ARNOLD L CHASSANOFF, DMD Diplomat, American Board of Dental Sleep Medicine
REFERRAL for ORAL APPLIANCE THERAPY
to DENTAL SLEEP MEDICINE of CONNECTICUT ARNOLD L CHASSANOFFDMD, D,ABDSM
FOR MEDICALLY NECESSARY TREATMENT
Date:
Referring Physician:
Patient Name:
Dr. Chassanoff,
The above patient has opted to pursue the modality of Oral Appliance Therapy.
Please consult with and evaluate regarding Oral Appliance Therapy for the treatment of sleep disordered breathing.If the patient meets the criteria for oral appliance therapy, please proceed with the proper dental/medical workup and treatment at the patient’s earliest convenience.Following delivery of the appliance proceed with short term titration procedures and long term follow up care.Please provide me with ongoing assessment of patient care and refer the patient back to me when you determine that they are ready for a follow up sleep study.
1. Primary Snoring 2. UARS, mild and Mod. OSA 3. CPAP Failures or Hybrid Cases 4. Min. 8 Teeth per Arch 5. Min. of 5mm. mandibular protrusion 6. Patients that travel 7. Very good results with surgical failures 8. Tongue Stabilizing Device for: edentulous patients, active TMJ issues
BRIEF OUTLINE OF OUR PROGRAM
1. Evaluation for oral appliance therapy 2. Selection of design 3. Insurance determination, financial arrangements 4. Fabrication and delivery of oral appliance 5. Titration, monitoring, home sleep test 6. Collaboration with MD for overnight PSG
