TMDiary Journal of the American Academy of Craniofacial Pain - Summer 2016

!!!
AACP’
s
31st
Annual
InternationalClinicalSymposiumLive Music Capital of the World
Journal of the American Academy of Craniofacial Pain
Volume 29 Number 1 | Summer 2016
July29–30, 2016 |HiltonAustin |Austin,TX

2016-2017
Dental Sleep Medicine
Mini-Residency
A comprehensive,multi-part
programconsistingof 3 three-
day modules plus guided self-
study and videoconferences.
Module I:
October 13-15, 2016
Module II:
January12-14, 2017
Module III:
April 6-8, 2017
All modules conducted at the
Tufts University School of
DentalMedicine, Boston, MA
Act Now - Previous Classes Have Sold Out!
For pre-registration, please visit www.aacfp.org, or contact the Tufts University
Office of Continuing Education: dentalCE@tufts.edu|617.636.6629

TMDiary is the official journal of the America Academy of Craniofacial
Pain. TMDiary is published twice yearly: Fall/Winter and Spring/Summer
and is intended solely for the use of Academy members and to act as an
open forum for disseminating pertinent clinical, scientific, and personal
information. Letters and articles represent the view of the writer and
do not necessarily represent the view of the AACP, this journal, or the
editorial staff.
Comments and letters to the editor from Academy members and
non-members are welcomed. Please send these items to the executive
director. The editorial staff reserves the right to select articles for
publication and edit same.
For more information concerning the American Academy
of Craniofacial Pain please contact:
Bill Carney, Executive Director
12100 sunset Hills Rd, Suite 130 | Reston, VA 20190
800.322.8651 | 703.234.4142 | 703.435.4390 fax
www.aacfp.org | central@aacfp.org
Mayoor Patel, DDS & Edmund Liem, DDS, Editors
Jack C. Cherin, DMD, Associate Editor and Photojournalist
NOTE: The statements and opinions contained in editorials and
articles in these publications are solely those of the authors and not
of the AACP or of its officers, members or employees. Statements and
facts contained in advertisements for products or services are the
responsibility of the advertisers alone. The editors and AACP directors
and officers, and employees disclaim all responsibility for facts and
opinions referred to in any articles or advertisements in this or other
publications by the AACP.
Table of Contents
President’s Report 4
Executive Director’s Report 5
Institute News: 7
New Courses Dominate the Institute’s
2016-2017 Schedule
Terry Bennett, DMD
TMD/Orofacial Pain and OSA, Correlation 8
or Causation?
Dave Shirazi, DDS, MS, MA LAc RPSGT D.ABCP D.ABC-DSM
The Rationale for Obtaining a Review of Systems 11
as Part of History and Physical Examination
Deepak Shrivastava, MD
ABCDSM Board Activity 14
Roger W. Roubal, DDS
Protocols for Photographic Documentation 15
for the TMJ, OSA and Orthodontic Practice.
(Part 2)
Edmund K.T. Liem, DDS
3 New Ways to Market Your Dental Practice 16
for Digital Survival
Sara Berg
What’s New with Medical Policies for 17
Obstructive Sleep Apnea
Rose Nierman, RDH
Report from the Australian Chapter of the AACP 18
Andrew Lee, DDS
Canadian Chapter Report: Chapter Gears Up 20
for 10th Anniversary Conference
Edmund K. T. Liem, DDS
ABCP Plans for Austin Summer Symposium 21
Jeanne K. Bailey, DDS
American Academy of Craniofacial Pain
12100 Sunset Hills Road | Suite 130
Reston, Virginia, 20190 USA
P: 703.234.4142 | F: 703.435.4390 | www.aacfp.org

TM Diary | Summer 2016 4
President’s Report
I am excited to have my friends in the
AACP return to Texas again for our annual
event. I’m sure you are aware that we
Texans are proud of our State, and I want
to personally invite you to attend a
wonderful conference and enjoy some
hospitality. Please take time to enjoy the
Texas capitol, music, and one of our five
major food groups: steak, chicken fried
steak, Mexican food, BBQ, or Tacos. Since
we have chosen to suspend the winter
conference, this will be our only time together until next sum-
mer, so please make arrangements to come. This will also mark
my last meeting as your president, and I would l like to take this
opportunity to personally thank you for your confidence and
affording me the privilege of serving the last two years.
I have to brag on a few individuals that have served the AACP
this year. First is our Immediate Past President and Institute
Director, Dr. Terry Bennett. Dr. Bennett has really energized the
Institute by making it more vital and by adding many courses.
Please visit the website link and take notice of the upcoming
courses listed: A Tongue-Tie course starting in June, Class 12 of
the CP Mini-Residency starting in September, an anatomy and
dissection course starting in September, Class 5 of the Sleep
Mini-residency starting in September, a Cone Beam course
starting in October, and the Tufts Sleep Course starting in Octo-
ber. You also need to know that Dr. Dennis Marangos has put
in many hours as our Education Committee chair this year, and
with the help of Dr. Stacy Cole are in the process of creating a
World Class online continuing education program for the AACP
by joining hands with an educational online group mdBrief-
Case. In the near future we will begin to roll out new online
programs. Finally, I would like to give special recognition to
Dr. Ed Lipskis our program chair for a tremendous effort to
bring great clinical symposium speakers to us. Planning our
Symposium is very likely the most difficult job in our Academy,
and Dr. Lipskis has done a fantastic job.
One of the tasks we have at each summer meeting will be to
elect new board members. The board of course is now much
smaller after the retirement of our founders, and it is being
filled with many new energetic members. Last year we were
thankful to add Dr. Larry Pribyl to the board, and we also dur-
ing the year appointed Dr. Cameron Kuehne to fill the vacancy
created by Dr. Rick Light as he moved up to the position of
Secretary. Dr. Kuehne had been the highest vote recipient in
line at the last board elections and will complete the term of Dr.
Light. Dr. CynthiaWiggins resigned from her position as secre-
tary, since she needed the extra time in her schedule to help her
daughter land a college softball scholarship. Dr. Elliot Alpher
and Dr. Jeanne Bailey will be completing their term limits on the
board this summer, and we will be voting for their replacements.
Please join me in thanking both of them for their dedication and
service to the AACP. Also every two years one of our board mem-
bers will be voted to move up to the President Elect position.
This will create altogether three open board positions to fill.You
will be able to read about the slate of candidates in the TMDiary:
Dr. JosephTregaskes, Dr. Gary Dennington, Dr. Greg Bixby,
Dr. Cris Simmons, Dr. Michael Hoefs, and Dr. Joseph Baba.
Remember as you make your choices, we need workers on the
board that are willing to take the rolls of committee chairs and
later fill the offices of the board.
We have been truly blessed with workers on our board this
past year as mentioned, and I don’t want their tasks to go
unnoticed, because these individuals are very busy behind
the scenes making things happen. Please again join me in
thanking each of them for their dedication to the AACP mem-
bers: Dr. Steve Olmos as President Elect; Dr. Richard Klein
as Treasurer; Dr. Rick Light as Secretary; Dr. Terry Bennett as
Immediate Past President and Institute Director; Dr. Deepak
Shrivastava, MD as Medical Director; Drs. Edmund Liem
and Mayoor Patel as directors of publishing, website, and the
online university; Dr. Rick Light as Secretary and Ethics/Bylaw
Committee Chair; Dr. Richard Goodfellow as Membership
Committee Chair; Dr. Ed Lipskis as Program Chair; Dr. Jack
Cherin for his extensive work in production of our periodicals
the FMO and TMDiary; Dr. Dennis Marangos as the Education
Chair; and Dr. Stacy Cole as the Institute Committee Chair.
There are also too many to list other Board Members and AACP
members that are busy in committees and behind the scenes
that are not mentioned. The take home point is that you know
that the AACP is thriving because of the many volunteer efforts.
The AACP has been very good to me, and I have enjoyed
immensely being a part of it, especially the fellowship of like-
minded individuals and educational opportunities. Again thank
you for your support, and I will always appreciate having had
the opportunity to serve. It has also been a pleasure working
with Bill Carney and Homaira at Drohan Management. I am
looking forward to seeing you at our Bigger in Texas Meeting.
Academy Transitions to New Leadership
By Jeffrey McCarty, DDS
AACP President

This has been a particularly eventful few
months for the AACP and for the staff
here at your Central Office. I have been
privileged to be your executive director
for five years now, and I have never seen
this volume of positive activity. And best
of all —it’s all designed to help you, our
cherished members, further your dental
educations and grow your practices.
The summer symposium in Austin is only
weeks away. The agreement the Academy signed with mdBrief-
Case is now yielding fruit and the AACP Institute is flush with
new and exciting continuing education programs. Please allow
me a few minutes to expand on these efforts.
The Annual Clinical Symposium
As you may be aware, the AACP Board of Directors voted last
summer to cease the production of the annual winter sym-
posium, which allows us to focus our year-round attention
on developing and presenting just one major clinical sympo-
sium— the annual summer meeting. Our wonderful vendors
and many of you loyal members have told us these past couple
of years that it was just too difficult to support two AACP
symposia each year. We listened! And now we are making the
summer program—complete with ancillary meetings for your
assistants—our primary concern.
AACP’s 2016 International Clinical Symposium—our 31st
annual summer program—will take place July 29-30 at the
beautiful Hilton Austin in Austin, Texas. Austin is the“Live Music
Capital of the World,”and our hotel’s central location will make
it easy for you to enjoy everything this vibrant city has to offer.
In the end, of course, our Symposium is all about the program.
This year we have perhaps the finest cadre of presenters we’ve
ever assembled, thanks to our tireless Program Chair, Dr. Ed
Lipskis. Professor Mariano Rocabado is our featured pre-
senter. I’m sure you’ve heard about this industry legend, but
if you haven’t been privileged to hear him in person, you’re in
for a treat.
Dr. Steven Olmos, our incoming Academy president, is
another internationally recognized lecturer and researcher
ready to energize you in Austin. World renowned oral and
maxillofacial surgeon Dr. Larry Wolford and pediatric specialist
Dr. Kevin Boyd are among the other stars of our program. You
simply can’t afford to miss out.
The AACP Online U
The most exciting development over the past few years has
been our collaboration with Canada’s mdBriefCase to expand
our Online U and to make it a much more sophisticated and
dynamic dental education resource. We have spent many
months now working closely with mdBriefCase to prepare
to launch this state-of-the-art dental education website. I’m
delighted to say we are ready to launch this fall!
Once we launch, you’ll find accredited programs for doctors
and assistants in your practice who want to further their educa-
tions and who find it more productive to study online at their
own pace and on their own schedule. AACP’s Online U fills
the bill! Stay tuned for many more Online U programs now
in the pipeline.
The AACP Institute
For personal, sophisticated, hands-on dental education nothing
can ever replace live programs. Dr. Terry Bennett, our AACP
Institute Director, continues to grow the Institute. There are cur-
rently four live programs dealing with craniofacial pain and/or
dental sleep medicine available for you to sign up for right now
at discounted member rates:
❱ AACP’s Craniofacial Pain Mini-Residency, Class 12, takes
place over four weekends (first session is September 8-10,
2016) in Fort Worth, Texas. This is the AACP Institute’s
cornerstone program. Completion will provide you with
the knowledge and clinical skills required to assess, dif-
ferentially diagnose, and effectively treat the majority of
craniofacial pain patients seen in today’s dental office.
Executive Director’s Report
Be Sure You are Taking Advantage of
Everything the Academy has to Offer!
By Bill Carney
Executive Director
Continued ➥

!!!
AACP’
s
31st
Annual
InternationalClinicalSymposium
July29–30, 2016 | HiltonAustin | Austin,Texas
Executive Director’s Report continued
❱ AACP’s Sleep Medicine and Dentistry Mini-Residency,
Class 5, takes place over ONE four-day weekend in San
Diego, California. The dates are September 28-October
1, 2016. Here you’ll learn everything you need to know
to successfully manage patients with sleep disordered
breathing issues—a huge potential profit center for
your practice.
❱ BRAND NEW—AACP’s Hands-on Dissection Course
will take place September 16-17, 2016 in Denver, Colorado.
Dr. Wesley Shankland and Dr. Stacy Cole will focus on
head and neck anatomy and neuroanatomy, with special
emphasis on pain perception and sleep.
❱ BRAND NEW—How to Read Conebeam CT for TMJ
and Sleep Dentistry will take place October 7-8, 2016
in Atlanta, Georgia. Dr. Dania Tamimi, a Harvard-trained
radiology expert who runs her own oral radiology practice
in Orlando, Florida, will teach clinicians how to review a
CBCT volume for the purposes of TMJ and Sleep Dentistry
diagnosis. You’ll quickly understand why diagnosis is 90% of
the treatment!
These Institute programs, coupled with the AACP/Tufts School
of Dental Medicine 2016-2017 Dental Sleep Medicine Mini-Res-
idency, are keeping us very busy here at the Central Office as
we process registrations. For more information and to register,
please go to www.aacfp.org.
Our Amazing Program Director
Before closing, I want to pay tribute to Homaira Sheikh,
your AACP Program Director here at the Central Office.
Homaira is by far the most valuable team member we have
ever had working here at the AACP Central Office.
I can’t begin to list all of the innovations and improvements
she has made. She has made the AACP Facebook page a
valuable marketing tool; she has streamlined and refined
the registration process for all programs; she has managed
the annual membership renewal process flawlessly; she has
made many, many wonderful improvements to the devel-
opment and management of the annual symposia; and she
has taken on the extremely complicated and critical task
of renewing our ADA CERP and our AGD PACE continuing
education certifications.
I hope you’ll join me in thanking Homaira for her tireless
efforts on behalf of the Academy. I am so grateful to have
her on our AACP team.
I look forward to seeing you in Austin this July.
Check out the candidates for election to the AACP Board
elsewhere in the issue. Come to Texas prepared to vote for
your favorite candidate.

First of all, I would like to thank all of you
who have attended any AACP Institute
meeting in the past few years. By choosing
these meetings, you are supporting the
very organization that you belong to, the
AACP. I know that there are many choices
for your continuing education dollars and
the AACP appreciates your continued
support of our nonprofit organization.
Ok, enough editorializing and on to the
better news. The 11th edition of the CFP mini residency was just
completed in April. We had 19 students for this class and I feel
that the AACP can be proud of all the people who completed the
course work. Testing is almost totally completed and this group
tested extremely well on all the work and I am proud to have
many of them complete all the requirements for their Fellowship
designation. In addition, we also just completed the 4th class of
the Dental Sleep Mini Residency that was held in Atlanta. This
was another great class and as expected, has led several of these
students to want to continue their education in the CFP resi-
dency that will start in the fall.
Several courses have been planned for the fall and you should
start getting brochures in the near future. First of all, in August,
we are adding a new course,“Beyond the TMJ”by Dr. Mayoor
Patel. This course will be held in Atlanta on August 26 and 27
and will focus on the advanced diagnosis and management of
orofacial pain, current theory and diagnostic aids used in the
differential diagnosis of craniofacial pain. This is an excellent
course to supplement what many of you have learned already in
the different TMD courses as it delves deeply into cranial nerve
pathology, vascular pain, neuropathic pain and much more. Sep-
tember, will see the start of the 12th CFP mini residency. This will
be the last year at the AATCC in Ft. Worth as American Airlines
will be keeping the whole facility for their own staff training. This
has been a great training facility for us and the search is on for a
new place to hold the course in the future. We are also having a
new course“Dissection of the Head and Neck Anatomy and Neu-
roanatomy with Special Emphasis on Pain Perception and Sleep”
in September. The course will be held on September 16 and 17 at
the beautiful Mountain West Dental Institute in Denver. This is a
gorgeous facility in downtown Denver and features 2 large audi-
toriums, 4 dental operatory setups, wet lab, and other lecture
facilities. This course will be taught by Drs.Wes Shankland and
Stacy Cole and will include two days of dissection of the head
and neck and will have clinical applications to dentistry from
post op restorative pain to TMD pain and also sleep and breath-
ing disorders. In other words, it’s going to tie all the stuff together
for you to actually observe the workings of all the pieces. To end
the busy month of September, we will start the 2nd session of
the four day Dental Sleep Mini Residency. The course dates are
starting on September 27th and end on October 1st and will be
held again at the beautiful ResMed facility in LaJolla California
just outside San Diego. This course will be basically the same
format as last year but will include bonus hours from our medical
director Deepak Shrivastava. Last year everyone liked the oppor-
tunity to complete this course in a four day period which helped
save on expenses of flying, hotels and out of office time.
In October, we are bringing Dr. DaniaTamimi to Atlanta to
host the course“How to Read Conebeam CT for TMJ and Sleep
Dentistry: Diagnosis is 90% of the Treatment.”Dr. Tamimi is a
Board Certified Oral and Maxillofacial Radiologist and has had a
major part in the writing of 3 different textbooks on this subject.
She is one of the leading Oral Radiologists in the country and we
are fortunate and happy to have her for this course. This course
should be a must for any of us who have a CBCT machine as she
will cover TMJ anatomy in both the CBCT and MRI, review the
growth and development of the TMJ and many other aspects
of what to look for when we take these images. Please look for
the brochure or eblast for further information on this and all the
other courses.
Fall is always a busy time for educational courses and I truly
hope that you look at what we are trying to offer in the way of
new courses and take advantage of these opportunities. Other
courses are being planned at this time and we will keep you
updated as they come about.
I just want to thank the AACP for the opportunity to serve as the
Institute Director as I have been able to meet and get to know
many of our new members as they start their long journey and
also get to be around many of our members who I have known
for a long time as they come to take advantage of some of the
new materials that is being offered.
New Courses Dominate the
Institute’s 2016-2017 Schedule
By Terry R. Bennett, DMD
Institute Director
Institute News

By now the majority of us have read the
article on JADA about the prevalence of
orofacial pain among our patients
between the ages of 18-931
, specifically
how one in 15 have musculoligamentous
pain, but one in 6 have dentoalveolar pain
(which includes referred pain to dentoal-
veoloar areas not associated with an
infectious process). In the 6-17 year old
subgroup the numbers are even more
bleak at one in 32
or one in 43
children and adolescents respec-
tively are suffering, largely in silence. If the prevalence is that
high in children, why aren’t they being treated or referred for
treatment? How did this happen seemingly‘all of sudden’?
The answer to that, in truth, comes as the answer to all such
questions in medicine: we never looked. We’ve heard that
expression called the new meaning of the acronym WNL, and
I have to say I would agree with it given my anecdotal observa-
tions of dentists and how they view their existing patient
population at new and recall appointments.
The challenge is in education as well treatment. Many of us
received minimal to no education on orofacial pain in our
pre-doctoral training, but much of what we were given or what
we believed to be efficacious is now outdated, outmoded or
more directly entirely inaccurate, such as the use of occlusal
equilibration as a methodology to treat chronic facial pain or
TMD (TemporoMandibular Disorders) or Sleep Bruxism (SB)4,
5, 6
. In fact, new research has demonstrated that raising the
occlusion iatrogenically with gold foil to mimic the supposed
‘high bite’did little to nothing increase masseter EMG activity
nor pain in patients already suffering from myofascial pain7
.
To have comprehensive knowledge which leads to diagnosis
and treatment (or referral) takes a worldly view on the subject,
whereby orofacial pain, TMD and musculoskeletal disorders
associated with the stomatognathic system are demonstrating
correlation and/or causation with a myriad of other disorders
such as tension headache, migraine and CN neuralgias8
. Further
studies have seen the correlation with ear pain9, 10
and somatic
tinnitus11, 12
and fibromyalgia13, 14
. Thankfully, were seeing a new
trend in predoctoral training in Orofacial Pain from University
of Minnesota, University of Tennessee, Memphis as well as Tufts
and others, and I’m hopeful that with great leaders such as
Drs. Mehta, Olmos and Lavigne leading the pre-doctoral and
post doctoral training, who take on this more worldly view of
the immense complexity of these patients, the mind of the cur-
rent and future dentist will go far beyond the enamel.
And the segue at the heart of the controversy lies in Sleep
Bruxism and its role in both TMD and OSA (Obstructive Sleep
Apnea). Many speculations have been made about SB as it
relates to all aspects of dentistry, and definitions and boundar-
ies need to be understood. Ultimately SB is a centrally mediated
movement disorder characterized by Rhythmic Masticatory
Muscle Activity (RMMA) associated with tooth grinding and
occasional tooth clenching15, 16
and has a world wide preva-
lence of 5.5%17
. Its classification is more along the lines of RLS
(Restless Leg Syndrome) and PLMD (Periodic Limb Movement
Disorder), unlike awake bruxism which has been associated
with nervous tics and reactions to stress18
. It has been observed
with causality to UARS (Upper Airway Resistance Syndrome),
which is not to be confused with OSA. UARS is a pre-OSA condi-
tion characterized by negative esophageal pressure changes
that happen concomitantly with decreased oronasal flow in the
absence of apneas or oxygen desaturation and also with brain
wave arousals that disturb brain wave activity from a deeper
stage of sleep to a lighter one, or REM to non-REM sleep19
. It’s
interesting to note that SB is also exasperated by sleeping in
the supine position20
, and though casually observed with OSA21
with resolution of SB when using CPAP therapy to treat OSA, it’s
when we narrow our focus to patients with UARS and SB, 86%
show resolution in SB with the use of CPAP22
. Which is signifi-
cant when we observe that SB does not typically resolve on
its own over time, regardless of the number of years between
observances23
.
Given this data, observance of the effects of SB on teeth and
associated structures should prompt the dental clinician to at
least educate and refer the patient for a sleep evaluation in an
overnight sleep study to evaluate for UARS with a physician.
The dental clinician may even inquire about the presence of
nasal obstruction with the patient. What is not recommended
is to mask the symptom of SB with an occlusal/night guard as a
stand alone treatment, not least of which is due to the possible
worsening of their Sleep Breathing Disorder that can be caused
by one24
, regardless of how small the worsening may be25, 26
,
this can be attributed due to the relatively mild nature of UARS
when compared to OSA.
Patients with SB have also been shown to overlap with TMD
and Orofacial pain, with at least one of the following symptoms
present: arthralgia, osteoarthritis and osteoarthrosis of the
condyle(s)27
, jaw pain (capsular) and myofascial pain28
, chronic
migraine, episodic migraine and tension type headache29, 30
.
TMD/Orofacial Pain and OSA,
Correlation or Causation?
By Dave Shirazi, DDS, MS, MA LAc RPSGT D.ABCP D.ABC-DSM
Continued ➥

Simultaneously and serendipitously we see questionable
improvement of these symptoms with the use of the said occlu-
sal/night guard or flat plane splints31, 32, 33, 34
. However we do see
improvements in these pain symptoms when the mandible is
advanced with anteriorly advancing orthotic therapy35, 36, 37
, and
improvements again with mandibular advancements in patients
with UARS38
and OSA39, 40, 41
, along with the well observed signifi-
cant reduction in SB with mandibular advancement42, 43, 44
.
REFERENCES
1
J Am Dent Assoc. 2015 Oct;146(10):721-8.e3. doi: 10.1016/j.adaj.2015.04.001.
Prevalence of Pain in the Orofacial Regions in Patients Visiting
General Dentists in the Northwest Practice-Based Research
Collaborative in Evidence-Based Dentistry Research Network.
Horst OV1
, Cunha-Cruz J, Zhou L, Manning W, Mancl L, DeRouen TA
2
J Orofac Pain. 2012 Winter; 26(1):17-25.
Clinical Signs of Temporomandibular Disorders and Various Pain
Conditions among Children 6 to 8 Years of Age: The PANIC Study.
Vierola A1
, Suominen AL, Ikavalko T, Lintu N, Lindi V, Lakka HM,
Kellokoski J, Narhi M, Lakka TA
3
Clin J Pain. 2014 Apr; 30(4):340-5. doi: 10.1097/AJP.0b013e31829ca62f.
Headache Associated with Temporomandibular Disorders
among Young Brazilian Adolescents.
Franco AL1
, Fernandes G, Gonçalves DA, Bonafé FS, Camparis CM
4
Cochrane Database Syst Rev. 2003;(1):CD003812.
Occlusal Adjustment for Treating and Preventing
Temporomandibular Joint Disorders.
Koh H1
, Robinson PG
5
J Prosthet Dent. 2001 Jul; 86(1):57-66.
An Evidence-Based Assessment of Occlusal Adjustment
as a Treatment for Temporomandibular Disorders.
Tsukiyama Y1
, Baba K, Clark GT
6
J Oral Rehabil. 2010 May; 37(6):430-51. doi: 10.1111/j.1365-2842.2010.02089.x.
Epub 2010 Apr 20.
Management of TMD: Evidence from Systematic Reviews
and Meta-Analyses.
List T1
, Axelsson S
7
J Oral Facial Pain Headache. 2015 Fall; 29(4):331-9. doi: 10.11607/ofph.1478.
Short-Term Sensorimotor Effects of Experimental Occlusal Interferences
on the Wake-Time Masseter Muscle Activity of Females with Masticatory
Muscle Pain.
Cioffi I, Farella M, Festa P, Martina R, Palla S, Michelotti A
8
J Pain Res. 2014; 7: 99–115.
Published online 2014 Feb 21. doi: 10.2147/JPR.S37593
Orofacial Pain Management: Current Perspectives
Marcela Romero-Reyes and James M Uyanik
9
Laryngorhinootologie. 2006 May; 85(5):327-32.
[Otalgia as a Result of Certain Temporomandibular Joint Disorders].
10
J Prosthet Dent. 1996 Jan; 75(1):72-6.
Otalgia in Patients with Temporomandibular Joint Disorders.
Keersmaekers K1
, De Boever JA, Van Den Berghe L
The overlap of TMD/orofacial pain and sleep disordered breath-
ing has been repeatedly observed and correlated45, 46
and is no
longer a question of‘if’or‘maybe’but a question of evaluation
and diagnosis by the dental and medical teams, and its up to
dental clinician who will often be the first in line to evaluate,
refer and possibly manage these issues that impact such a large
percentage of the population. When this happens, and I believe
in my heart that it will be much sooner rather than later, we can
change again the meaning of the acronym WNL to We’re Never-
Endingly Looking.
11
10.1371/journal.pone.0126254 2015 May 21. doi
Subtyping Somatic Tinnitus: A Cross-Sectional UK Cohort
Study of Demographic, Clinical and Audiological Characteristics
Jamie Ward, Claire Vella, Derek J. Hoare, and Deborah A. Hall
12
Otolaryngol Head Neck Surg. 2011 Nov; 145(5):748-52. doi:
10.1177/0194599811413376. Epub 2011 Jun 25.
Tinnitus with Temporomandibular Joint Disorders: A Specific
Entity of Tinnitus Patients?
Vielsmeier V1
, Kleinjung T, Strutz J, Bürgers R, Kreuzer PM, Langguth B
13
J Rheumatol. 1996 Nov; 23(11):1948-52.
The Relationship between Fibromyalgia and Temporomandibular
Disorders: Prevalence and Symptom Severity.
Plesh O1
, Wolfe F, Lane N
14
Revista Brasileira de Reumatologia (English Edition)
Volume 55, Issue 2, March–April 2015, Pages 189–194
Temporomandibular Disorders in Fibromyalgia Syndrome:
A Short-Communication
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TMD/Orofacial Pain and OSA, Correlation or Causation? continued
Continued ➥

21
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Epub 2015 Jul 14.
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Non-Splint Multimodal Therapy for Treating RDC/TMD Axis I Patients:
A Randomised Controlled Trial.
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, Maruyama H1
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Simmons HC 3rd1
, Gibbs SJ
37
Cranio. 2006 Apr; 24(2):119-29.
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TMJ Internal Derangement Treatment with Maxillary Anterior
Repositioning Splint or SVED and Mora Splints: A Comparison
with Untreated Control Subjects.
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, Caputi S, Teté S, Orsini G, Festa F
38
J Prosthet Dent. 2002 Apr; 87(4):427-30.
Oral Device Therapy for The Upper Airway Resistance
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Cranio. 2000 Apr; 18(2):98-105.
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of Sleep Apnea Syndrome and Snoring on Respiratory Function
and Sleep Quality.
Yoshida K1
40
Swed Dent J Suppl. 2003; (163):1-49.
A Mandibular Protruding Device in Obstructive Sleep
Apnea and Snoring.
Fransson A1
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43
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45
Sleep Disorders and their Association with Laboratory Pain Sensitivity
in Temporomandibular Joint Disorder
Michael T. Smith, PhD,1
Emerson M. Wickwire, PhD,1
Edward G. Grace, DDS,2
Robert R. Edwards, PhD,3
Luis F. Buenaver, PhD,1
Stephen Peterson, BA,1
Brendan Klick, MS,1
and Jennifer A. Haythornthwaite, PhD1
46
Article in Journal of Pain 9(4):14-14; May 2008.
Relations Between Objective Sleep Data, Sleep Disorders, and Signs
and Symptoms of Temporomandibular Joint Disorder (TMD)
Continued ➥

Dr. Dave Shirazi Bio:
Dr. David Shirazi graduated from Howard University College
of Dentistry, in Washington D.C. in 2000, and earned a Masters
degree in Oriental Medicine from Samara University in 2006
and is a board licensed Acupuncturist. He has completed over
2000 hours of continuing education in TMD and facial pain,
craniomandibular orthopedics, and sleep disordered breath-
ing. He has also completed a hospital mini-residency in oriental
medicine at the China Beijing International Acupuncture
Training Centre which is the only organization the World Health
Organization (WHO) has authorized to teach internationally
on acupuncture and herbology, and another at Kyung Hee
University and Medical Center, the #1 medical hospital and
medical school in Korea. In 2011, he became a board licensed
RPSGT, the first dual degreed dentist and Sleep Technologist.
He is the founder of the Bite, Breathe and Balance study group,
dedicated to the multidisciplinary approach to treating cra-
niofacial pain and sleep disorders. Dr. Shirazi is the director of
a state of the art private practice, The TMJ and Sleep Therapy
Centre international family, one of 40 Centres throughout the
world, and is located in the beautiful hills of Thousand Oaks,
CA. Personally, Dr. Shirazi enjoys hiking and camping in the
state parks, traveling, and speaking. He is married to the love
of his life Kimberly Shirazi, and have welcomed their first born,
Maximus. They live in Malibu Lake, a subset of Agoura Hills
where they are very close to nature.
Dr. David Shirazi’s Disclosures:
Affiliated and primary investigator of multiple research studies.
Dr. Shirazi’s Sleep Lab conducts research for multiple industries
including the pharmacutical industry. Adjunct Board volunteer,
and lecturer for AACP, lectures privately. Dr. Shirazi is not paid
to endorse any product or technique.
The Rationale for Obtaining a Review of
Systems as Part of History and Physical Examination
By Deepak Shrivastava, MD
The Review of Systems (ROS) is an inven-
tory of specific body systems performed by
the health care provider in the process of
taking a history from the patient. The ROS
is designed to bring out clinical symptoms,
which the patient may have overlooked or
forgotten. In theory, the ROS may illumi-
nate the diagnosis by eliciting information,
which the patient may not perceive as being
important enough to mention to the provider. The rules for
documenting the ROS are identical for both the 1995 and 1997
E/M guidelines (Evaluation and management).
There are FOURTEEN Individual Systems
Recognized by the E/M Guidelines:
1. Constitutional (e.g., fever, weight loss)
2. Eyes
3. Ears, Nose, Mouth, Throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Integumentary (skin and/or breast)
10. Neurological
11. Psychiatric
12. Endocrine
13. Hematologic/Lymphatic
14. Allergic/Immunologic
Coding Tip: There are no specific rules about how much
to ask the patient about each system. This is left up to the
discretion of the individual examiner.
There are THREE Levels of ROS Recognized by
the E/M Guidelines:
1. Problem Pertinent ROS: Requires review of ONE system
related to current problem(s)
2. Extended ROS: Requires review of TWO to NINE systems
3. Complete ROS: Requires review of at least 10 systems
CodingTip: When documenting the ROS, it is not necessary
to list each system individually. It is acceptable to document
a few pertinent positive or negative findings and then say:
“All other systems were reviewed and are negative.”
Coding Tip: It is not necessary that the physician personally
perform the ROS. It is acceptable to have your staff record
the ROS or to let the patient fill out an ROS questionnaire.
Continued ➥

However, the physician MUST review the information and
comment on pertinent findings in the body of the note. In
addition the physician should initial the ROS questionnaire
and maintain the form in the chart as a permanent part of
the medical record.
Coding Tip: Many physicians overlook the fact that many
follow-up encounters DO require a ROS. There is a percep-
tion that a ROS only needs to be done during your initial
encounter with the patient, but this is not correct. For
example, an extended ROS is required for a level 3 hospi-
tal progress note or a level 4 office follow-up visit with an
established patient.
eCoding Tip: You DO NOT need to re-record a ROS if there
is an earlier version available on the chart. It is acceptable
to review the old ROS and note any changes. In order to
use this shortcut, you must note the date and location of
the previous ROS and comment on any changes in the
body of the current note. For example, if you are seeing an
established patient in the office you can say:“Complete ROS
which was performed during a previous encounter was
re-examined and reviewed with the patient. There is noth-
ing new to add today. For details, please refer to my previous
note in this chart, dated 11/23/2015.”
A sleep specific review of systems ensures that the provider has
a through understanding of individual’s sleep and its complica-
tions. Proper discovery, evaluation, and management improve
patients’quality of care and outcomes.
Explanation on Specific Items in
Sleep Review of Systems:
Underweight patients are likely to have poor sleep, insomnia
and other similar problems. The cause of low body weight may
relate back to a medical or psychiatric condition that can have
both a direct and an indirect effect on the sleep.
Overweight is a self-explained confounder that worsens
obstructive sleep apnea, may lead to obesity hypoventilation
syndrome, and may be a contributor to pulmonary hyperten-
sion. Obesity perpetuates cardiac problems and asthma. It
causes insulin resistance and worsens diabetes. It worsens
GERD related acid reflux and can worsen OSA. Obesity also
contributes to high blood pressure.
Unintentional weight loss is always a bad sign. It may lead to
sleep related complications due to underlying conditions as
well as poor physical and mental health.
Dry mouth is an indication of mouth breathing. However, it
may be a manifestation of underlying connective tissue dis-
order like scleroderma or Sjogern syndrome. In patient using
CPAP dry mouth can indicate air-leak.
Tinnitus can worsen by the use of CPAP by oral appliance.
Postnasal drainage indicates increased congestion and high air-
flow resistance. It increases incidence and intensity of snoring.
It also can predict future problems with CPAP use.
Headaches are a strong indicator of possible obstructive sleep
apnea. On the other hand, OSA and sleep disruption can cause
migraine headaches. The treatment for headache itself can
have significant effect on sleep and insomnia.
Poor vision can be due to refractory error in vision and has
been shown to be a result of macular degeneration worsened
by sleep apnea. Diabetes and hypertension both can cause
retinopathy and other problems. Dry eyes again can be due to
connective tissue disorder that has significant effect on sleep
and sleeping pattern.
Allergic/Immunologic: Allergies increase the incidence of
snoring and sleep apnea. In patients, using CPAP congestion
leads to non-use of CPAP. Seasonal allergies can cause symp-
toms during certain months. Management, adequate therapy,
and control of sleep apnea depend on control of perennial and
seasonal allergies. Allergy can therefore impede the success of
the oral appliance therapy. Allergies can also alter the course of
other diseases like asthma further complication the manage-
ment of sleep apnea.
Asthma is a well-known confounder in OSA. It can worsen OSA
and OSA can worsen asthma control. Obesity is an increasingly
known risk factor for asthma suggesting a complex relationship
amongst these disorders. Medications used in asthma treat-
ment can further cause side effects like insomnia in susceptible
individuals and indirectly affect OSA management.
Sinus problems influence breathing and nasal patency as well
as use of oral appliance or CPAP usage. The airflow from CPAP
can alter the humidification of mucous membranes and worsen
sinus tenderness, secretions, dryness, and other symptoms.
Lupus and other rheumatologic disorders can affect respira-
tory system and can manifest in symptoms like shortness of
breath, cough, and bleeding and lung fibrosis. Presence of such
disorder should prompt concomitant medical management by
specialist medical physicians. Many of these disorders cause
muscle weakness and can change work of breathing and cause
variable response to OSA treatment. Just like OSA, these disor-
ders have involvement of organ systems in the body.
The Rationale for Obtaining a Review of Systems... continued
Continued ➥

HIV/AIDS patient pose an infection control risk but also develop
different complications like weakness, muscle wasting syn-
dromes, malnutrition, neuropathies and myopathies. Many
prophylactic and anti-retroviral medications have significant
side effects on sleep.
Respiratory: Lung disease in any form and stage affects sleep
and wakefulness. Combination of COPD and OSA is more det-
rimental condition recognized as overlap syndrome. Current
data suggests that these patients have more frequent, steep,
and sustained oxygen desaturations, causing intense oxidative
stress on the cardiovascular system. Neuromuscular diseases
and lung fibrosis have complex physiologic derangements
that lead to oxygen and hypoventilation problems. Managing
OSA with these concurrent conditions requires special medical
attention and treatment modalities.
Shortness of breath is a nonspecific symptom but is not a part
of sleep apnea syndrome. This is important to realize as evalu-
ation and co-management of shortness of breath is equally
important. Coughing may represent uncontrolled acid reflux
disease, worsened by OSA; cough variant asthma or aspiration.
Cough is another non-specific yet very important symptom of
clinical significance. Both cough and shortness of breath may
represent congestive heart failure as a complication of OSA.
Snoring is precursor to spectrum of OSA syndrome. Snoring
may be occasional, positional, affected by behaviors and
medications, and may be nightly. Absence of snoring could
represent complete cessation of airflow and apnea.
Cardiovascular: Sleep disorder breathing affects the cardiovas-
cular system in more than one way. Individual may present with
cardiovascular (CVS) condition and could have central or obstruc-
tive apnea or both. CVS manifestations may present themselves
at the initial evaluation. Sleep disordered breathing worsens
the CVS complications and impedes the treatment efficacy.
Adverse effects of sleep disorder breathing like hypertension,
poor glycemic control, atherosclerosis, and cardiac arrhythmias
are well recognized. Presence of pacemaker indicates history of
cardiac rhythm disturbance. Palpitations represent similar distur-
bance. Chest pain may indicate many conditions that affect OSA
directly. Clearly, angina related chest pain is more of a concern
than chest pain related to acid-reflux or indigestion. In any case,
chest pain demands immediate attention before undertaking
OSA treatment. Swelling on feet or hands may be a result of fluid
overload or congestive heart failure.
Gastrointestinal: Gastric reflux is important confounder as
it gets worse with undiagnosed and untreated sleep apnea
and improves with treatment. Irregular bowel habits could
represent poor quality sleep, poor eating habits, and effects of
medications and or medical conditions. Stomach ulcers can be
result of stress related gastric acid secretion and pain interrupt-
ing the sleep. Gallbladder may cause pain especially after fatty
meals and can be a source of poor sleep.
Genitourinary: Kidney disease in any form can be a risk factor
for sleep-disordered breathing. However, medical literature
supports higher incidence of sleep apnea in end-stage renal
disease and in dialysis patients. Enlarged prostate is a cause
of nocturia and can be confused with sleep apnea related
nocturia. Nocturia can cause insomnia and fragmented sleep.
Other conditions associated with sleep apnea like diabetes can
also cause hyperglycemia-induced nocturia. Medication like
furacemide taken in the evening can be a source of nocturia.
Painful frequent urination could be due to urinary tract infec-
tion or structural problems. Impotence is a major problem
associated with obstructive sleep apnea due to reduced levels
of testosterone. Menstrual cramping can cause sleep depriva-
tion due to not only pain and discomfort but also related to
hormonal changes and their influence on sleep.
Pregnancy is a special situation as sleep apnea related hypox-
emia affects both maternal and fetal health and outcomes. Due
to increase in body fluid volume and hormonal changes dur-
ing pregnancy sleep pattern changes in every trimester. A full
spectrum of sleep-disordered breathing ranging from snoring
to severe sleep apnea can occur. It can predispose to eclem-
psia, seizures, gestational high blood pressure, and diabetes.
Congenital and developmental problems, ADD and ADHD
are fetal complications related to sleep apnea. . Fetal loss and
maternal death is possible. Immediate evaluation and treat-
ment is required especially in obese pregnant women.
Birth control pills do not have direct side effect on the sleep
however; they do affect hormonal balance and can disrupt
sleep. Menopause is a special time of women’s reproductive
cycle. It comes with hot flashes, disrupted sleep, and insomnia.
There is increased incidence of sleep apnea as well.
Integumentary (Skin): Skin conditions can be uncomfortable,
may represent systemic illness and their treatment may have
effect on the sleep. Brittle nails may be a result of electrolyte
and mineral changes in the blood and may be caused by
anemia. Hair loss in many situations suggests stress and under-
lying medical conditions. Poor wound healing is generally a
derangement of blood glucose and/or immune suppression for
example with steroid use. Malnutrition can cause many integu-
mentary symptoms.
Musculoskeletal: Pain and sleep have very profound recip-
rocal relationship. Chronic pain syndromes, chronic fatigue
syndrome, and fibromyalgia have very specific patterns on elec-
troencephalogram and sleep stages. A well-recognized pattern
is popular as alpha-delta sleep. Many neuro-muscular disorders
affect sleep, cause obstructive and central sleep apnea, and
require special montage setups during a sleep study. There may
be significant treatment implications as well as a variability of
response to treatment.
Continued ➥

Neurological: Numb fingers and hand may indicate neuropathy
related to many underlying causes. Stroke and paralysis sug-
gests a bilateral relationship with sleep apnea. Sleep disordered
breathing can develop after the stroke and stroke may be the
result of sleep disordered breathing. Stroke also increases the
aspiration risk due to poor swallowing function. Stroke is a
known cause of a special breathing pattern called Cheyne-Stokes
breathing. Many times this pattern is reported on the full sleep
study. The other cause of Cheyne-Stokes breathing is congestive
heart failure. Many neurologic symptoms may be non-specific
but do represent underlying disease. Seizures pose a special risk
as most of the seizures occur during sleep and can complicate
evaluation and management. Movement disorders are a cause of
both disrupted sleep and increased sleepiness. Special problems
include Parkinson’s disease and REM-behavior disorder.
Psychiatric: Sleep is linked to mental health just like neuro-
logical conditions. Anxiety, depression, and other psychiatric
disorders have both non-specific and many specific effects on
sleep. Poor quality sleep adversely affects disorders like ADHD
and learning disabilities. Sleep fragmentation and other sleep
related conditions can worsen dementia. Medications and sub-
stances of abuse all have significant impact on sleep. Alcohol,
a socially accepted drug causes many adverse effects on sleep.
It decreases sleep latency and is used by many as sleeping-aid.
However, it causes muscle relaxation, worsens apnea, increases
arousal threshold further worsening the oxidative stress on car-
diovascular system and causes diuresis presenting as nocturia.
Alcohol once metabolized in the system wakes up individual in
the early morning causing reduced total sleep time.
Hematologic/Lymphatic: Blood disorders like polycythemia or
high red blood cell count is a result of hypoxemia. Anemia can
be caused by nutritional deficiencies and may be responsible
for high heart rates, compensatory high cardiac output failure,
poor exercise capacity, and sense of weakness. Cancers have
independent affect of sleep and cause insomnia by direct and
indirect mechanisms. Chemotherapeutic agents have multiple
side effects on sleep. Nosebleed clearly has implications for
CPAP users but it can also affect the oral appliance therapy and
any hematologic disorder can complicate any potential surgical
interventions in the management of sleep apnea.
Endocrine: Sleep controls most of the hormones in the body.
It is important to review endocrine system. Different types
of arthritis can disturb sleep due to pain and discomfort in
finding a comfortable position. Chronic pain syndromes have
direct effect on sleep stages. Cold hand and feet may indicate
presence of Raynaud’s phenomenon commonly noted in indi-
viduals with certain rheumatologic disorder. Hypothyroidism is
implicated in the sleep-disordered breathing and its manage-
ment. Sleep apnea worsens blood sugar control. Episodes of
hypoglycemia may indicate erratic glycemic control. Individuals
with the sleep disorder develop poor autonomic function and
therefore develop significantly more hypoglycemia than those
with normal function.
The sleep specific review of system is important to build a solid
foundational database. This brings out any pre-existing condi-
tions. Concomitant management of complications related to
sleep disordered breathing is equally important in the general
well-being and clinical outcomes of the patient.
Upon the resignation of Dr. Jamison Spencer from the
Presidency of the ABCDSM, I assumed the position of President.
Following the Board by-laws, Dr. Gary Demerjian assumed the
position of President-Elect. This left a void of two at large board
members positions. Again following the by-laws, the board
nominating committee brought forward four qualified diplo-
mates for the Board to consider to be elected to the board.
I am proud to announce our two new board members.
Dr. Karen Wuertz of North Carolina and Dr. Kim Ledermann
of Minnesota were elected to the two open board seats.
ABCDSM Board Activity
By Roger W. Roubal, DDS
American Board of Craniofacial Dental Sleep Medicine President
I also want to congratulate our newest ABCDSM Diplomates.
They will be presented their certificates during the AACP
summer meeting in Austin. The following will be honored:
Drs. Behzad Fareid, Nicole Ferrara, Mark Barnes,
Aron Larsen, Tara Perry, Marc Marlette, Keith Stucki,
Karina Patel, and Gary Dempsey.
I will be attending the meeting and hope to meet those of
you who are not yet acquaintances of mine, and please do
not hesitate to bring forth any questions or suggestions
pertaining to Board activity.

Protocols for Photographic Documentation for the
TMJ, OSA and Orthodontic Practice. (Part 2)
By Edmund K.T. Liem, DDS
In the last edition of TMDiary I have dis-
cussed the photographic equipment and
setup that are very helpful in producing
consistent, reliable and excellence photo-
graphic documentation of TMD, OSA and
Orthodontic patients.
In this edition of TMDiary I will discuss
the implementation of a protocol that
will help every practice in achieving this.
Remember the key words: Consistency
and Repeatability.
Credibility of your practice relies heavily on consistent excellent
records and photographic documentation is one of the most vis-
ible one. When photographic documentation is of a poor quality;
some might have (for the wrong reasons) questions about the
quality of diagnosis and treatment. In order to have consistent
records it is important that every team member sticks to Stan-
dard Operating Procedure or in short: Protocols.
The first images that should be taken for every patient are the
ones for the head and neck.
What to do when the patient wears glasses?
I recommend to take only one picture with glasses on.

As you already know, the process of
gaining new patients is more than just
hanging a sign outside your door saying,
“Now Accepting New Patients,”or“New
Patients Welcome”. Your dental office
isn’t a motel with a vacancy sign, so take
strides in bringing attention to your office
in better ways. Over the years, the percep-
tion of how a dentist should grow his or
her practice continues to change. And, in
such a digital world, that means you need to remain up-to-date
with the latest advancements, including marketing.
Fierce competition means you need to set your practice apart
from the rest. But how do you do that? With a solid marketing
plan that covers all spectrums. Yes, quality and reputation can
get many patients in the door, they still can’t find the informa-
tion they need without access to a website, Google listing,
Social Media accounts, and other areas. By implementing the
following marketing strategies, you can accomplish your goals
of improved reputation and new patients:
Website and Content Marketing
The cornerstone for a solid marketing strategy is the availability
of a website for your practice, but not just any website. When
creating a website for your practice, it must be responsive,
which means it will load, display and function properly across
all devices—that means desktop, laptop, smartphone or tablet.
Google prefers sites that are mobile-friendly, but they also like
websites that provide up-to-date, quality content. Not only
should your website be functional, but it should also be
educational.
It is one thing to create a website, but you need content to
make it work and that is where Content Marketing comes into
play. Provide information about your practice and your staff,
your updated bio with office location, and then educational
information about each of the services you offer. With a page
of content dedicated to each of your services, not only will you
help to educate your patients, but you will allow your website
to be searchable online and indexed by Google—good job!
Social Media and Blogging
Most of us have our own personal social media accounts, but
what about your dental practice? Facebook, Twitter,YouTube
and Instagram have all revolutionized dental marketing. Through
social media and blogging, staying in touch with your patients
3 New Ways to Market Your
Dental Practice for Digital Survival
By Sara Berg
on an ongoing basis has never been easier! Social media allows
dental teams to put a face to the practice, while offering educa-
tional materials and updates on the practice so that the patient is
always updated and feels part of your dental family.
In addition to social media, it is important to utilize a blog on
your website. Through an active blog you will not only enhance
your content marketing and leverage your Google search
results, but you can further educate your patients on important
topics. This is also a helpful way to generate Newsletter topics,
while also providing email marketing areas that you can also
share via your practice’s social channels. Each area of marketing
is connected to the next, which is why it is important to gener-
ate an effective marketing strategy that includes both social
media and blogging.
Emails and Newsletters
Don’t forget about emails. A major source for marketing and
advertising your practice is through monthly or weekly emails.
However, before you begin to send emails to your patients
or potential patients, it is important to accumulate existing
patients’email addresses. Through email marketing you can not
only stay in touch with your existing patients, but it can also
help to send reminders of upcoming appointments, promo-
tional offers and updates within the practice.
Everyone checks their emails on a daily basis—sometimes
more than once a day if you’re anything like me. I tend to check
my emails non-stop throughout the day and even on the week-
ends. While your job or office might be open for a set time,
it doesn’t mean the rest of the world stops, so I try to always
remain up-to-date with my emails. When you begin your email
marketing campaign, start off slowly—you don’t want to bom-
bard your patients or cause your emails to go into the“Spam”
folder. Start off with an introductory email and then keep up
with once a month Newsletters. From there, when you have
more to share, you can up the frequency of emails to twice a
month or even once a week.
But remember to make your emails interesting. A bland subject
line will cause recipients to simply move past the email or
delete it without even bothering to open it. Try catchy phrases
like,“Say No to Jaw Clicking,”or“It’s time to enjoy your favorite
food without pain,”or even,“Treat Your TMD and Enjoy That
Tasty Burger”. Have fun with it and keep your patients up-to-
date with important information.
Continued ➥

The good news is you don’t have to do it on your own!
With over 6 years of professional experience in Content
Marketing, specifically in the dental field and specialty areas,
such as Craniofacial Pain, TMD and Dental Sleep Medicine,
I have a wealth of knowledge that helps practices across the
country improve their online presence to set them apart as
thought leaders in the industry, such as Dr. Mayoor Patel in
Atlanta, Georgia, Dr. Bonnie Foster in Warrenton, Virginia,
Dr. Kambiz Kashfian in Beverly Hills, California and many
others. An effective marketing strategy can help your practice
stand out from the rest.
Three Ways to Market Your Dental Practice... continued
It is important to remember that your competitors
are constantly advancing, too, so why
not update your practice’s marketing plan?
To learn more about Website and Content
Marketing for your practice, please contact me
by emailing SaraAnneBerg@gmail.com
or visiting my website at
http://saraanneberg.wix.com/dentalwriting
In the ever evolving arena of Dental Sleep
Medicine (DSM), it’s important to keep up
with individual insurer’s medical policies.
The criteria for coverage found in these
policies can greatly affect the success of
your pre-authorization request or claim
payment. There are significant changes
for 2016 including the fact that more
insurers than ever reimburse for oral
appliances for Obstructive Sleep Apnea
(OSA). More insurers also allow patients to utilize their In-Net-
work deductibles and copayments in order to reduce the out of
pocket costs (a GAP exception or Network Insufficiency request
during the preauthorization phase).
What’s New with Medical
Policies for Obstructive Sleep Apnea
By Rose Nierman, RDH
Nierman Practice Management
Premera Blue Cross Documented Attempt of a
Prefabricated Device and Occlusion Considerations
Premera Blue Cross Policy, Effective July, 1, 2016, for
custom molded and fabricated oral appliances (Code
E0486) the following criteria must be met:
Custom-made intraoral appliances may be considered
dentally/medically necessary as an alternative to a
prefabricated intraoral appliance, when the following
criteria are met: Documented attempt and failure of a
prefabricated device (E0485).
Documentation must include: 3 or more months of
clinical history indicating failure to successfully
wear a prefabricated appliance; OR Type II or type III
malocclusion so severe that a prefabricated appliance
would not be successfully fitted or worn.
Aetna Updates to Sleep Apnea Policy
A single panoramic x-ray of the jaws and a lateral
cephalometric x-ray are considered medically
necessary for the evaluation for an oral appliance
for OSA. A second lateral cephalometric x-ray with
the bite registration or oral appliance in place is
considered medically necessary to visualize the
mandibular repositioning and the changes in the
airway space.Replacement of oral appliances is considered
medically necessary at the end of 5-years. In many
plans, replacement of the appliance is considered
medically necessary prior to the end of the 5-year
Reasonable Useful Lifetime (RUL) due to a change
in the member’s condition.
Replacements needed due to misuse or abuse
are not covered.Cephalographic X-rays for diagnosis of OSA are
considered experimental and investigational.
The OSA oral appliance summaries listed below demonstrate
that oral appliances are indeed developing into a predictable
reimbursement option and that different insurers do vary in their
guidelines. For example, one insurer now requires documenta-
tion of any attempt and failure of a prefabricated device (E0485)
or the presence of a Type II or III occlusion class as criteria for
reimbursement of a custom device. Another considers payment
of a panorex and up to two cephalometric x-rays as medically
necessary while others will reimburse for a panorex or a single
radiologic scan only. Some of the Blue Shield policies state that
oral appliance therapy is medically necessary when there is an
absence of TMJ disorder or periodontal disease.
I’ve included two examples below (text emphasis
such as bold, or italic are mine):
Continued ➥

Another important takeaway from our policy review at Nier-
man Practice Management is from United Health Care’s (UHC)
“Medically Necessary Plans”DME policies which state:
Durable Medical Equipment (DME) and Related Supplies,
Prosthetics and Orthotics are medically necessary when:
— Ordered by a physician; and
— The item(s) meets the plans medically necessary
definition (refer to the plan specific document(s);
— CMS DME MAC criteria are met
— Item is not otherwise excluded from coverage.
Because the UHC policy states that“Medically Necessary Plans”
follow Center for Medicare and Medicaid Services (CMS) and
Durable Medical Equipment (DME) guidelines, it behooves
the office to inquire if the patient has a Medically Necessary
Plan. Medicare uses the Pricing, Data Analysis Coding (PDAC)
contractor to determine which custom made appliances are
approved to be billed under HCPCS code E0486 so if the insurer
utilizes Medicare’s coding guidelines, valid reimbursement
may require the use of a Medicare Cleared appliance. The list of
cleared appliances can be accessed at www.DMEPDAC.com.
Due to of these variations in policies, in order to not only
obtain, but to also retain reimbursements, it’s essential to
ensure that your narrative reports demonstrate a through his-
tory taking and exam with all of the information needed for
documentation. Also, with all the fluctuations in DSM and TMJ
treatment policies, it is essential for offices billing medical insur-
ance to take a refresher course in CrossCoding and
Medical Billing in Dentistry.
If you have any questions for us here at Nierman Practice
Management or would like access to the web links to the poli-
cies discussed, please email Contactus@DentalWriter.com.
Rose Nierman is the Founder and CEO of Nierman
Practice Management, the industry leader in helping
dentists implement sleep apnea treatment, TMJ therapy
and medical billing. NiermanPM has a 27-year track record
of providing the highest quality Sleep Apnea and TMJ
Continuing education along with DentalWriter™ Software
for narrative reports and documentation.
What’s New with Medical Policies... continued
The Australian Chapter has had another busy year fulfilling our
charter to educate and increase the knowledge of our mem-
bers in the complex world of Sleep and Craniofacial Pain.
Our membership numbers have remained quite stable and it
is always a challenge to increase the interest and membership
numbers in the AACP.
A strategy that has increased our numbers is to include Associ-
ate Members from the Allied Health Professions who form such
an important part of the multidisciplinary team required to
treat our patients successfully. We now have a significant mem-
bership of Chiropractors, Physiotherapists , OralMyofunctional
Therapists and other Allied Health Professionals. These Asso-
ciate Members are active supporters of our events and have
contributed significantly to our Chapter.
In the previous year, we have held 3 Local Chapter Meetings
and our annual International Symposium held in Sydney in
March this year.
Report from the Australian Chapter of the AACP
By Andrew Lee, DDS
Australian Chapter President
The Topics for our Local Chapter Meetings last year were:
— About Sleep: Thinking on the Bed and Outside the Box
— TMD: What to do when you haven’t got a Clue
— ENT Essentials: the ABC of Allergy in Dentistry
These Local Chapter days are held every quarter and usually
feature local Australian experts in their fields giving talks on
their areas of expertise. We try to make these clinically relevant,
and the topics are derived from ideas gleaned from our general
membership. We have had some fantastic speakers at these local
Chapter days and I would extend the invitation to all of our inter-
national membership to also attend one of these as I am sure
that you would find it enjoyable, useful and educational.
Our annual International Symposium was held in March this
year in Sydney and the feedback we received from the attend-
ees was fantastic. We were also delighted to host Ed and Lynne
Lipskis who were representing the AACP Board at our meeting.
We hope that both Ed and Lynne enjoyed the scientific presen-
tations and also the more social aspects of the Symposium and
their visit to Australia.
Continued ➥

Our Committee organised a stellar line up of international speak-
ers, some of the best in the world in their fields to present their
current research and information in their areas of expertise.
The Symposium was Titled: Neuralgias,
Myalgias and Other Pains in the Head.
Some of our world class speakers included Dr. James Fricton,
Dr. Lorimer Moseley, Dr. Gary Heir, Dr. Rafael Benoliel,
Dr. Manuel Graeber, Dr. Steven Scrivani, Dr. Daniel Clauw
and Dr. Tara Renton.
James Fricton gave us two talks on improving the outcomes for
patients with chronic pain and also a wide ranging review on
all of the treatment modalities for TMD and craniofacial pain
based on all of the recent published research. My conclusion
from his talks is that a lot more research needs to be done in
this challenging field.
Lorimer Moseley also gave us two very entertaining as well as
informative sessions on the brain and pain and the psychologi-
cal aspects of chronic pain, the perception of pain and how
the mind can be influenced in the treatment of chronic pain.
Lorimer is a gifted presenter and well worth seeing if you ever
have an opportunity to do so.
Dr. Manuel Graeber is one of the foremost NeuroPathologists
in the world and he gave us a fascinating presentation on the
role of astrocytes and glial cells in neuroplasticity and pain. The
highlight was his imaging with ultra high resolution MRI of the
cellular processes of astrocytes as they interacted with the neu-
ronal junctions. The technology of the imaging now available is
incredible and seeing live cells functioning in vivo was amazing.
Dr. Tara Renton gave us a rather disconcerting presentation on
post traumatic trigeminal neuropathy and left many of us ner-
vous about ever picking up a handpiece or forceps again as she
went through all the things that can go wrong in clinical prac-
tice and can have an adverse effect on the trigeminal nerve.
She also showed us a really neat keyhole surgical technique
for impacted third molar removal that I had never seen before.
Unfortunately, none of my local Oral Surgeons had ever seen it
either so they will have to cope with a higher risk of post- oper-
ative trigeminal neuropathies.
Local Aussie presenters, Radiologist Andy Whyte and Oral
Surgeon Ian Rosenberg showed fascinating imaging of
arthroscopy of the TMJ and the correlation of the arthroscopic
imaging and MRI of the TMJ. Many of us have never seen
images of an in vivo TMJ and it was most useful to actually have
a look at this joint that we treat in clinical practice.
Gary Heir gave us 3 presentations on 3 different topics and
showed the breadth and depth of his knowledge and was also
a most engaging presenter, making some dry topics interesting
and accessible for his audience.
Steven Scrivani showed functional neural imaging with high
resolution MRI during orofacial pain and headaches and gave
a second presentation on the pathophysiology of neuropathic
pain. The recent research he and his team have done in this
field has really expanded our understanding and it was most
instructive hearing from the coalface of research.
Rafi Benoliel gave us 3 erudite presentations on trigeminal
neuralgia, neurovascular pain and other uncommon facial pain
conditions and engaged and educated the audience in the
complex topics he was asked to present on.
Daniel Clauw gave us 2 presentations on the treatment of
chronic pain. He and his team are one of the foremost research-
ers in this field and again it was fascinating to learn what the
most current knowledge is about treatment of chronic pain.
We also had great presentations from some local Australian
specialists in orofacial pain in Drs. Rob Delcanho, Ramesh
Balasubramaniam and Dr. Mark Dexter.
The three days of the Symposium went by in a flash with hardly
a spare minute to relax as the programme was so jam packed
with great speakers and information. The feedback we have
had from the audience was uniformly excellent and it seems
that everyone thoroughly enjoyed the programme that we
had organised.
Planning for our next Symposium in 2017 is now almost com-
pleted and we look forward to hosting this again in Sydney on
the 17th-19th March 2017. This Symposium is titled—Sleep
and Pain: From Research to Reality and we have organised
another amazing line up of speakers including Professors
David and Leila Gozal, Giles Lavigne and Peter Svensson.
We also have 2 more local Chapter Meetings in 2016. The next
one in August 27th, titled: Medical Modalities for TMD
I would encourage any of the international and USA based
members of the AACP to join us at any of our meetings. Come
and experience some Aussie hospitality as you learn and I’m
sure that you won’t regret it.
To close this report, I’d like to thank the Committee of the
Australian Chapter. They have worked very hard all year in
organising our events. I’d also like to thank the AACP Board for
their support and a very special thanks to the President of the
AACP, Dr. Steven Olmos, without whom, there would not be
an Australian Chapter of the AACP.
Report from Australian Chapter... continued

The Canadian Chapter of the American Academy of Craniofa-
cial Pain (AACP) was founded at the 2007 Annual Meeting of
the AACP held in Denver. At that time, the goal of the founding
Canadian members was to create a network of support and col-
laboration for Canadian dentists and to facilitate the sharing of
an increasing amount of knowledge of craniofacial pain across
all regions of Canada. Very soon afterwards, sleep breathing
disorders were included because of their inseparable connection
to pain.
Our 1st Conference was held in 2007 and continued every
year and here we are this year at our 10th Conference!
This growth and success would not have been possible
without the loyalty and generous support of our members.
Over the past 9 years we had a line-up of excellent speakers;
to name a few: Dr. Mariano Rocabado, Dr. Gilles Lavigne,
Dr. Steve Olmos, Dr. Barry Sessle, Dr. Indira Narang,
Dr. Anika Isberg, Dr. Mark Abramson, Dr. Jamison Spencer,
Dr. Larry Wolford and many more.
This year’s conference theme is:
TMD, OSA Ortho... more than a structural connection!
For this year we have teamed up with another organization:
the North American Association of Facial Orthotropics (NAAFO);
this is a group that follows the growth guidance principles that
are defined by Prof. John Mew. You can find information about
this on their website: www.orthotropics-na.org.
Canadian Chapter Report
Chapter Gears Up for 10th Anniversary Conference
By Edmund K. T. Liem, DDS
Canadian Chapter President
For our 10th anniversary meeting we have another
impressive lineup of speakers; among the speakers will be
Prof. John Mew and his son Dr. Mike Mew; we will have
Dr. Deepak Shrivastava, Dr. Steven Olmos, Dr. Bill Hang
and many others. This year’s conference will be in beautiful
Vancouver, BC on Canada’s west coast. The dates are:
November 4-5, 2016.
Full information is available on our new website:
www.aacpcanada.org
If you have never attended our conferences, this might one
of the best time to do so. The city of Vancouver is spectacular
in its beauty and has many things to offer. For those who have
the US dollar as currency, you will have a substantial benefit
in the very favorable exchange rate (at this time a at least a
25% savings).
Please visit our website: www.aacpcanada.org for informa-
tion and registration. If you register early (before September
1, 2016) you will benefit from a discounted registration fee
and you will also receive all the video recordings of the pre-
sentations for free. We will do everything we can to make this
conference a memorable one!
Looking forward to greet you in beautiful
Vancouver, BC!
Call for Oral Examiners
Training Review Session
for Oral Examiners
Thursday, July 28, 2016
3:30 pm
Hilton Austin | Austin, Texas
Oral Examinations
Thursday, July 28, 2016
4:00 pm–6:00 pm
Hilton Austin | Austin, Texas
Your expertise would be greatly appreciated.
To volunteer to serve as ABCP oral
examiner in Austin, send email to:
mpateldds@me.com
Mayoor Patel, DDS, MS
ABCP Examination Committee Chair
(678) 984-9558

!!!
ABCP Plans for Austin Summer Symposium
By Jeanne K. Bailey, DDS
American Board of Craniofacial Pain President
The ABCP has been working all year in preparation for the AACP Summer Symposium.
The Board of Directors has not only been planning for the administration of the annual
ABCP written and oral examination process, but convocation and the summer ABCP
Diplomate luncheon meeting.
The written examination will be administered onThursday, July 28. Registration will
be outside Room 619 at our host hotel, the Hilton Austin in Austin, Texas, at 8:30 AM.
The written examination will be promptly administered from 9:00 AM until 1:00 PM
that same day. The oral examinations will be scheduled by appointment only.
Dr. Mayoor Patel and the Credentialing Committee will schedule the oral examina-
tions. Oral examinations will be held on Thursday evening, July 28, from 4:00 PM
to 6:00 PM and Friday, July 29, from 8:00 AM until 12:00 NOON.
Oral examiners will meet for examiner training at 3:30 PM on Thursday, July 28,
in room 619 at the Hilton Austin. The ABCP would like to thank all of the ABCP
Dilpomates who volunteer their expertise to administer the ABCP oral examina-
tions. Three examiners are assigned to each examinee to review three oral case
presentations. Examinees must present and defend an internal derangement
case, a myofascial pain case and a third case that can be either an internal
derangement or myofascial pain case. The coordination of examiner training
and scheduling three examiners per examinee is a challenging task, but the
Credentialing Committee handles the challenge extremely well.
The ABCP Diplomate members meeting and luncheon will be held from
12:00 PM to 1:30 PM on Friday, July 29, in Salon J of the Hilton Austin.
Salon J is directly adjacent to the General Session ballroom. At the meeting,
the Board of Directors will review the accomplishments for the previous
year. I would like to personally thank all the Diplomates who supported
the ABCP and me the past year. Thank you so much for your assistance.
The AACP convocation will be held on Friday evening, July 29, from
5:00 PM to 6:00 PM in Salon H (the General Session ballroom) at the
Hilton Austin. Many doctors and assistants will be honored during
the graduation/awards ceremony. Award recipients should report at
4:30 PM that day to room 602 to dress and line up for convocation.
Please plan to attend this time honored ceremony to recognize and
support the individuals who have worked very hard to continue
their education. The ABCP will honor and award four doctors who
earned their ABCP Diplomate status. The ACBP would like
to congratulate: Joseph G. Baba, DDS | Wichita, KS
E. Kyle Dalton, DDS | Little Rock, AR
John Halmaghi, DDS | Southfield, MI
Wennifred Sinyu Hsu, DDS | Hollister, CA
AACP’
s
31st
Annual InternationalClinicalSymposium | July29–30, 2016 | HiltonAustin | Austin,TX
LiveMusicCapitaloftheWorld

Approved PACE Program Provider
FAGD/MAGD Credit
Approval does not imply acceptance by a state or
provincial board of dentistry or AGD endorsement
3/1/2015 to 2/28/2018
Rondeau
Seminars
The Leader in Dental Continuing Education
Are your patients suffering from snoring
and sleep apnea? Learn how to identify
the patients who are already in your
practice who need your help.
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DIPLOMATE INTERNATIONAL BOARD OF ORTHODONTICS
DIPLOMATE AMERICAN BOARD OF CRANIOFACIAL PAIN
DIPLOMATE-ACADEMY OF CLINICAL SLEEP DISORDERS DISCIPLINES
DIPLOMATE AMERICAN BOARD OF DENTAL SLEEP MEDICINE
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In the January 2006 issue of the medical journal Sleep, the American Academy of Sleep Medicine recommended that oral appliances be the
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• Sleep Apnea Symptoms and Causes
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• Surgical Solutions for Sleep Apnea
• Comparison of Different Oral Appliances
• References and Articles
• Marketing Your Sleep Practice
• Sample Reports to Sleep Specialists,
MD’s, Dentists, and E.N.T.’s
• How to Bill Insurance Companies
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