Dr. Nugent works with Medical Doctors for a complete patient experience:
The initial problems of merging dental care and medical care is based on the historical separation of the two disciplines. The has always been perplexing as both dentistry and medicine care for the same patients. The mouth is not magically separate from the rest of the body. The biggest hurdle our office has faced is dealing with medical insurance. Dr. Nugent works under a Medical Doctor’s prescription for an oral appliance to treat obstructive sleep apnea. Dentists are becoming included in the triage and treatment of patients with obstructive sleep apnea and are vital due to the huge number of undiagnosed sleep apnea patients. Routine dental cleanings offer a perfect time to talk about the patient’s quality of sleep as these appointments are an hour long.
Because the obstructive sleep apnea research over the last two decades has validated the effectiveness of mandibular advancement devise (MAD), the MAD has become a more popular prescribed alternative to CPAP therapy. Almost always, dentists have functioned independently of physicians, with a separate training programs. Dentistry has not adopted The International Classification of Diseases (ICD – 9/10) diagnostic coding system of the International Classification of Sleep Disorders (ICSD-2) diagnostic system. Plus, dentists are not generally trained to use Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) that are used by other health care providers for medical treatment coding. Dentistry uses the Current Dental Terminology (CDT), a proprietary treatment coding system.
Unlike medicine, which primarily functions as a group practice based, hospital-aligned profession dentistry is primarily a solo practice-based, non-hospital-aligned profession. Traditional dentists are responsible for diagnosing and treating dental and periodontal disease, and play a key role in facial cosmetics through general dentistry, orthodontics and cosmetic dentistry.
Despite the existence of nine dental subspecialties, the majority of dentists practice general dentistry, providing much of the specialty care within the general dental office.
It is very common for dentists to provide various forms of oral appliance therapy, including removable prosthetic devices for missing teeth, night guard splint therapy to protect teeth and orthodontic appliance care to align teeth. These procedures are considered dental care with a dental diagnosis, and are generally covered by dental insurance.
The diagnosis of obstructive sleep apnea and jaw-related musculoskeletal disorders are considered medical diagnoses, and treatment is directed by a medical doctor. Providing an oral appliance that alters tongue posture to avoid airway collapse is considered medical care. Qualified dentists, while following a medical doctors prescription, can provide mandibular advancement appliances for obstructive sleep apnea. These devices are considered medical care, and are generally covered under medical insurance.
This requirement for physician diagnosis and physician-directed treatment creates a challenge for dentist, who are trained as both the diagnosticians and treatment providers. The necessity for a physician diagnosis and referral is a new paradigm for the practicing dentist. Dr. Nugent has set up a system to work with Board Certified Sleep Physicians for complete patient care. Screening dental patients for possible undiagnosed snoring and obstructive sleep apnea is encouraged by both medicine and dentistry. Once identified through questionnaires and interviews, Dr. Nugent helps the patient set up a sleep test. A sleep test is the ONLY way to diagnosis obstructive sleep apnea. A board-certified sleep physician reads the sleep test and gives a diagnosis and if appropriate a prescription for a oral appliance.
If the patient is diagnosed with snoring, then Dr. Nugent will treat the condition with an oral appliance. This treatment is not generally covered by insurance.
If the patient is diagnosed with obstructive sleep apnea, appropriate therapy is at the physician’s discretion. CPAP therapy remains an effective therapy. Although CPAP therapy is the primary treatment recommended by the physician, CPAP patients encounter many problems with their treatment. However, oral appliance therapy is also considered an accepted initial therapy option for mild to moderate OSA. Furthermore, if CPAP therapy is intolerable, oral appliance therapy is advised. Oral appliance therapy, in combination with CPAP therapy, is also considered as a treatment choice in severe OSA cases.
When dentists become involved in multidisciplinary care and provide oral appliance therapy, they become part of the medical team. The dentist treating obstructive sleep disorders assumes the co-management of musculoskeletal issues involving the jaw. Physical therapy or other physical medicine referrals may be appropriate.
For medical doctors, it is helpful to have their patients see a dentist for routine dental care.
Dental problems, notably periodontal disease can worsen medical problems. The disconnect between medicine and dentistry is becoming smaller due to significant findings supporting the association between periodontal disease and systemic conditions such as cardiovascular disease, type 2 diabetes, and adverse pregnancy outcomes. Significant effort has brought numerous advances in revealing the etiological and pathological links between this chronic inflammatory dental disease and these other conditions. Thus, there is reason to hope that the strong evidence from studies may guide medical doctors towards greatly improved awareness that treatment of periodontal infection can improve these systemic illnesses and their patients health.
Studies have shown that periodontal disease is associated with heart disease. While a cause-and-effect relationship has not yet been proven, research has indicated that periodontal disease increases the risk of heart disease.
Scientists believe that inflammation caused by periodontal disease may be responsible for the association.
The increased bacterial burden resulting from poor oral hygiene and periodontal diseases may increase the risk for certain respiratory diseases such as pneumonia and chronic obstructive pulmonary disease (COPD). Improved oral hygiene and effective periodontal care could reduce the numbers of pathogenic bacteria in the mouth, therefore preventing the onset of serious respiratory infection in vulnerable subjects.
Diabetic patients are more likely to develop periodontal disease, which in turn can increase blood sugar and diabetic complications.
People with diabetes are more likely to have periodontal disease than people without diabetes, possibly because people with diabetes are more susceptible to contracting infections. In fact, periodontal disease is often considered a complication of diabetes. Patients who do not have their diabetes under control are particularly at risk.
Research has suggested that the relationship between diabetes and periodontal disease goes both ways – periodontal disease may make it more difficult for people who have diabetes to control their blood sugar.
Severe periodontal disease can increase blood sugar, contributing to increased periods of time when the body functions with a high blood sugar. This puts people with diabetes at increased risk for diabetic complications.
Additional studies have pointed to a relationship between periodontal disease and stroke. In one study that looked at the causal relationship of oral infection as a risk factor for stroke, people diagnosed with acute cerebrovascular ischemia were found more likely to have an oral infection when compared to those in the control group.
Evidence for the link between periodontal disease and rheumatoid arthritis comes from the commonality of their pathogenesis and clinical presentation. The immunological and pathological processes occurring in periodontitis and RA are nearly identical. Both conditions are characterized by chronic inflammation in a soft-tissue site adjacent to bone. In both diseases, the inflammatory mediators released include IL-1, IL-6, and TNF-alpha, among others. Furthermore, antibodies to the same bacterial species are found in periodontal tissues and synovial tissues in individuals with RA. There is also a strong genetic association between the two diseases.
The clinical manifestations occurring in both periodontitis and RA are also remarkably similar – pain, swelling, and tenderness. If left untreated, the chronic inflammatory processes ultimately lead to bone destruction.
Research studies have suggested that women with periodontal disease may be more likely to deliver babies prematurely or with low-birth weight than mothers with healthy gums. According to the Center for Disease Control and Prevention (CDC), babies with a birth weight of less than 5.5 pounds may be at risk of long-term health problems such as delayed motor skills, social growth, or learning disabilities.
For the best patient care, it is advisable for medical doctors to make sure their patients have routine dental care. Dr. Nugent and team can both screen for periodontal disease and obstructive sleep apnea for comprehensive totally patient care.