627 Unique opportunity to merge two practices to one FOLSOM/RESCUE/EDH AREA: 5 Op digital 3 Equip, Coastal Community, Modern, Busy strip SONOMA COUNTY: 2018 GR $906K. 1,000 sf, large one. #CA622 center location near hi-end residential. 2019 GR practice, modern space w/ low overhead. 2019 3 Ops w/ opportunity to expand. Paperless, GR $802K. Office condo also for sale. #CA581 BAKERSFIELD AREA: Practice +RE (Merger $845K. #CA643 Dentrix, Digital, I/O Cam. Selling both Practice w/ #CA622) 5 Ops, 4 hyg days. Most specialty FREMONT: 4 Equip Ops in 1,800 sf. Dentrix and portion of dental building ownership. #CA594 SOUTH BAY/LOS ANGELES AREA: referred, room to grow! 2019 GR $376K #CA623 New Listing! Family practice est. in 1950. 3 Ops, PMS, Digital X-ray, Diode Laser, I/O Cam. SONOMA COUNTY: Price Reduced! Modern #CA547 BAKERSFIELD PEDO: Rare opportunity to Digital, Strong hyg. prog. Great area. 2019 GR GP offering a broad range of service. 6 Ops in purchase successful 30+ yr old practice w/ Ortho/ $651K. #CA671 FREMONT: Priced to sell! 40+ yrs Goodwill. 2,200 sf, seller-owned facility. 2018 GR $802K w/ Oral Surgery services. Over 4k active patients, avg. SOUTH BAY/TORRANCE AREA: 6 Ops in Spacious 2,900 sf suite with 9 Equip Ops in 4 hyg days. Digital, Dentrix, I/O Cam, Laser. 40 NP/mo. $2.5M+ GR for past 3 yrs. #CA599 stand-alone bldg. 2019 GR $578K. #CA607 MOVE-IN READY, this will not last! #CA564 prof. bldg. 44 yrs. Goodwill. SoftDent, Digital X- COVINA: Well-established, great visibility, 4 rays, I/O Cam, and Laser. Visiting Specialists GREATER EL DORADO HILLS: Multi- SONOMA COUNTY: Large GP, 2018 GR above Ops, Digital X-rays. Seller refers out most difficult keeps procedures in-house. Strong hyg. prog. 2019 doctor practice, 3,000 sf office, 8 Ops, 7 Equip, I/ $2.8M. Stand-alone 3,000 sf prime Real Estate, 72 specialty work so there is room to grow. Bright, GR of $972K. #CA624 O Cam, Digital X-rays & Pano. 2019 GR $2.2M. NP/mo.10 hyg days. 6 Ops, Pano X-ray, Dexis, cheery space, word-of-mouth referrals. #CA634 Sellers will consider working back P/T. #CA578 Cameras, Laser, Dentrix. Both Business & Real WEST COVINA: New Listing! State-of-the-art Estate for sale or Lease. Doctor Retiring. #CA544 DIAMOND BAR: New Listing! Beautiful 5 Ops practice with 3 Ops and is all digital and modern GREATER SACRAMENTO: Price Reduced in Prof. Bldg., Digital, Dentrix, Must-see, call for with 1 day of Hygiene/wk. 2019 GR $1.2M+ with by $50K! PPO Practice with 4 Ops, digital SONOMA COUNTY: 2018 GR $2M+. 8 Ops in an appointment. #CA672 Adj. Net of $420K in a great location with low sensors, imaging system, I/O Cam. Practice open 4,600 sf, 13 hyg days on 4½ day/wk. 42 yrs rent. #CA661 33 yrs. 2017 GR $652K; Office Condo available Goodwill. Doctor retiring and will work back. HUNTINGTON BEACH: New Listing! 4 Ops, for purchase. #CA561 Paperless, Digital, hi-tech, modern. #CA601 located in a busy retail center with great visibility. WESTERN SAN FERNANDO VALLEY: Practice utilizes Digital X-rays and Easy Dental 5 Ops, 4 Equip, EagleSoft, Digital, Laser, I/O Cam. GREATER SACRAMENTO: Great area w/ 38 VACAVILLE AREA: Centrally-located & hi- PMS. 2019 GR $466K. #CA673 12+ yrs Goodwill, Prof. bldg. near hospital. yrs Goodwill. 4 Ops in 1,100 sf. 2018 GR of $1M traffic location with 25+ yrs Goodwill. 5 Ops in Accepts PPO and 3 HMO plans. 2019 GR $405K. + on 32 hrs/wk. #CA656 1,700 sf. 2019 GR $556K on 32 hrs/wk. #CA645 LOS ALAMITOS: New Listing! Beautiful state- of-the-art practice with 4 Ops, and mostly #CA614 HAYWARD: Dr. retiring from cozy, 900 sf, 3 4 Ops, 1,650 sf w/ below-market rent. VALLEJO: associate-run. Digital, cash and PPO in a great SAN DIEGO Op practice with opportunity to purchase part of 2019 GR $791K, 4 hyg days/wk, low OH. #CA469 location. GR $900K w/ $390K Adj. Net. #CA662 the bldg. Desirable area. #CA649 WOODLAND/DAVIS AREA: 6 Ops, 40+ yrs LOS ANGELES: Price Reduced! West Side, 5 ENCINITAS: 4 Ops. Busy retail center. LAKE TAHOE AREA ENDO PRACTICE: Goodwill. Real Estate available. 2018 GR $1.1M+ Ops, 4 Equip, EagleSoft, Digital, 40 yrs Goodwill, Remodeled 5 yrs. ago with new equipment. 3 Ops, 3 digital sensors, Cone Beam in 1,100 sf. on 32 Dr. hrs/wk. #CA629 Up-and-coming area. 2018 GR $523K. #CA640 Dentrix, Digital, Pano, and Laser. 4 hyg. days/wk. Consistent GR $525K for the last three years on YUBA CITY AREA: 46 yrs Goodwill, GP 2018 GR $813K. #CA574 32 avg. Dr. hrs/wk. #CA602 LOS ANGELES: New Listing! Near Glendale, 4 Practice with 3 Ops w/ 4th Open in 1,400 sf. Priced Ops in stand-alone bldg w/ great visibility. Low LA JOLLA: New Listing! UTC Area, Leasehold LAKE TAHOE AREA: GP practice with 5 Ops below professional Valuation. 2018 GR $271K. rent and $6K/mo. CAP check. Room to grow! GR with patients. 7 Ops Digital in retail center with w/ 6th Open, Operatory views of Lake Tahoe, #CA580 $200K+ with low OH. #CA665 strong anchors. Priced to sell! #CA663 only 34 Delta Premier patients, 2,100 sf. 2019 NORTH COUNTY COASTAL ORTHO: 4 GR $579K on 22 avg. Dr. hrs/wk. #CA608 CENTRAL CALIFORNIA LOS ANGELES: 7 Ops. Prof. bldg. in great location of LA. Strong hyg. program w/ 5+ hyg. Chairs + Consult Room, Desirable area, Digital MONTEREY: 4 Op, 1,600 sf in highly desirable CENTRAL COAST ENDO PRACTICE: 3 Ops, days/wk and 37 yrs. Goodwill. 2018 GR $983K w/ Pano/Ceph, Excellent location. 2018 GR $273K. area with plenty of free parking. 2018 GR $1M+ $277K Adj. Net. #CA606 #CA653 on 32 hrs/wk. #CA650 Digital X-rays, Paperless, Cone Beam CT, and PBS Endo Software. 2018 GR $1.1M+ w/ $635K Adj. NORTH ORANGE COUNTY: 5 Ops, has been NORTH COUNTY PERIO: 4 Ops, 3 Equip. MONTEREY PENINSULA: Practice Net. #CA489 open since 1965. Dentrix, digital Pano. Retiring Newer equip. including CT Scanner, Digital, established for 70+ years, 32 w/ present owner. seller will assist w/ smooth transition. One-story Dentrix. Well-maintained complex. Priced to sell Beautiful 1,130 sf office w/ 3 Ops. Dentrix PMS, CENTRAL VALLEY PEDO PRACTICE: New Listing! Shared space w/Ortho, 7 Op, 3,800 sf. prof. bldg. 2018 GR $231K. Room to grow. Most quickly. 2018 GR $269K. #CA605 Dexis Digital X-ray, I/O Cam, Diode Laser. 2019 specialty procedures are referred out. #CA558 POWAY: 3 Ops, located in a busy strip center w/ GR $520Kon 4 day/wk. #CA625 2019 GR of $610K as part-time practice. Great starter practice or satellite office. #CA660 ORANGE COUNTY: New Listing! 5 Ops, room to grow! Digital X-rays, I/O Cam, Pano, and NORTHERN CA PEDO PRACTICE: Large Beautiful office, Digital, Paperless, Hi-traffic area Laser. 2018 GR $226K. #CA659 practice in downtown location, 5,000 sf with 7 FRESNO AREA: GP and Prosthodontic Practice prime for a GP to purchase. 4 Ops, 1,500 sf, Digital with great signage and low-rent. #CA670 SAN DIEGO COUNTY ORTHO: Rare equip Ops, 2 add'l plumbed. 2018 GR $3M+. Opportunity in the San Diego County area, #CA658 Sensors, film Pano, DentalMate Software, ORANGE COUNTY ENDO PRACTICE: Built attractive office bldg. 2018 GR $386K. #CA588 in 2018, 6 Ops, 5 Equip, 3 Scopes, Cone Beam CT, Established office with updated computer PLEASANT HILL: 23+ yrs Goodwill. 1,438 sf fully digitized and paperless. 19 yrs Goodwill. GR hardware. Paperless with many years of goodwill. modern office on busy roadway. 4 Ops, Dentrix GREATER FRESNO AREA: Great location for well-established practice with 40+ yrs Goodwill. 6 for the past 3 yrs at $1.3M+. Very low OH. Seller Excellent location. This will sell quickly. #CA615 PMS, Paperless, Digital Pan, I/O Cam, Diode retiring. #CA593 Laser. 2018 GR $762K on 4 day/wk. #CA654 Ops, Digital X-ray, Diamond Dental PMS. 2018 OUT OF CALIFORNIA GR $638K. #CA621 PALM SPRINGS AREA MULTI- REDDING AREA: Modern practice in 1,600 sf GREATER MODESTO AREA PEDO SPECIALTY: Priced to sell @ $775K - 5 Ops, CENTRAL COAST, OREGON: Minutes to with 4 equipped Ops, 1 additional plumbed. 2019 lecture room, 28 yrs Goodwill. Hi-end, mostly cash the ocean. 3 Dr. days/wk, 2 hyg days/wk. 2019 GR $558K on 32 hrs/wk. #CA648 PRACTICE: Digital, 7 Op practice in 2,812 sf. Practice has small growing patient base, priced as patient base. Dentrix, Digital, CT Scan & Gemini GR $404K, practice positioned for growth, ROCKLIN/LINCOLN AREA: 10 Ops, 6 equip, start-up/acquisition opp. #CA646 Dual Wave Laser. History of collecting $1.2M+/yr Doctor is retiring. #OR112 4 plumbed,. 2,619 sf. Growth potential in all on 4 days/wk. #CA604 MERCED AREA: 30+ yrs Goodwill in great SOUTHWEST PORTLAND: 7 Ops, 6 Equip, Specialties, 2018 GR $747K on 4 days/wk. PASADENA: 4 Ops, 3 Equip, Dentrix, Digital, Dentrix, Digital, Pano. Well-maintained leased #CA641 location. 4 Ops, Dentrix, Digital, I/O Cam, Laser, Pan/Ceph. 2018 GR $691K. #CA642 CBCT. Great location! This won’t last! #CA651 space. 2019 GR $598K. #OR115 Northern California Office www.henryscheinppt.com Southern California Office 1.800.519.3458 1.888.685.8100 Henry Schein Corporate Broker #01230466 Specialists in the Sale and Appraisal of Dental Practices Serving California Dentists since 1966 Practices How much is your practice worth?? Wanted Visit PPS at CDA Anaheim Booth 1157

NORTHERN CALIFORNIA SOUTHERN CALIFORNIA (415) 899-8580 – (800) 422-2818 (714) 832-0230 – (800) 695-2732 Raymond and Edna Irving Thomas Fitterer and Dean George [email protected] [email protected] www.PPSsellsDDS.com www.PPSDental.com California DRE License 1422122 California DRE License 324962

6176 SANTA CRUZ Delta PPO practice topped $1 Million in 4003 PEDO - CHINESE / HISPANIC 3,000+ Charts. Move to your office. collections in 2019. Great location, great technology. 4-ops, 3-D Cone Full Price $150,000. Beam and Cerec. 4006 ALTA LOMA High identity Center. Absentee. Grossing $700,000. 6175 OAKLAND’S DESIRABLE COMMUNITY Collections in 2019 4011 DIAMOND BAR Dream Million Dollar location. 5-ops. Adjacecent again topped $1.4 Million. Strong profits. 11-days of Hygiene per week. restaurants bring in lots of people. FP $150,000. 6174 HUMBOLDT COUNTY’S UNIVERSITY COMMUNITY – 4018 TWO SOUTH ORANGE COUNTY PRACTICES Each does ARCATA Special area to raise one’s children and enjoy quality of life. $800,000. Owned by same Dentist. Best location, great foundation, dedicated Team. Seller works 3-day week. 4019 $1 MILLION NET PROFIT Opportunity of a lifetime. Call Tom. 2019 collected $350,000+. Beautiful Victorian building available as BAKERSFIELD Small City. Grossing $40,000/month on 2-days. 5-ops. optional purchase. Practice screams to be full-time. BURBANK - NORTH HOLLYWOOD HMO Grossing $2.2 Million. High 6173 SAN FRANCISCO – “OUT-OF-NETWORK 2019 collected Tech. 5 ops. $1,315,000. 6-ops. 8-days of Hygiene. 1,500+ active patients. Contract CAPISTRANO BEACH Grossing $200,000 “fee for service” in 16 hours with specialists to perform referred work in-house and take to next level. per-week. 6172 SAN FRANCISCO’S EAST BAY - “OUT-OF-NETWORK” HEMET Seller works one day and produces $240,000. Practice $110 2019 collected $850,000 with Profits of $430,000. 4-days of Hygiene. ,000. Requires skilled, easy-temperament and great communicator as Successor. Bargain on Real Estate. IRVINE Female Dentist grossing $1 Million. Will share office. 6171 SANTA ROSA Great DNA here for this long-established practice. Strong patient foundation per 6+ day Hygiene Schedule. Consistent $1+ LA HABRA Huge Shopping Center. Well maintained. PT Seller will stay. Million in Collections each of last 5-years. Great Team. 4-operatories. LADERA RANCH 4-ops. Grossing $500,000. High Growth area. LAGUNA WOODS Grossed $800,000 during Renovation. Renovation 6170 MANTECA / RIPON AREA 2019’s revenues totaled $850,000+. 5-days of Hygiene. Practice refers endo, most OS and implant placements. done. Should gross $1 Million. Extensive patient base. Successor should con-tract with specialists to MIRACLE MILE NEAR FAIRFAX Beautiful corner suite with Wilshire perform work being referred. Office is perfect for making this a full- view. 3-ops recently remodeled. service practice. ORANGE Grossing $1.2 Million. State-of-art beautiful! 6169 VACAVILLE Long established Delta PPO practice. 5-days of ORANGE COUNTY High profile shopping center. Grossing $1.5 Million. hygiene. 2019 trending $700,000+ with Available Profits of $285,000. ORANGE COUNTY Near Chapman / Tustin Streets. Gross $400,000. Great north side location. Merge or grow. 6168 SACRAMENTO’S CAMPUS COMMONS “Bread & butter” ORANGE COUNTY BEACH 5-ops. Gross $1.2 Million first year. Area Delta PPO practice averages $480,000 in collections per year. Well liked growing. Dentist. 10+ weeks off a year. 4-days of Hygiene. 3-D Cone Beam. Great ORANGE COUNTY BEACH CITY Absentee. Grossing $900,000+. 4-ops, implant upside as retirees in area require this ser-vice. Practice here and room for 5th. live in Folsom or El Dorado Hills. ORANGE COUNTY BEACH CITY Grossing $800,000 part-time. 6167 DOWNTOWN PALO ALTO – “OUT-OF-NETWORK” Perfect Valuable Real Estate may be available. for Skilled Dentist seeking strong patient relationships and insurance PALM SPRINGS AREA Grossing $1.5 Million. 8-ops. independency! 2019 trending $825,000+ on Owner’s 3-day week. Office REDLANDS 5-ops. Grossing $500,000. Part Time. Full Price $450,000. has been upgraded and charting is paperless. RIVERSIDE Female DDS Grossing $300,000. 3-ops. Full Price $250,000. 6166 TRI-VALLEY’S PLEASANTON 2019 trending $850,000+ in SAN JUAN CAPISTRANO BEACH Grossing $200,000 on 16 hour week. collections. Averages 20 new patients per month. Attractive 4-op office, SANTA CLARITA 70,000 Autos pass daily. Tremendous upside. Full Price Digital Pan and Fabrication Center. Very profitable. $250,000. 6165 ROSEVILLE ORTHO – “OUT-OF-NETWORK” Stanford SAN DIEGO GROUP DSO. 4 offices grossing $3.7 Million. Ranch. $455,000 invested in build-out, furnishings, computers and SOUTH BAY AREA ets $750,000 on Gross of $2.3 equipment. 3-chair Bay. Digital Pan with Ceph. Averages 3 New Patients Total Absentee. N per month. Full Price $125,000. Million. Can grow to $3.5 Million. SOUTH ORANGE COUNTY Crown Valley Shopping Center. Grossing 6164 SAN FRANCISCO’S UNION STREET - “OUT-OF- NETWORK" Highly regarded as evidenced by 25+ new patients per near $800,000. month. Collections topped $2 Million each of last 3-years with Profits SOUTH ORANGE COUNTY 2-offices, each doing near $800,000. averaging $1 Million. Paperless. 3-D Cone Beam. Available by one Seller 6163 LAKEPORT Attractive option to practicing in competitive areas in UNION PRACTICE - INLAND EMPIRE Grossing $650,000 on 2.5 day expensive housing markets. 6-op facility completely net-worked. 2019 week. Nets close to $400,000. collected $969,000. UPLAND 3-ops, low overhead. Seller will transition. Full Price $360,000. 6158 FORTUNA Relaxed lifestyle in Humboldt County’s Banana Belt. WANTED: IRVINE - NEWPORT BEACH - COSTA MESA – TUSTIN Adjacent to Ferndale. Perfect for Dentist seeking small town living. 2019 Dentist lost lease. Owner will merge high-end $800,000 practice into yours. collected $379,000. 6-weeks off. Lots of work referred. WEST LOS ANGELES Prestigious Medical Building. Unique. CDA JOURNAL, VOL 48, Nº4

CONTINUED FROM 226 In this case, the analyst advised the Keeping open communication is Even with the most careful precautions, dentist that unless the employee has also essential while the employee is on employee injuries are an unfortunate reality paid time off, she must have a note from leave. The onus is on the employee in any workplace. Should an injury occur in her doctor restricting her from work. to provide updates to the employer your practice, expedient reporting to your Some dental practices allow employees throughout the period of disability, and workers’ compensation carrier is essential. to take unpaid leave; this is dependent they should keep the employer apprised Maintaining open lines of communication on the office’s internal policy. of an expected return-to-work date. with your employee not only helps the The dentist considered allowing the It’s also important that employers claim process go smoothly, it is critical to employee to take the time to obtain engage in open discussions with mitigate further injury and ensure your an MRI, as he was concerned that she their employees regarding work employee is back to work quickly. n would be unable to perform her duties at modifications and accommodations. work. The analyst informed the dentist It is a good practice to allow TDIC’s Risk Management Advice that he should refer the employee employees to be on modified duty Line is a benefit of CDA membership. If back to the workers’ compensation while they heal, if appropriate and you need to schedule a no-cost consultation doctor for reevaluation to determine approved by the patient’s medical with an experienced Risk Management if work restrictions were necessary or doctor. All of these discussions analyst, visit tdicinsurance.com/RMconsult if she should not be working at all. should be documented in writing. or call 800.733.0633.

APRIL 2 0 2 0 229 QUESTIONS MOST OFTEN ASKED BY SELLERS:

1. Can I get all cash for the sale of my practice?

2. If I decide to assist the Buyer with financing, how can I be guaranteed payment of the balance of the sales price?

3. Can I sell my practice and continue to work on a part time basis?

4. How can I most successfully transfer my patients to the new dentist?

5. What if I have some reservation about a prospective Buyer of my practice?

6. How can I be certain my Broker will demonstrate absolute discretion in handling the transaction in all aspects, including dealing with personnel and patients?

7. What are the tax and legal ramifications when a dental practice is sold? QUESTIONS MOST OFTEN ASKED BY BUYERS:

1. Can I afford to buy a dental practice?

LEE SKARIN 2. Can I afford not to buy a dental practice? INC. & ASSOCIATES

3. What are ALL of the benefits of owning a practice?

4. What kinds of assets will help me qualify for financing the purchase of a practice?

5. Is it possible to purchase a practice without a personal cash investment?

6. What kinds of things should a Buyer consider when evaluating a practice? 7. What are the tax consequences for the Buyer when purchasing a practice? Offices: Lee Skarin & Associates have been successfully assisting Sellers and Buyers 805.777.7707 of Dental Practices for nearly 30 years in providing the answers to these and other questions that have been of concern to Dentists. 818.991.6552 Call at anytime for a no obligation response to any or all of your questions Visit our website for current listings: www.LeeSkarinandAssociates.com 800.752.7461 CA DRE #00863149 Regulatory Compliance CDA JOURNAL, VOL 48, Nº4

Texting Patients? Collecting Patient Information on a Website? Know the Rules.

CDA Practice Support

arlier this year, a patient filed a ■ Provide individuals with a and clearly identify the person or complaint against a Florida dental simple method to opt out of business initiating the message. practice for allegedly violating the receiving communications. ■ The domain name used must Telephone Consumer Protection ■ Immediately honor the be publicly registered to the Act (TCPA) of 1991 by sending opt-out requests. person or business initiating Etexts to the patient without permission.1 It However, when an individual initiates the message or to the company is one of many complaints consumers have contact with a business and provides a contracted to do the marketing. filed against businesses for contacting them cellphone number, the business is not ■ Subject line should accurately via their cellphones without obtaining limited in the number of calls made to reflect the content of the message. their consent. Given the importance of the individual’s cellphone number to ■ Message must be clearly and communicating with both current and complete the requested communication. conspicuously identified as an ad. future patients, a dentist should be aware of To initiate contact with a patient ■ Emails must include a valid the rules for communicating with them via via the patient’s cellphone to discuss physical postal address of the person texts, cellphone calls, emails and websites. any topic other than treatment and or business initiating the message. appointment reminders, a dental practice This can be a current street address, Texting or Calling a Patient’s must obtain the patient’s consent to a post office box with the U.S. Cellphone do so. Refer to the FIGURE for sample Postal Service or a private mailbox The Federal Communications language to use to obtain consent. registered with a commercial Commission in 2015, using the authority mail-receiving agency established of the TCPA, issued an order that requires Email under postal service regulations. a business to obtain an individual’s consent The federal CAN-SPAM Act ■ Emails should provide a clear prior to placing a call or sending a text and California law apply to all email and conspicuous explanation of message to that individual’s cellphone messages, including business-to-business how the recipient can opt out of number. A health care exemption to the communications that are advertisements getting future emails. The opt-out order applies if the communication: or promotions of a commercial product method should be internet based. ■ Is sent only to the cellphone or service or that promote content A menu to allow a recipient to opt number provided by the patient on commercial websites. Unsolicited out of certain types of messages to the health care provider. commercial emails may not be sent can be offered, but the option ■ States the name and contact to or from California email addresses. to stop all commercial messages information of the health care An example of a marketing email must be included in the menu. provider (information must be at is a promotion for teeth whitening ■ Opt-out requests must be the beginning of a voice call). sent to a dental practice’s patients of promptly honored; 10 business ■ Does not include telemarketing, record. Appointment reminders are not days is the maximum period solicitation, advertising, billing considered commercial communications. to comply. The recipient or financial content (including It is a good idea to obtain an individual’s cannot be required to pay insurance information requests). consent prior to sending them email, even a fee or provide additional ■ Complies with the HIPAA if the email is not a commercial message. information in order to have Privacy Rule. Verbal consent to receive emails is allowed, an opt-out request honored. ■ Is short (one minute or less for but the consent should be documented. ■ Once a recipient has opted voice calls and 160 characters Following is a summary of the main out, the email address may or less for text messages). requirements for marketing email: not be sold or transferred, A health care provider must: ■ Header information — “From,” even in the form of a mailing ■ Limit communication to “To,” “Reply To” and the list, except if it is being used one per day and three per originating domain name and by a third party to assist with week for each individual. email address — must accurately CAN-SPAM compliance.

APRIL 2 0 2 0 231 APRIL 2020 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 48, Nº4

When sending a group email to Add the following to a patient information collection form. The patient should initial or sign patients, a dental practice should ensure email addresses are entered this section of the form. If a dental practice intends to contact the patient on their cellphone only in the “BCC” field so as not to for marketing purposes, the practice should add appropriate language to the consent. impermissibly disclose protected health information (PHI). If a dental practice I consent to the dental practice using my cellphone number to (choose one or both) hires a third party to send marketing o call communications and the recipient list o text includes patient email addresses, the regarding appointments and to call regarding treatment, insurance and my account. practice should sign a HIPAA business I understand that I can withdraw my consent at any time. My cellphone number is associate agreement with the third party.

Website Chats and Information Collection A dentist considering adding a chat FIGURE. Sample language for patient information collection form. feature to their practice website should ensure chat sessions are secure and in compliance with HIPAA Security Rule safeguards. If a third party is utilized to operate the chat feature, the third party should sign a HIPAA business associate agreement with the dental practice. If a commercial website operator, such as a dental practice, collects personal information on California residents through the website, the operator must post online and comply with its privacy policy, as required by the California Online Privacy Protection Act. The privacy policy must contain certain elements, and the policy is in addition to the HIPAA Notice of Privacy Practices required to be posted on the website. n

REFERENCE 1. Dental practice hit with Florida lawsuit over unsolicited texts, Jan 7, 2020. news.bloomberglaw.com/privacy-and-data-securi- ty/dental-practice-hit-with-florida-lawsuit-over-unsolicited-texts.

Regulatory Compliance appears monthly and features resources about laws that impact dental practices. Visit cda.org/ practicesupport for more than 600 practice support resources, including practice management, employment practices, dental benefit plans and regulatory compliance.

232 APRIL 2 0 2 0 CARROLL “Matching the Right Dentist to the Right Practice” & C O M P A N Y

4408 SONOMA COUNTY Beautiful 2,100 sq. ft., 6 op practice, 4 4366 SONOMA COUNTY GP Fabulous practice and location in a doctor-days & 3 hygiene days per week. Average gross receipts stellar North Bay town. Beautiful, well-appointed office with 4 ops in $1M+. Asking $590K. 23-year perio practice, also ideal for GP; 1,425 sq. ft. Excellent storefront location on a well traveled road, loyal, seasoned staff and great location. walking distance to pedestrian-friendly downtown center. 900+ active patients, all fee-for-service. 4 doctor days/week and 4 4407 SAN MATEO GP Exceptional 5-operatory San Mateo practice hygiene days/week. Last two years’ average GR $786K with in popular health provider neighborhood generating significant daily average adj. net of $341K. Asking price $450K. Seller will help for business draw. Beautiful 2,200 sq. ft. seller-owned facility, smooth transition. handsomely equipped to highest standards. Average GR $1.4M, average overhePaEdN61D%IN. SGeasoned and loyal staff. Seller willing to 4362 MARIN COUNTY GP 36 years of goodwill, Seller-owned help for a smooth transition. 1,550 square foot facility with 5 fully-equipped ops. Prime position in charming town; desirable area known for temperate weather, easy, 4387 SF GP 50 year Nob HIll neighborhood practice with outdoor living and natural beauty. No Delta Premier patients. approximately 1,000 active patients. Almost no Delta Premier Excellent reputation and word-of-mouth referrals. Retiring seller will patients. Average GR $600K. Seller transitioning into retirement. help for smooth transition. Average Gross Receipts last 2 yrs is Asking $315K. $450K. Asking $248K for the practice. Bldg condo is available for purchase. 4381 SOUTH SF GP 23 year practice close to Kaiser Hospital; phenomenal shopping and residential mix area. 4 op facility with 4360 SALINAS GP Seller transitioning into retirement and offering new/recently upgraded equipment. Great location in desirable well-established practice located near downtown Salinas and neighborhood. Owner willing to help for smooth transition of the Salinas Valley Memorial Hospital. Average Gross Receipts $250K. practice. Average gross receipts approximately $250K with average Asking $133K. 60% overhead. Asking $170K. Retiring seller very motivated. Contact us for more detail. 4389 SALINAS GP Stable, 2400+ patient base. Seasoned and dedicated staff. Practice with an emphasis on Restorative treatment. 4359 SANTA CRUZ GP 30+ years of goodwill within walking 4 doctor days & 5 hygiene days per week. Average GR $910K. distance of the beach! Located in a well-known, attractive, single Asking $670k. Retiring owner. story professional building with ample parking, good visibility and easy access. 2 doctor days/week, 2 hygiene days/week, 380 active 4375 LOS GATOS DENTAL FACILITY Unique opportunity in patients with approx. S10OnLeDw patients/mo. 3 fully equipped ops in highly desirable area! Seller offering two full suites of state-of-the-art 850 sq. ft. Average GR $250K with adj. net of $135K. Asking price equipment and modern, 2-operatory facility including furniture, $150K. fixtures and leasehold assets in medical office building adjacent to Los Gatos Community Hospital. Asking $250K. 4394 SANTA CRUZ GP Retiring seller offering 33+ years of goodwill in stunning 1,534 sq. ft. facility with 4 fully-equipped ops. 4351 SEBASTOPOL AREA GP & BLDG. Beautiful, modern Pristine leasehold improvements/gorgeous cabinetry make this a practice in seller-owned building (available for purchase); 3 fully- must-see! Prime corner location with dedicated parking lot, situated equipped ops, room for a 4th. Pristine equipment including digital X- in one of the most desirable areas of Santa Cruz, close to shoreline ray, most purchased 2016-2018. 2019 GR annualized at $679K+ and tourist attractions. 2019 GR $887K with adj. net of $353K. with adj. net of $210K. Average 3.5 doctor days/week and 4 1,500+ active patients with average of 19 new patients/ hygiene days/week. 800 active patients, all fee-for-service. 70+ month. Seller works 3+ days/week with 5+ days of hygiene. Asking years of goodwill = long-standing, loyal patient base in scenic $729K. vineyard country. Asking $305K for practice, $425K for building. Owner/doctor willing to help for smooth transition. 4376 SANTA CRUZ GP High revenue opportunity in 31-year practice. Average GR $1.6M with average adj. net of $756,029.00. UPCOMING SJ GP grossing over $900K plus Redwood Shores, Owner/Doctor works 4 days/week. Hygiene 6 days/week. 1,200+ Redwood City, and Los Gatos GPs. active patients. Easy freeway access and parking; close to all amenities. Nicely appointed 1,200 sq. ft office with 4 ops. Owner/ Doctor will help for smooth transition. Asking $1,206,000.00

4382 MONTEREY COUNTY GP Established practice in Monterey County, California Coast. Multiple ops can expand, approx. 900 active patients, 4 days of hygiene per week. Ideal for a mature, experienced dentist for this adult-focused practice in an Extraordinary location. Periodontal emphasis with Mike Carroll Pamela Carroll-Gardiner Mary McEvoy Carroll communicative technology in each operatory for multiple crown and implant restorative procedures. Loyal, committed staff will remain CalRE# - 00777682 through transition. Future opportunity to purchase office building.

carroll.company [email protected] (650) 362-7004 (650) 362-7007 Call us today at (855) 337-4337 or visit www.integritypracticesales.com

A Professional Team Dedicated to Your Success

Bill Kimball, DDS Darren Hulstine Trevor Kimball, PhD Brian Flanagan Ken Skeate Tim Miller Broker / Partner Broker / Partner President Northern California Southern California Southern California (619) 933-6225 (805) 878-0633 (805) 748-7439 (707) 898-0842 (805) 338-5850 (714) 272-8408 DRE# 01921421 DRE# 01899816 DRE# 02078646 DRE# 01947466 DRE# 00885612 DRE# 02107070

“Integrity Practice Sale’s customer care, reliability, and knowledge about the rapidly changing dental practice sales market is the highest anyone could expect to find.” - R. Adames, DDS

Call us today at (855) 337-4337 and approach your sale with confidence. Visit www.integritypracticesales.com to see all our dental practices for sale.

Palm Springs: $325,000 | 4 ops Santa Barbara County: $270,000 | 3 ops San Francisco: $1,057,000 | 4 ops South Bay + RE: $649,000 | 6 ops Santa Barbara + RE: $1,200,000 | 4 ops San Anselmo: $200,000 | 2 ops West Covina: $95,000 | charts Santa Barbara County: $179,000 | 4 ops Fairfield: $55,000 | 3 ops Diamond Bar: $370,000 | 6 ops Santa Maria + RE: $360,000 | 4 ops Bakersfield: $185,000 | 4 ops Glendale: $550,000 | 4 ops N. San Luis Obispo County: $1,500,000 | 6 ops Bakersfield: $350,000 | 4 ops Agoura Hills: $225,000 | 3 ops San Luis Obispo: $861,000 | 3 ops Porterville: $1,140,000 | 12 ops Newhall: $250,000 | 5 ops Central Coast: $454,000 | 5 ops Bakersfield: $275,000 | 3 ops Valencia: $600,000 | 5 ops Central Coast: $548,000 | 4 ops Fresno: $860,000 | 4 ops Thousand Oaks: $85,000 | 3 ops Central Coast: $390,000 | 3 ops Folsom: $330,000 | 6 ops Westchester: $550,000 | 4 ops Central Coast Endo: $750,000 | 5 ops Sacramento: $420,000 | 4 ops Camarillo: $275,000 | 5 ops San Luis Obispo County: $650,000 | 4 ops Rancho Cordova: $215,000 | 4 ops Ojai: $350,000 | 4 ops Carmel: $495,000 | 4 ops Sacramento Area: $315,000 | 5 ops Ventura: $475,000 | 6 ops San Jose: $200,000 | 4 ops Shasta County: $135,000 | 5 ops Ventura Turnkey: $110,000 | 3 ops Watsonville + RE: $491,000 | 5 ops S. Lake Tahoe: $215,000 | 3 ops California City: $350,000 | 6 ops

DRE #01911548 Broker-Partners: Darren Hulstine and Bill Kimball, DDS Ethics CDA JOURNAL, VOL 48, Nº4

What Would You Do If Your Patient Cheated on You?

Teresa Yang, DDS

“Before my high school reunion, The CDA Code of Ethics discusses on shoulders, hands, hips, knees I want to get veneers on my two autonomy: “Patients have the right and any other joint? If a lower cost front teeth,” announced my patient to determine what should be done option was necessary, would I travel of a couple years. We were both with their own bodies … Respect to Mumbai for implant dentistry? excited about this topic, as if we for patient autonomy affirms this Could I overcome this? Clearly, by were planning a shopping expedition dynamic in the doctor-patient her presence, the patient wished for the perfect dress for the event. relationship.” Obviously, the patient to persist in our relationship. I launched into the narrowness does not belong to the dentist. She I decided to continue treating the of the lateral incisors next to her can go to a Beverly Hills cosmetic patient. I admired the naturalness and much wider centrals — and suggested dentist or a clinic in Mumbai. intended imperfection of her smile. She the patient consider restoring four Still, what are my ethical said the cosmetic dentist recommended teeth. I pointed to the unevenness obligations in continuing care for a mouthguard, to which she responded, of the gingival heights — and this patient? “Well, my dentist can do that.” symmetry being the foundation The Code of Ethics further states: Over the years, she has referred of beauty. I showed her the cant “In serving the public, a dentist may many friends and family to my practice. of her occlusal plane. I discussed exercise reasonable discretion in I even attended her daughter’s wedding color at the outset, not wanting accepting patients into the dental recently. Had I ended our association, the question, “Should I bleach my practice. However, in keeping it would have been my loss. n teeth?” on the day of delivery. with the core value of justice, it is The patient came in a year later, unethical for a dentist to refuse to Teresa Yang, DDS, is a guest author after the reunion, with her new accept a patient into the practice, for the Judicial Council. She is a past member veneers on teeth Nos. 8 and 9. “I deny dental service to a patient and chair of the Council on Peer Review, only wanted to do my two front or otherwise discriminate…” currently serves on the CDA Foundation ones,” she confessed, like a teenager There is no hard-and-fast rule. In Board, is a trustee for the Western Los Angeles displaying her hidden piercing. my exercising “reasonable discretion,” Dental Society and editor of its newsletter. The patient had gone elsewhere I could argue that trust has been to have her veneers placed — and eroded in this relationship and I Have an ethical question you’d like now she was back in my office. can no longer provide the patient to have addressed by the Judicial I felt betrayed. Wasn’t I her with the optimum level of care. Council? Email [email protected]. dentist? Or did we have an open Every time I see the centrals, I will patient-dentist relationship like an feel like I’m back in dental school open marriage, giving her the freedom and told to “do over” a procedure. to seek care elsewhere? My ego was Or I can set aside my feelings bruised. Didn’t she realize I was just as of hurt or loss of confidence and competent as the “cosmetic dentist” put myself in the patient’s position. she chose for her veneers? After all, I If I needed a hip replacement, had spoken to her about symmetry. would I seek care from a surgeon And I thought: Do I need who exclusively works on hips and to keep seeing this patient? knees or someone who operates

APRIL 2 0 2 0 235 Timothy Giroux, DDS John M. Cahill, MBA Edmond P. Cahill, JD Your Life’s Work Jon B. Noble, MBA Mona Chang, DDS Comes Down To BAY AREA BAY AREA CONTINUED BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED

This Decision AC-989 SAN FRANCISCO (Facility): Busy Retail Shop- CC-1030 SANTA ROSA: Extraordinary practice in DN-1046 SANTA CRUZ AREA: Opportunities like this does not come along, HG-815 TRUCKEE AREA: Amazingly priced at 50% of Collections! ~1000 sf w/ ping Plaza w/ major anchor tenants! 3 ops $99k prime location. 30k+cars drive by per day! 1683sf except once in a lifetime! Office 2050 sf w/ 5 ops. Total sq ft3880. 3 ops $150k/ Real Estate Available What separates us from AC-1059 DALY CITY: Amazing practice w/ seasoned w/5ops. Great opportunity! Only $325k $595k /Real Estate: $1.1mil HG-983 GRASS VALLEY: Newly remodeled office in highly desirable neighbor- staff in highly desirable neighborhood. 1500 sf w/ 4 CC-1049 SANTA ROSA: Fully Remodeled, Amazing DN-1084 SAN JOSE: Built-out in 2015, this beautiful, spacious, modern office hood! ~1250 sf w/ 3 ops. Reduced Price $185k/Real Estate Available other brokerage firms? ops $345k Location. 2000 sf w/ 5 ops $500k Real Estate Also is conveniently located! 2204sf w/ 4 ops + 2 add’l Now Only $495k HG-987 LAKE TAHOE AREA: LIVE THE DREAM! The mountains are calling you

AC-1072 DALY CITY: Seller to work back until May Available DN-1107 SAN JOSE: Quality, family-oriented practice. Hesitate & you to this Alpine Paradise! ~ 3,400 sf w/ 6 Ops $785K/Real Estate Available Western Practice Sales is locally 2022! 1045 sf w/ 3 ops. Plumbed for 1 add’l $450k CC-1096 VACAVILLE: Little Gem located in Retail may miss out on the best decision of your life! 1200sf w/ 3op. HN-879 SONORA: Great Cash-Flow for Only 3 Days a Week! 2950 sf w/ 3 owned by dentists and has been AC-1075 DALY CITY: Rare 2 DR Practice in Daly City. Shopping Center. 1500 sf w/ 4 ops ONLY $89k $535k ops Reduced Price: $265k proudly serving dentists in One seller would like to work-back. $795k CG-1048 SONOMA: This highly successful family- NORTHERN CALIFORNIA HN-991 PLACERVILLE: Quality, conservative and compassionate practice! Will California for over 45 years. Our AG-944 SAN FRANCISCO: An opportunity like this oriented practice has it ALL! ~1500 sf w/ 4 ops consider work back. 1,654 + 473 sf w 5 ops. $675k personal attention to our sellers does not come along very often! ~998 sf w/ 3 ops $630k EG-1012 EAST SACRAMENTO: A practice like this one does not come Reduced $495k CN-911 SANTA ROSA: This fabulous practice is the CENTRAL VALLEY & SOUTHERN CALIFORNIA and reputation of integrity and available very often! ~ 2900 sf w/ 8 Ops $2.5M AG-993 WEST PORTAL AREA: Desirable area w/ easy heart of the Wine Country! 2250 sf w/4 ops + EG-1016 LINCOLN: Look no further than this growing community to honesty has made us Northern commute to downtown San Francisco. ~1000sf w/ 3 1add’l. Seller Motivated $465k springboard into your success! ~1800 sf w/ 4 Ops Reduced $560k IG-1007 GREATER MODESTO AREA: Combines a quality learning environ- California’s Preferred Dental ops Reduced Price: $395k CN-1090 VACAVILLE: This amazing, state-of-the-art EG-1039 SIERRA FOOTHILLS: The ideal opportunity to practice in this ment with relaxed rural living. ~3000sf w/ 6 ops. $645k Practice Broker. AG-1079 SAN FRANCISCO: Quality Practice in Heart practice is an outstanding opportunity! 2400 sf w/ 7 community! ~1100 sf w/ 4 Ops $330k IN-1091 TRACY: Spacious, beautiful, modernly equipped, well-designed and of City! 1800 sf w/ 5 ops offering in-house special- ops + 1 add’l. $695k / Real Estate $780k is a fully digital office! 2,200sf w/ 6 ops. $490k EG-1061 SOUTH AUBURN VICINITY: Come live, play and practice in the

ists $685k DC-1080 ALAMEDA: Established for 25 years. Seller heart of this pristine town! ~1100 sf w/ 4 Ops $330k JC-811 FRESNO COUNTY: Seller willing to consider Associateship for qualified Our extensive buyer BC-949 ALBANY: Desirable commercial/residential retiring from this amazing practice. 1200 sf w/ 3 ops EG-1092 GRASS VALLEY/AUBURN: If you’ve always wanted to live in Gold DDS w. intention to Buy In! Considerable Goodwill in Community! 3,000 sf database area. Medical Prof Bldg w/ good frontage. 3200sf $575k Country, look no further! ~ 1500 sf w/ 4 Ops $295k w/ 6 ops $350k w/ 4 ops $695k Real Estate: $1.8 DC-1094 LOS GATOS Facility: Unbeatable location! 2 EG-1093 AUBURN: Enviable location, stable patient base and located in JC-823 LOS BANOS: Heavy emphasis on hygiene. 1000 sf w/ 3 ops $80k allows us to offer you… BC-1010 ANTIOCH: Amazing Opportunity in Health story Med/Prof Bldg near Netflix Headquarters! JC-1054 VISALIA: Practice AND REAL ESTATE! Prof Bldg on major thorough- the heart of town! ~ 1000 sf w/ 3 Ops $120k Better Exposure Prof. Complex 2118 sf w/ 2 equipped ops + 3 add’l 1059 sf w/ 2 ops $200k EG-1100 CARMICHAEL: Be rewarded for your talent and skill at this prov- fare. 2,260 sf w/ 6 ops $275k/ Real Estate $517k $225k DG-986 CAMPBELL: The ideal opportunity to prac- en location. ~ 2,271 sf w/ 5 Ops $535k Real Estate Available Better Fit BC-1022 OAKLAND: “Pill Hill” Area adjacent to tice in this community! ~988 sf w/ 3 ops Seller EG-1104 ROSEVILLE: Spacious, modern office is equipped with mostly SPECIALTY PRACTICES hospital! 1064 sf & 2 ops. Plumbed for 1 add’l Motivated $288k new, state-of-the-art equipment. ~ 1500 sf w/ 4 Ops $295k Better Price! $150k DG-1006 MONTEREY AREA: This practice is one EN-1055 ROCKLIN Facility: Build your own success here in this family- BG-843 WALNUT CREEK Perio: Priced at 50% of collections! ~1085 sf w/ 4 BC-1056 SAN RAMON (Facility): Move-in ready which every dentist aspires to! ~3400 sf w/ 8 ops ops $390k oriented community! 1650 sf w/ 4 ops +1 add’l. $95k facility in well maintained professional complex. Reduced $1.2M EN-1077 DAVIS: Imagine living and practicing here! Hesitate and you may DG-1078 SARATOGA Ortho: One-of-a-kind, modern, high-tech orthodon- 1698 sf w/ 4 ops $60k DG-1009 CARMEL: Amazing fee-for-service practice miss out on your dream! 1100sf. w/ 5 ops. $575k tic boutique practice! ~ 1400 sf w/ 5 Ops $980K BG-1085 BERKELEY: Stay young and on the cutting w/ no contracts! ~1150 sf w/ 4 ops $575K IC-1102 MERCED Endo: Strong Referral Base, Professional Corridor, Highly EN-1095 SACRAMENTO: Outstanding Growth Potential! Seller retiring and edge as you practice in this UC collegiate town! ~ DG-1014 MONTEREY: Don’t miss your opportunity refers out most Specialties. 1000 sf w/ 3 Ops. $75k Desirable Neighborhood. 2500 sf w/ 5 ops. Plumbed for 2 add’l $210k 1,600 sf w/ 4 ops $975k to live and practice in beautiful Monterey! ~1125 EN-1108 GRANITE BAY Facility: Perfect for a satellite office or start-up BN-1023 RICHMOND: This is a rich opportunity for sf w/ 4 Ops. $650k practice! Updated & equipped with high-tech equipment! 1,500 sf w/ 5 ops. the astute dentist! 1450sf w/2 ops + 2 add’l. $50k/ DG-1081 SAN JOSE: Located in popular retail $195k Real Estate $750k shopping center. Spacious 2800 sf office w/ 8 fully FC-650 FORT BRAGG: Family-oriented practice. 5 ops in 2000 sf $350k BN-1060 LAYAFETTE: Imagine living, practicing & equipped ops $295k for the Practice & $400k for the Real Estate raising your family here in this community! 1400sf DG-1099 SANTA CRUZ: Consistently voted as the FG-1086 UKIAH: This excellent opportunity awaits your talent and skill! w/ 3op. Seller Motivated $225k BEST DENTIST in Santa Cruz! ~ 1,547 sf w / 4 Ops. ~1200sf w/ 4 ops $550k BN-1067 SAN LEANDRO: Imagine owning this $550k FN-855 NO. HUMBOLDT: Seller relocating! Long-established, 100% FFS family-oriented practice with a large patient base. DN-1031 CUPERTINO: This remarkable practice practice! 1600 sf w/ 3ops + 1 add’l. $190k/ Real Estate Available We are a proud member of: * Western Practice Sales is a member of 1495sf w/ 3 ops 2 + 1 add’l. $325k awaits only your talent and skill! 1500sf w 3 ops + 1 American Dental Sales (ADS Transitions), GN-1071 REDDING: Streamlined policies & loyal patient base, this quality a nationally recognized organization of CC-846 SAN RAFAEL: Prof/Retail Building Complex. 3 add’l. $1.25M practice is your springboard to success! 2264sf w/ 4 ops. $525k dental practice brokers throughout the ops 640 sf Collections $433k in 2017 $275k DN-1041 SAN JOSE: This stunning practice is an United States. ADS members have a GN-1073 PARADISE: Quality, fee-for-service practice with a stellar repu- strategic alliance & combined marketing CC-963 SANTA ROSA: Practice & Real Estate Avail- excellent opportunity for new grads! 1207sf w 2ops efforts with other practice brokerage tation! 1800sf w/ ops. Reduced! $325k / Real Estate Available firms, financial companies & lending Call or email today for a free able! 1765 sf w/ 5 ops Practice $395k & Real Es- + 1 add’l. Reduced! $175k HG-1068 LAKE TAHOE AREA: Imagine living and practicing in the majestic organizations. All ADS companies are copy of Dr Giroux’s book tate $735k DN-1003 PLEASANTON Facility: An excellent oppor- Sierra Nevadas and lake community! ~2500 sf w/ 3 Ops. $315k/Real Estate independently owned and operated. CC-979 NOVATO: Seller Retiring. 803 sf w/ 3 ops tunity for a graduate or a dentist seeking a Satellite Available near downtown and Old Town Novato. $195K location. 1000sf w/ 3ops. Now Only $60k Top Ten Issues for HG-1089 CALAVERAS COUNTY: Est. 25 yrs w/ Stellar Reputation! 3000+ sf w/ (Real Estate $215k) 6 ops $465k/Real Estate Also Available Dentists Contemplating Retirement in Ten Years or Less 800.641.4179 [email protected] “ASK THE BROKER” can now be found at WWW.WESTERNPRACTICESALES.COM Timothy Giroux, DDS John M. Cahill, MBA Edmond P. Cahill, JD Your Life’s Work Jon B. Noble, MBA Mona Chang, DDS Comes Down To BAY AREA BAY AREA CONTINUED BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED

This Decision AC-989 SAN FRANCISCO (Facility): Busy Retail Shop- CC-1030 SANTA ROSA: Extraordinary practice in DN-1046 SANTA CRUZ AREA: Opportunities like this does not come along, HG-815 TRUCKEE AREA: Amazingly priced at 50% of Collections! ~1000 sf w/ ping Plaza w/ major anchor tenants! 3 ops $99k prime location. 30k+cars drive by per day! 1683sf except once in a lifetime! Office 2050 sf w/ 5 ops. Total sq ft3880. 3 ops $150k/ Real Estate Available What separates us from AC-1059 DALY CITY: Amazing practice w/ seasoned w/5ops. Great opportunity! Only $325k $595k /Real Estate: $1.1mil HG-983 GRASS VALLEY: Newly remodeled office in highly desirable neighbor- staff in highly desirable neighborhood. 1500 sf w/ 4 CC-1049 SANTA ROSA: Fully Remodeled, Amazing DN-1084 SAN JOSE: Built-out in 2015, this beautiful, spacious, modern office hood! ~1250 sf w/ 3 ops. Reduced Price $185k/Real Estate Available other brokerage firms? ops $345k Location. 2000 sf w/ 5 ops $500k Real Estate Also is conveniently located! 2204sf w/ 4 ops + 2 add’l Now Only $495k HG-987 LAKE TAHOE AREA: LIVE THE DREAM! The mountains are calling you

AC-1072 DALY CITY: Seller to work back until May Available DN-1107 SAN JOSE: Quality, family-oriented practice. Hesitate & you to this Alpine Paradise! ~ 3,400 sf w/ 6 Ops $785K/Real Estate Available Western Practice Sales is locally 2022! 1045 sf w/ 3 ops. Plumbed for 1 add’l $450k CC-1096 VACAVILLE: Little Gem located in Retail may miss out on the best decision of your life! 1200sf w/ 3op. HN-879 SONORA: Great Cash-Flow for Only 3 Days a Week! 2950 sf w/ 3 owned by dentists and has been AC-1075 DALY CITY: Rare 2 DR Practice in Daly City. Shopping Center. 1500 sf w/ 4 ops ONLY $89k $535k ops Reduced Price: $265k proudly serving dentists in One seller would like to work-back. $795k CG-1048 SONOMA: This highly successful family- NORTHERN CALIFORNIA HN-991 PLACERVILLE: Quality, conservative and compassionate practice! Will California for over 45 years. Our AG-944 SAN FRANCISCO: An opportunity like this oriented practice has it ALL! ~1500 sf w/ 4 ops consider work back. 1,654 + 473 sf w 5 ops. $675k personal attention to our sellers does not come along very often! ~998 sf w/ 3 ops $630k EG-1012 EAST SACRAMENTO: A practice like this one does not come Reduced $495k CN-911 SANTA ROSA: This fabulous practice is the CENTRAL VALLEY & SOUTHERN CALIFORNIA and reputation of integrity and available very often! ~ 2900 sf w/ 8 Ops $2.5M AG-993 WEST PORTAL AREA: Desirable area w/ easy heart of the Wine Country! 2250 sf w/4 ops + EG-1016 LINCOLN: Look no further than this growing community to honesty has made us Northern commute to downtown San Francisco. ~1000sf w/ 3 1add’l. Seller Motivated $465k springboard into your success! ~1800 sf w/ 4 Ops Reduced $560k IG-1007 GREATER MODESTO AREA: Combines a quality learning environ- California’s Preferred Dental ops Reduced Price: $395k CN-1090 VACAVILLE: This amazing, state-of-the-art EG-1039 SIERRA FOOTHILLS: The ideal opportunity to practice in this ment with relaxed rural living. ~3000sf w/ 6 ops. $645k Practice Broker. AG-1079 SAN FRANCISCO: Quality Practice in Heart practice is an outstanding opportunity! 2400 sf w/ 7 community! ~1100 sf w/ 4 Ops $330k IN-1091 TRACY: Spacious, beautiful, modernly equipped, well-designed and of City! 1800 sf w/ 5 ops offering in-house special- ops + 1 add’l. $695k / Real Estate $780k is a fully digital office! 2,200sf w/ 6 ops. $490k EG-1061 SOUTH AUBURN VICINITY: Come live, play and practice in the

ists $685k DC-1080 ALAMEDA: Established for 25 years. Seller heart of this pristine town! ~1100 sf w/ 4 Ops $330k JC-811 FRESNO COUNTY: Seller willing to consider Associateship for qualified Our extensive buyer BC-949 ALBANY: Desirable commercial/residential retiring from this amazing practice. 1200 sf w/ 3 ops EG-1092 GRASS VALLEY/AUBURN: If you’ve always wanted to live in Gold DDS w. intention to Buy In! Considerable Goodwill in Community! 3,000 sf database area. Medical Prof Bldg w/ good frontage. 3200sf $575k Country, look no further! ~ 1500 sf w/ 4 Ops $295k w/ 6 ops $350k w/ 4 ops $695k Real Estate: $1.8 DC-1094 LOS GATOS Facility: Unbeatable location! 2 EG-1093 AUBURN: Enviable location, stable patient base and located in JC-823 LOS BANOS: Heavy emphasis on hygiene. 1000 sf w/ 3 ops $80k allows us to offer you… BC-1010 ANTIOCH: Amazing Opportunity in Health story Med/Prof Bldg near Netflix Headquarters! JC-1054 VISALIA: Practice AND REAL ESTATE! Prof Bldg on major thorough- the heart of town! ~ 1000 sf w/ 3 Ops $120k Better Exposure Prof. Complex 2118 sf w/ 2 equipped ops + 3 add’l 1059 sf w/ 2 ops $200k EG-1100 CARMICHAEL: Be rewarded for your talent and skill at this prov- fare. 2,260 sf w/ 6 ops $275k/ Real Estate $517k $225k DG-986 CAMPBELL: The ideal opportunity to prac- en location. ~ 2,271 sf w/ 5 Ops $535k Real Estate Available Better Fit BC-1022 OAKLAND: “Pill Hill” Area adjacent to tice in this community! ~988 sf w/ 3 ops Seller EG-1104 ROSEVILLE: Spacious, modern office is equipped with mostly SPECIALTY PRACTICES hospital! 1064 sf & 2 ops. Plumbed for 1 add’l Motivated $288k new, state-of-the-art equipment. ~ 1500 sf w/ 4 Ops $295k Better Price! $150k DG-1006 MONTEREY AREA: This practice is one EN-1055 ROCKLIN Facility: Build your own success here in this family- BG-843 WALNUT CREEK Perio: Priced at 50% of collections! ~1085 sf w/ 4 BC-1056 SAN RAMON (Facility): Move-in ready which every dentist aspires to! ~3400 sf w/ 8 ops ops $390k oriented community! 1650 sf w/ 4 ops +1 add’l. $95k facility in well maintained professional complex. Reduced $1.2M EN-1077 DAVIS: Imagine living and practicing here! Hesitate and you may DG-1078 SARATOGA Ortho: One-of-a-kind, modern, high-tech orthodon- 1698 sf w/ 4 ops $60k DG-1009 CARMEL: Amazing fee-for-service practice miss out on your dream! 1100sf. w/ 5 ops. $575k tic boutique practice! ~ 1400 sf w/ 5 Ops $980K BG-1085 BERKELEY: Stay young and on the cutting w/ no contracts! ~1150 sf w/ 4 ops $575K IC-1102 MERCED Endo: Strong Referral Base, Professional Corridor, Highly EN-1095 SACRAMENTO: Outstanding Growth Potential! Seller retiring and edge as you practice in this UC collegiate town! ~ DG-1014 MONTEREY: Don’t miss your opportunity refers out most Specialties. 1000 sf w/ 3 Ops. $75k Desirable Neighborhood. 2500 sf w/ 5 ops. Plumbed for 2 add’l $210k 1,600 sf w/ 4 ops $975k to live and practice in beautiful Monterey! ~1125 EN-1108 GRANITE BAY Facility: Perfect for a satellite office or start-up BN-1023 RICHMOND: This is a rich opportunity for sf w/ 4 Ops. $650k practice! Updated & equipped with high-tech equipment! 1,500 sf w/ 5 ops. the astute dentist! 1450sf w/2 ops + 2 add’l. $50k/ DG-1081 SAN JOSE: Located in popular retail $195k Real Estate $750k shopping center. Spacious 2800 sf office w/ 8 fully FC-650 FORT BRAGG: Family-oriented practice. 5 ops in 2000 sf $350k BN-1060 LAYAFETTE: Imagine living, practicing & equipped ops $295k for the Practice & $400k for the Real Estate raising your family here in this community! 1400sf DG-1099 SANTA CRUZ: Consistently voted as the FG-1086 UKIAH: This excellent opportunity awaits your talent and skill! w/ 3op. Seller Motivated $225k BEST DENTIST in Santa Cruz! ~ 1,547 sf w / 4 Ops. ~1200sf w/ 4 ops $550k BN-1067 SAN LEANDRO: Imagine owning this $550k FN-855 NO. HUMBOLDT: Seller relocating! Long-established, 100% FFS family-oriented practice with a large patient base. DN-1031 CUPERTINO: This remarkable practice practice! 1600 sf w/ 3ops + 1 add’l. $190k/ Real Estate Available We are a proud member of: * Western Practice Sales is a member of 1495sf w/ 3 ops 2 + 1 add’l. $325k awaits only your talent and skill! 1500sf w 3 ops + 1 American Dental Sales (ADS Transitions), GN-1071 REDDING: Streamlined policies & loyal patient base, this quality a nationally recognized organization of CC-846 SAN RAFAEL: Prof/Retail Building Complex. 3 add’l. $1.25M practice is your springboard to success! 2264sf w/ 4 ops. $525k dental practice brokers throughout the ops 640 sf Collections $433k in 2017 $275k DN-1041 SAN JOSE: This stunning practice is an United States. ADS members have a GN-1073 PARADISE: Quality, fee-for-service practice with a stellar repu- strategic alliance & combined marketing CC-963 SANTA ROSA: Practice & Real Estate Avail- excellent opportunity for new grads! 1207sf w 2ops efforts with other practice brokerage tation! 1800sf w/ ops. Reduced! $325k / Real Estate Available firms, financial companies & lending Call or email today for a free able! 1765 sf w/ 5 ops Practice $395k & Real Es- + 1 add’l. Reduced! $175k HG-1068 LAKE TAHOE AREA: Imagine living and practicing in the majestic organizations. All ADS companies are copy of Dr Giroux’s book tate $735k DN-1003 PLEASANTON Facility: An excellent oppor- Sierra Nevadas and lake community! ~2500 sf w/ 3 Ops. $315k/Real Estate independently owned and operated. CC-979 NOVATO: Seller Retiring. 803 sf w/ 3 ops tunity for a graduate or a dentist seeking a Satellite Available near downtown and Old Town Novato. $195K location. 1000sf w/ 3ops. Now Only $60k Top Ten Issues for HG-1089 CALAVERAS COUNTY: Est. 25 yrs w/ Stellar Reputation! 3000+ sf w/ (Real Estate $215k) 6 ops $465k/Real Estate Also Available Dentists Contemplating Retirement in Ten Years or Less 800.641.4179 [email protected] “ASK THE BROKER” can now be found at WWW.WESTERNPRACTICESALES.COM Tech Trends CDA JOURNAL, VOL 48, Nº4

A look into the latest dental and general technology on the market

Lockdown Firewall & Privacy Protection Travor Photo Light Box Kit ($103.89, Travor) (Free, Confirmed Inc.) To place emphasis on the product itself, photographers often employ Lockdown is a simple, free open-source app available for iPhones, small, portable enclosures with built-in lighting and interchangeable iPads and Macs that creates a firewall to block many of the hidden backdrops. In this era of online shopping, the product photo is trackers and ads that people encounter daily. often the only visual connection the consumer has to something they are buying. Clinical dentistry appears to have little use for Lockdown is an easy-to-use, set-it and forget-it app that works such techniques because patients themselves cannot be fit into such seamlessly in the background. Once installed from the App Store, enclosures. What can fit, however, are casts, surgical guides and a users go into the app and grant permissions for it to create a virtual plethora of customized occlusal devices. For those moments when private network (VPN) profile. The app works by creating a local high-quality images of such items are needed (e.g., presentations, VPN server that resides on the device and not in the cloud. When publications, marketing materials), the Travor Photo Studio Light the VPN profile setup configuration is complete, users simply tap on Box could be of great help, allowing practitioners to control the big power button to turn the firewall on. All internet traffic on the backgrounds and lighting to best highlight their work. device is then routed through its VPN service, which blocks access to domains that are commonly used by trackers. Users can add This review evaluated the 32-inch by 32-inch light box with a Nikon their own domains to block or enable preconfigured suggestions by D90 and iPhone XI as cameras. tapping on the Block List button. A history of blocked domains can The Travor Photo Studio Light Box is a simple device. It is a be found by tapping on the View Log button. The main screen also collapsible cube lined with reflective fabric and sporting dimmable provides statistics of the number of trackers the app has blocked LED lights built into the top to provide up to 13,000 lumens. Four daily, weekly and for all time. If a user encounters a website or app different plastic backdrops are included (red, black, white and that is malfunctioning, users can simply tap the big power button to blue), along with a host of hollow metal tubes to give the cube turn the firewall off and determine if the firewall is the cause. For a structure. Assembly of the Travor is not the easiest of tasks as its truly private browsing experience, users can upgrade to a Lockdown modular construction does not give it a great deal of stability until VPN subscription via an in-app purchase. This enables Secure it is put together. Once assembled, however, the Travor is easy Tunnel, which provides bank-level encryption of all internet traffic so to operate: Slip on the backdrop of choice, turn on the light and that browsing histories and private locations are anonymized. photograph an object from the front or top via closable flaps Data privacy has become an important topic among consumers secured by Velcro. Whether using a DSLR or mobile phone, every as they become more aware of how companies use their personal object photographed and filmed looks clean, unmarred by excessive information. Although it may not be possible to prevent all tracking shadows or distracting backgrounds. When not in use, the light box of personal information when interacting with websites and apps, fits into the included carry bag, which unfortunately does not protect consumers can exercise their rights to privacy by using firewall the product at all. Caution should be used when storing the Travor apps, such as Lockdown, to stop the majority of data trackers from because the plastic backdrops can be easily folded and damaged, collecting information on a daily basis. which could result in the backdrops casting unwanted shadows. For the clinician who has a need for the highest quality of photographs, — Hubert Chan, DDS the Travor is an affordable, albeit fragile and fickle, option for product photography. — Alexander Lee, DMD

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