VADDS

OP = Original Poster No need to convince me. But, you should know what you up against. I wrote exactly what I would tell you if we were meeting to discuss your dental eligibility. VADIP came about primarily to provide an option for Veterans not eligible for VA out-patient dental care. However, any Veteran, dental eligible or not, can enroll. Same premium, same benefits. It is going to take a strong grass-roots push for elected officials to vote to extend dental eligibility to cover all Veterans for dental problems secondary to service connected diseases. Senator Bernie Sanders, has introduced a bill that would provide dental care to all Veterans. People should write their Senator and request they support the bill. At this point, it has no chance of passing.

Class IIa does not apply to bruxism. Service Trauma is defined as a line of duty related injury to teeth by an external force. Combat or training injury, getting hit by a tool, even a car accident while on AD all qualify. Bruxism, or just biting on something hard are not considered service trauma. It would be a mistake if VBA rated the OP for bruxism. The VBA classifies bruxism as a neuromuscular symptom of stress, not a separate disease. Bruxism has no disease diagnosis code, no rating criteria. Contrary to what the dentist told the OP, it is now widely accepted that PTSD may cause or worsen bruxism. Most likely, during the course of completing the TMJ DBQ, there was evidence of a disorder in the joint. Since bruxism may cause a TMJ disorder, the OP was granted TMJ secondary to the PTSD, at 0%, based on the ROM measurements. Class III and VI eligibility rules are clear: The dental treatment must have an evidenced based, direct impact on the medical condition. Examples include removing infected teeth before joint surgery or heart valve replacement. There is substantial evidence in the medical literature that a dental abscess can seed a prosthesis with bacteria, having potentially catastrophic consequences. Providing dental to a PTSD patient may improve overall health, but the same can be said about providing needed dental care to anyone with any disease. it seems logical and fair that the VA provide dental care to correct problems caused by a service connected disease or its management. But, that is going to take a change in the CFRs, which means complaining to your elected representative, not VA Eligibility or the dental clinic. Besides bruxism, a whole lot of damage to teeth is caused by the dry mouth people get from many different drugs. For the VA to absorb this potentially huge new workload, it is going to take more dentists, more clinics, more money. Again, all of this has to happen in Congress. There is absolutely nothing in the VADIP programs that exclude service connected conditions from coverage. The OP was given bad info. By the way, I think Metlife has a better program, since its high option has a $3000 yearly cap.

Jon: Check out the links in jbasser's post, see what makes sense for your situation. For most Vets, the Metlife High Option Plan makes sense: - It has a $3000 per person annual limit - NO waiting period for anything other than orthodontics. - $3000 will pay your cost share for $6000 worth of major dental care. - A network dentist will also have agreed to Metlife's fee reimbursment rate, meaning: your cost share for intermediate and major procedures will be for a fee significantly less than if you just walk in off the street. Also, if you exceed your yearly maximum, additional care will be billed to you at pre-negotiated network fees. - Exams, xrays, and routine cleanings are covered at 100% and do not count against your yearly maximum per person. - Emergency visit coverage, plus having a dentist who knows you and will accomodate you if you do have an emergency. - A big benefit of a comprehensive dental insurance plan is to take full advantage of the preventive services offered: twice a year exam and cleaning, etc. Prevent major problems by ctaching them when they are not so severe.

I believe your original question was about alternative treatment modalities for OSA. I mentioned max-man advancement. It is very effective for Obstructive apnea. Below is just one Abstract from the current literature. If you are as desperate as you say, I suggest you ask for a referral to a VHA Facility that has the Oral Surgery Staff to perform this type of surgery "Although nasal continuous positive airway pressure therapy is considered the first-line treatment of obstructive sleep apnea, surgery has been shown to be a valid option for patients who are intolerant to positive pressure therapy. In the past 20 years, maxillomandibular advancement has been widely accepted as the most effective surgical therapy for obstructive sleep apnea syndrome. Maxillomandibular advancement has been shown to enlarge the pharyngeal and hypopharyngeal airway by physically expanding the facial skeletal framework. It has also been shown that the forward movement of the maxillomandibular complex increases tissue tension. This decreases the collapsibility of the velopharyngeal and suprahyoid musculature and improves lateral pharyngeal wall collapse, all of which have been shown to be significant components contributing to the upper airway obstruction in obstructive sleep apnea. The outcome of maxillomandibular advancement has been extensively reported, with success rates of 57% to 100%. A recent meta-analysis of 627 patients from 22 studies showed an overall success rate of 86%. The long-term follow-up of 56 patients for 43.7 months from 3 studies showed a surgical success rate of 89%. These data are similar to my experience with an 89% success rate in more than 600 maxillomandibular advancement procedures performed. Copyright © 2011 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserve"

Not every person with OSA is overweight. Anatomical changes that develop with aging reduce the caliber of the posterior airway space is a cause. But, the research is overwhelming that weight gain is a major factor in the severity of a individual person's disease and weight loss improves the condition in the majority of overweight people with OSA.

I don't mean this facetiously: lose weight, a lot of weight. Most patients' OSA improves dramatically with weight loss. Hard to do, but better than dying. I have recently dropped 35 pounds and the difference in my sleep quality is amazing. My wife checks me to make sure I am still breathing, it is so quiet. Pharyngeal, Uvular, and nasal surgery do very little for most patients. There is a drastic surgery that does: Bi-Max Protrusion The maxilla is detached and moved forward. The mandible is also surgically advanced. This is also called "orthognathic surgery" Braces are usually required to create a stable new bite. Moving both jaws forward increases the caliber of the posterior, inferior pharynx, where most apneic episodes start. It also pulls the base of the tongue forward. An oral surgeon who would do this surgery would use both MRI and CT to predict if the changes in an individual patient justifies the surgery.

For the one-time dental benefit after release from active duty, the discharge must be other than dishonorable. From the Dental Program Handbook, 1130.1: 1. In the case of Gulf War Veterans (which includes Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn Veterans), they must have served on active duty and been discharged or released, under conditions other than dishonorable, from a period of active military, naval, or air service of not less than 90 days. For others, they must have been discharged or released, under conditions other than dishonorable, from any other period of active military, naval, or air service of not less than 180 days. I bet the same applies to all VA care.

john999: Would your local VA dental service not make a dental device for you?

Something else to consider: For those of you who are struggling with high pressures: There is clinical research out there documents wearing the dental device while wearing the mask lowers the pressures needed to treat the apnea

If you haven't done so yet, try a Breath Right Nasal Strip. That will tell you how much the deviated septum is contributing. Personally, I'd do the dental appliance first. If it doesn't work out, all you've lost is two trips the clinic.

Our Sleep Lab sometimes refers a Veteran with moderate/severe OSA to my service, to make a dental appliance, when the patient does not want/tolerate CPAP. A custom made device is effective, just not as effective as CPAP. Rule of thumb is that an appliance reduces the apneic episodes per hour by 50%...enough to make a difference. Studies show a dental appliance is more effective than upper airway surgery. An appliance and upper airway surgery combined is more effective than either therapies alone. The VA's Central Dental Lab is licensed to fabricate the TAP-3 OSA appliance, one of the best on the market. Many VA dental services accept Sleep Lab consults under the eligibility provisions of "Medically Adjunctive Care". Ask your sleep doc if the VA dental service there offers that service, and submit a consult if it does.

Dental insurance Programs may be worthwile if you are someone who makes maximum use of the exam and prevention benefits that are covered at 100%. If you put aside money and wait for something to come up, the something that comes up may be very expensive to treat. Another advantage of insurance is that a network dentist has agreed to a certain fee schedule. With insurance, you may $350 of the $700 the dentist has agreed to take from the insurance.Without insurance, you'll pay the dentist's full fee, $1000 or more.

There is a lot of published information on what the terms of the dental insurance program will be. Just Google: "ChampVA dental pilot" You'll find the the specifics of the benefits, the VA has asked insurance companies to submit bids to provide. The key in the request for the "proposal" is the term: "The program must be completely self-supporting," In other words, enrollees will be bearing all of the cost of the entire program, including the insurance company's profit. It is going to be very similar to TRICARE Retired Dental Insurance Program. It will be premium based. Some things will be covered 100%, most will have co-pays. The VA also submitted a Cost Impact Analysis to Congess for the program. Cost to taxpayers was estimated to be just a few hundred thousand dollars a year, just enough to hire a couple of GS employees to manage some administrative tasks. Unfortunately, anyone waiting for this program with high expectations is in for a let-down.

Yes, in addition to QTC, a provider can have a personal services contract with VHA. 4 years ago, one of my San Antonio C&P exams was by a QTC doc, off of Fredericksburg Road, if I recall, near the Medical Center. The audiology was done by an ENT in a private office, northeast part of town. Not sure if he was affiliated with QTC, or had a separate contract.

Some C&P exams are performed by QTC Medical Services, whiich has a contract with the VBA. QTC personnel work for QTC, not the VBA or VHA. Most C&P exams are performed by VHA personnel, either GS or fee-employees. In my System, all C&P exams are performed by VHA staff or fee consultant part time employees.

Unless you requested to be seen by a primary care provider, they had no business requiring you to do so. Eligible vets are entitled to direct access to dental care, never setting foot into another VA clinic if they so choose. The reason vets, only wanting dental care, are misled into seeing a PCP is so a "vesting exam" can be documented, which gets that facility several thousand dollars, supposedly to treat the "new" patient. It is about dollars, not the vet's health or safety. As far as San Antonio? Lived there for 15 years, can't wait to get back.

I don't know about the rest of it, but the VA will provide one episode of dental care to a separating soldier, provided they are discharged under other than dishonorable circumstances.

Berta: Another dental example is tooth decay caused by dry mouth, which can result from medications, and most especially after head and neck radiation for cancer. There is currently no way to compensate a veteran for damage to teeth that results from the medical treatment for another disease. The VA actually proposed rule changes last year to establish a disease diagnosis code for salivary gland disease. One of the proposed rating criteria is an increase in dental decay. A 10% rating has been proposed for dental decay caused by either primary salivary disease, or secondary to treatment of a service connected medical condition.

If the vet was awarded 20%, it was for the TMJ disorder, secondary to PTSD associated bruxism. There are no rating criteria for bruxism, there is no disease diagnosis code for bruxism. It is literally impossible to assign a percentage to it. Bruxism is now widely accepted to be caused or worsened by PTSD. TMJ disorders may be exacerbated by bruxism. VBA is granting bruxism/PTSD related secondary TMJ service connection. As always, the percentage is based on ROM and the Deluca Factors' impact. The BVA decision posted here made a ruling that the bruxism was service connected. The BVA decision was probably the end point of a process that began 3-4 years before the decision, when there was still controversy about the connection between PTSD and bruxism. That issue is settled: bruxism is associated with PTSD. A rating decision is not required. It is a symptom, like insomnia or night terrors. De facto, it is service connected. What changed for the vet as a result of the BVA ruling? The vet can't be compensated for the tooth damage. The vet did not become eligible for VA dental care. If bruxism ever becomes a compensable dental disability, the vet would have to undergo a C&P exam with rating criteria applied, along with every other vet claiming a disability for PTSD associated bruxism. But first, the VA rules would have to be amended to create a disease code for it, decide what rating series it belongs in, and establish rating criteria to assess the severity of it. Here is the bottom line: If a vet with PTSD and bruxism develops a TMJ disorder, file for the TMJ secondary to PTSD. That is now a straight shot. Filing for bruxism alone will get you nowhere

Berta: It is perfectly appropriate and reasonable to file for secondary connection for TMJ, if the TMJ was caused by PTSD associated bruxism. That was not the issue under discussion. What I stated was that it will be inappropriate for VBA to rate and grant service connection for bruxism, until and unless the VA requests a rule change to to the CFRs to create a disease diagnosis code for bruxism, add it to the 9900 Series, and establish criteria to rate the severity of it.

The undertone of your question is that you are familiar with the CFRs, and I'm inventing something not contained in them. What I posted is latest VHA and VBA Policy, based on interpretation of the regulations as they have existed for years, applied to a relatively new issue. The policy directive to not grant ratings for non-compensable dental conditions was contained in a letter from the VBA's Director of Compensation to all VAROs, about 2 years ago. I've cut and pasted the letter in VBN. The CFRs contain the rating schedules, including the 9900, aka dental series. Bruxism is not one of the compensable dental conditions. So, unlike say TMJ disease, there is no legal authority to grant a disability rating percentage to it, and confer Class I dental eligibility. Nor is it in any other rating series. There are no criteria to assess the severity of it, there is no disease diagnosis code for it. The damage to the teeth from bruxism is a visible side effect of a PTSD symptom: abnormal neuro-muscular activity associated with the high stress state. The issue is not whether or not PTSD is associated with bruxism. There is much literature to support that it is. The issue is that the damage to the teeth is not rateable.

A couple more thoughts just on the bruxism part of your post: 1. BVA appeal decisions do not establish precedence. They apply only to the appeal under review, based on a host of variables individual to each appeal. When the issue of PTSD and bruxism first appeared, there was a lot of confusion and mis-information on both the VHA andVBA sides of the house. The presentation I referenced reflects the evolution of a consenus of opinion on how VBA manages bruxism claims. 2. The "favorable" citation establishes what I said in my earlier message is now widely accepted: PTSD can cause bruxism. To establish service connecton for it, the MH provider treating the vet only needs to document it in the vet's medical record as part of the PTSD notes. It does not require a VBA rating decision to establish service connecton for it. What current US Code does not do is provide for compensation of bruxism, whether primary or secondary. Nor does an individual's PTSD related bruxism create eligibliity for treatment of it.

Bruxism is a symptom, not a rateable condition. There is no disease diagnosis code for it, nor rating criteria. It is well documented, widely accepted that bruxism may be caused by PTSD or other stress disorders. TMJ disorders are dental disabilities that are compensable. If you develop a TMJ disorder in the future, damage to the jolnt may well have been caused by the bruxing, and you could file for TMJ disorder secondary service connection. This isn't my opinion. It is from a recent presentation by the Chief of Quality Assurance for Medical Disability Evaluation, VBA Central Office.

Many VA dental services are struggling to keep up with demand. An exam every two years is the goal of the current national quality metric, and many services are falling short of even that. Another big issue in VA Dentistry, as this string attests to, is that there is no defined or standard benefit that should be provided to every eligible vet, no matter where they live. It is luck of the draw whether you live near a VA facility that provides cutting edge care, or one that provides only basic services. Most are somewhere in-between

Papa: It's nice of you to share your positive experience with VA dental. Yes, the bar is high for VA dental care eligibility. For those who are eligible, national patient satisfaction surveys show most vets are very happy with the care they receive.