Dental scam??

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Dental scam??

Postby Sleepy PSGT » Fri Mar 27, 2009 7:31 am

This is my first post here and I would like to say that I'm a bit angry with the situation I've just been appart of.

I have a patient come in for a PSG, he let me know that he was in for a dental visit and noticed CPAP machines in the office. When he asked about them the he was told about oral appliances and was given an at home apnea testing kit.
When he was told about the results they said. "I cant believe how many times you stoped breathing, and for as long as 2min at a time."
He was then being told that an oral appliance would take care of his sleep issues. Well the patient talked to his PCP and was set up for a PSG split night study.
And this is where I come in.
The patient was concerned about having to buy the oral appliance out of pocket and was happy to find out after a long time why he is so tired through out the day.
The study starts.
No apnea noted, the patient was on his back the entire study. Achieved REM supine. And only light snoring/heavy breathing was noted.
Now, after seeing this I have some questions.
Are at home testing kits that unreliable?
Is this guy being taken for a ride by being sold an oral appliance.
With more and more people on CPAP it would be an easy way to make some money to have PAP machines in a dental setting and with out having to do a thing, the patient will probly say something about being on PAP or something about their sleep..... instant qualification for an at home testing kit and another oral appliance out the door at what price $$ can you say cha ching.

Now I know that these have a place in the apnea world and have seen them work for some patients (but not a large number of them) everyone is different and they are not 100%. In most cases with a high AHI and high PAP pressure at best they may reduce your overal AHI or lower your PAP pressure.

I did make note in his chart about his previous study and what he was told. I hope that his PCP will pick up on this and tell this guy to get a new place to have his dental work done.

Any thoughts?
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Postby jwpegram » Fri Mar 27, 2009 12:04 pm

I'm no expert but I've done extensive research on the Oral Appliances. I have severe OSA (AHI 75) I've used both the TAP3 and Somnomed MAS for several months each, recently had a PSG with the Somnomed that should a reduction to (AHI 14). One of the things I learned quickly in my research was that Oral Appliances have been used for some time by dentists to treat snoring (whether that snoring was apena related or not). I've seen many posts on here where a persons dentist prescribed an Oral Appliance without a PSG solely because the patient said they snored and had sleep issues. Unfortunately, they aren't as regulated as I think PAP's might be. It would be hard to say whether or not dentists are using OA's to scam people, it's certainly a possiblity (probably a high one at that) and I certainly was concerned with having a dentist that new about OSA before I went looking for one. Luckily, my dentist has severe OSA, can't tolerate CPAP and has used OAT himself.

It's hard to say if he's being taken for a ride because there are so many things that cause sleep related problems. The patient may snore and his dentist may truly think he's helping him. I think you did the responsible thing with the chart notation. I'm guessing you're a sleep tech and I'm not sure what the regulations are but maybe it's something you should contact the physician who ordered the PSG about.
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Postby justplainbill » Fri Mar 27, 2009 2:18 pm

I am neither a medical professional nor am I a sleep professional. However, there are more than a few things that strike me as questionable.

The first is whether the dentist in question has any professional qualifications to be offering CPAP machines and/or prescribing them to clients. While it may be possible that the dentist has gotten certification in sleep disorders, I would recommend checking this out. There do seem to be some professionals who have attended courses or seminars which they represent as a qualification and in some rural communities they might be the best thing available. But they are not a replacement for real sleep specialists. It would be worth asking how this dentist determines who needs a CPAP and how he determines the treatment pressure (which certainly cannot be done at-home).

Second, at-home testing, in my limited understanding, comes in several different forms and the more sophisticated at-home testing (as I understand it) seems to be fairly reliable at dealing with straight-forward obstructive apnea. A full sleep study can tell you much more about a person's sleep than an at home study. I somehow doubt that this at-home study was very thorough.

I would recommend that the patient get a written copy of the results of this sleep study to see what was measured (which may have been nothing more than a monitoring of blood oxygen level) and what was not and to see what the results were. I would also recommend that the patient get a copy of the report from the PSG (you mention there was no apnea, but you have not mentioned anything about hypopneas or other sleep indicators). I would recommend that the patient compare these reports with the sleep doctor supervising the PSG (the PCP might also be a resource, but not if the PCP is unknowledgeable about apnea, sleep, and CPAP). But, as jwpegram has pointed out, oral appliances do have a role to play in a variety of disorders, including the treatment of mild sleep apnea (although I have mild sleep apnea and am on CPAP quite happily). And for an oral appliance, I believe you would want to have it fitted by a dentist. On the other hand, since I am not confident about this dentist's competence to diagnose apnea and to deal with CPAP this also calls into question (for me) the dentist's competence to be dealing with oral appliances for apnea as well.

I would recommend that the patient or PCP or someone might want to check with the state board of dental examiners to see what qualifications this dentist has in this area. If a closer examination of the facts of this situation confirms that this dentist has inadequate knowledge, experience and expertise in this area, I would think that a complaint of some form would be in order.

Another issue might be whether the patient has been using the oral appliance and whether (s)he has noticed any difference with it. If not, then perhaps the most direct course of action might be for the patient to return te appliance and request a full refund.

As to what your own personal and professional responsibilities are, I would urge you to discuss these issues with your supervisor.

I hope this is of some help. If you hear anything further about how this develops, please let us know.

Best wishes,
Bill
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Postby Sleepy PSGT » Fri Mar 27, 2009 9:34 pm

Thank you both for your responses.

I do agree that oral appliances have a place in the apnea world no doubt in my mind, I have seen patients with lower AHI's with them. However, having them termed as a "cure" for apnea by some is a crime in my book.
The patient described his home testing kit as one belt, nasal cannula, oximeter. So this test should have been able to show o2, chest effort, and reductions in flow. Now, the patient was told he stopped breathing alot, and for up to 2min at a time. The testing kit could show that with those three attached. But in the full PSG he had an AHI of <5.

I informed my supervisor who then scheduled a meet with our sleep doc. After reading the scored results of his study today, I believe that he was either lied to or there was some sort of mix up, false readings in his home testing kit.

When I first talked with this patient I realy did hope that I would find apnic events put him on PAP and get him some much needed sleep. As I said this patient has other medical issues and has been trying to figure things out, a very nice guy too.
I am still angry with all of this as I am a sleep tech who is on PAP at home too.
Im not going to let this go until someone figures out what went wrong here.

jwpegram: do you use PAP with your appliance or are you feeling better even with an AHI of 14?
I think one of the biggest advantage to oral appliance is being able to reduce PAP pressures for those who can not tolerate higher pressures.
And I will say this agian, not all apnic patients are the same, an oral appliance may work wonders for some but not at all or very little for others.
I always tell my patients to study up on all available treatments before spending the money out of pocket. If PAP is tolerated, your ins company will cover it more often then not, then give it a shot and realy try for 3 months. The #1 problem with PAP is comfort and patient compliance. I have seen many try it for a week then give up and want another treatment. It actualy took me 3 weeks to get to the point that I could use my PAP through out the entire night with out ripping it off my face in my sleep lol.
Im not about to go spend that kind of money to get an appliance now that Im tolerating it hehe, but everyone is different.

Again thank you for your responses,
I hope this does not jade anyone from looking at all of the options available to them.
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Postby Linda » Fri Mar 27, 2009 9:49 pm

Hi Sleepy PSGT,

Wow, this is most disturbing, and I'm glad you posted about it.
It's put many questions in my head, now that you've pointed this out.

If this patient hadn't gone for another opinion, by talking to his PCP, he might well have gotten that dental device. He would have had no coordination of testing and treatment with any doctor, preferably someone knowledgable in sleep medicine. I assumed home sleep studies would have to be ordered and the results reviewed by a medical professional trained in sleep medicine. Hmmm.


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Postby jwpegram » Sat Mar 28, 2009 9:22 am

Sleepy PSGT wrote:jwpegram: do you use PAP with your appliance or are you feeling better even with an AHI of 14?
I think one of the biggest advantage to oral appliance is being able to reduce PAP pressures for those who can not tolerate higher pressures.
And I will say this agian, not all apnic patients are the same, an oral appliance may work wonders for some but not at all or very little for others.
I always tell my patients to study up on all available treatments before spending the money out of pocket. If PAP is tolerated, your ins company will cover it more often then not, then give it a shot and realy try for 3 months. The #1 problem with PAP is comfort and patient compliance. I have seen many try it for a week then give up and want another treatment. It actualy took me 3 weeks to get to the point that I could use my PAP through out the entire night with out ripping it off my face in my sleep lol.

No I don't use the PAP at all. I will say I gave it almost 6 months, multiple masks, multiple machines and tried every pill on the market to sleep, the problem was either I could never go to sleep or I'd go to sleep but wake up with it off after recording only an hour or so. After a while I was feeling so bad, "sticking with it" just wasn't an option for me so we tried the OA. I could tell an immediate difference. Would I have dropped the $2500 for it had the machine worked? In my case, probably. I feel much better, but not what I'd term as "normal". Understand though, I never went into it as a cure, and I completely agree that anyone touting it as a cure is as irresponsible as someone touting CPAP as a cure. Even at 100% reduction in AHI neither is a cure and shouldn't be presented as such. I haven't tried to use the PAP and the OA but then I've had extensive exams done on my neck and everyone I've seen has since recommended the OA since I had so much trouble tolerating the CPAP. If insurance paid for the things, I'd say you should get one and try it but since they don't and you tolerate the machine then it's a much harder decision. That's a lot of money for a chance at being able to lose the machine and there's no guarantee you will even if it does help, but without trying one and having testing you can't truly know that so it's kind of a catch 22 right now.

I'll also say this, they do need some kind of regulation. I knew my dentist sold the TAP3 but I only considered it after he talked to me about his own severe OSA and could explain to me the results of my PSG to me. Not an expert but where I live, those are few and far between so I at least felt comfortable he understood the difference in treating a snoring and something more serious. He also never said it was a cure, simply and alternative to the CPAP that may help. I do believe that's the exception rather than the rule but how that problem gets fixed I don't know.
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Boil and Bite

Postby papahemi » Sat Mar 28, 2009 6:51 pm

jwpegram- During your research into Oral appliances did you ever try a boil and bite appliance such as the "Pure Sleep"? As a fellow Somnomed Mas user I agree it may be awhile before insurance companies (especially HMO's) recognize the OA in the treatment of OSA. I consider my self one of the fortunate ones to have benefited from my Somnomed MAS.
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Re: Boil and Bite

Postby jwpegram » Sat Mar 28, 2009 7:57 pm

papahemi wrote:jwpegram- During your research into Oral appliances did you ever try a boil and bite appliance such as the "Pure Sleep"? As a fellow Somnomed Mas user I agree it may be awhile before insurance companies (especially HMO's) recognize the OA in the treatment of OSA. I consider my self one of the fortunate ones to have benefited from my Somnomed MAS.

If you mean one of the "over the counter" types, no I never did. By the time I got to that point I understood (at least to some degree anyway) what's moving by moving the lower jaw forward and I never saw how a bite block type thing would help. I'm not familiar with the Pure Sleep, unless it's that thing on the tv I see for snoring. Maybe in minor cases it might help but I don't know.
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TMJ specialist

Postby sleepermatt » Fri Sep 25, 2009 12:21 pm

I was reffered to by my ENT to a Dentist specializing in TMJ.

I was there for sleep apnea with an AHI of 31 and the dentist told me that I have had temple headaches since high school and didn't notice them because of my high pain tolerance.

After having two sleep specialists and an ENT tell me my airway was fine he said it was small because I hold my tongue to the front of my teeth. Anyone ever hear of that as a dign of a small airway?

When he was done with the exam the office saleman came into tell me what would be included in my treatment plan. The device which they make onsite would be fitted after EIGHT sittings! A free pillow with WASHABLE pillow case would be included. And they would use a home sleep study machine currently non-operational to proce it is effective all for the low price of $3300. I might still get an oral appliance but not from there. His homemade device didn't allow for any movement.
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