DENTAL SLEEP MEDICINE
Insider February 2015
TIGHTENING THE EMA DEVICE The EMA by Myerson is fabricated by several reputable dental labs including Keller, Dynaflex and others. It has been one of my old faithfuls for years now because of its simplicity. It has a very low profile design which encourages patient compliance while also With Dr. Gy Yatros maximizing tongue space. However, over time, the trays occasionally lose a bit of retention. Sometimes, they even come back from the lab a
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bit loose. Naturally, that’s never happened using any of the labs I just mentioned (wink, wink!). But even when that happens, there is a simple tool you can utilize to add retention and get more life out of the EMA while also avoiding unnecessarily returning the device to the lab. Check out this short video to see how a pair of Hilliard Pliers can save you time and money‌.
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O “Like most dentists, I am a creature of habit, and now Uncle Sam was telling me that I could no longer use my devices of choice”
r at least I thought so. That was when Medicare decided that any device delivered to manage obstructive sleep apnea had to have a fixed permanent hinge. At that time, there was only one device that met that standard, and it made only by 3 labs! What was the device? A Herbst®! Like most dentists, I am a creature of habit, and now Uncle Sam was telling me that I could no longer use my devices of choice. Really, a clunky low tech Herbst; a device fresh out of the 80’s? Could it have been any worse? How were my patients going to deal with those obtrusive ugly metal tubes? More importantly, was this dreadful device going to work and manage the horrible symptoms of Obstructive Sleep Apnea? Guess what? I was wrong! In the 2 years since the Medicare edict, I have delivered a couple hundred Herbst devices to my patients and the clinical results have been beyond my expectations. Patients are generally accepting of the device and Physicians and sleep technicians find them easy to advance during titration PSG's.
Dr. Kenneth Mogell, D.M.D Boca Raton, FL
Nonetheless, there were limitations with the traditional Herbst. These have now been addressed with SomnoMed’s new SomnoDent Herbst AdvanceTM. Shorter metal tubes and 8.0 mm of advancement
capability are significant improvements from the customary Herbst device. The new device also eliminates the confusion regarding the direction in which to advance the screw key hole for protrusion, as it is now in the same upward direction on both sides of the device. Patients become easily confused when they titrate on their own and don’t necessarily advance the device symmetrically and knowing precisely how far a device had been protruded was always an issue with the conventional Herbst devices. I’m sure we have all experienced the patient who returns to the office complaining of muscle pain, only to discover they have advanced one side more than the other. SomnoMed has designed the Herbst Advance with a visual calibration indicator that will tell you exactly how far the device has been advanced from its start point. With it, asymmetry in titration can be a thing of the past. Change in a time-honored device like a Herbst was inevitable. SomnoMed listened to dentists practicing dental sleep medicine and made modifications that have been game changing. Because of these enhancements, I have made the Herbst Advance my primary choice for an oral device to manage my patient’s obstructive sleep apnea.
By Dr. Stacy Ochoa
It’s happened to many of us. We’ve marketed our Dental Sleep solutions to our patients of record. We’ve had brochures in the lobby. We’ve screened almost all of them. Hygiene has identified patients with the signs and symptoms of SDB & we’ve walked them through testing and when appropriate, we’ve treated them with dental devices. Now, what do we do? The low-lying fruit has all been picked and you’ve gotten a hankering for treating more patients with OSA because, well, because it is REWARDING in every way; it’s personally satisfying, it’s interesting, and it adds revenue to the practice, BUT NOW WHAT? Where do new sleep patients come from??? I’ve tried multiple different avenues. Billboards didn’t do well for me. I’ve heard that others have had more success. Maybe it was placement, maybe the messaging, I’m not quite sure but it wasn’t a valuable allocation of my resources. I’ve made some TV appearances that worked well, but those are few and far between. Radio ads have done very well for my practice and even
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though the return on investment (ROI) has been outstanding, the financial outlay can be significant. So, where do new sleep patients come from??? My highest ROI has been from presentations we’ve presented to the public, to prospective patients. It’s really very simple, costs very little, and has produced anywhere from 2-4 OAT patients from each meeting. Contact local civic organizations such as the Elks Lodge, the Kiwanis Club or other groups. You can also take out a small ad in a local newspaper. Promote the event as a FREE PRESENTATION about how readers can get energy back, sleep better, and possibly get off of their much maligned (ALTHOUGH EFFECTIVE!) CPAP. Either organize the presentation to be held during one of the organizations’ regularly scheduled meetings or book a room at the local library, a small coffee shop, or other frequented, wellknown meeting place. When doing this, consider your target demographic so DO NOT BOOK THE CHAMPAGNE ROOM AT THE HOT NEW NIGHTCLUB!!! I’ve spent as much as $100 on a room and as little as zilch in other situations. Then, either an articulate, knowledgeable staff member that believes in what we’re doing, you, or another individual can present a 30-45 Powerpoint defining the problems inherent to sleep apnea, the importance of a medical diagnosis, and your potential dental device solution. You’ll find that a significant number of attendees have already been diagnosed and are present because they are CPAP intolerant. This addresses one of
the common issues I experience with referrals I receive from my radio ads; many of those patients are undiagnosed. As I said though, many of the people that come to these public seminars are seeking a CPAP alternative. Consider this… On the high end, I have spent $100 for the room & 90 minutes of my time speaking to a group and answering questions. This resulted in 4 new OAT patients. I’m making this dollar amount up for the sake of this conversation, but let’s say your fee is $2,500. Using this algorithm, I was able to dramatically improve 4 peoples’ quality of life and make $10k with an investment of $100. Fine, even if you factor my time at (again, NOT a real number) $500/hour, that’s $10,000 total collections - $750 my time ($500 x 1.5 hours) - $100 room rental = $9,150. That is an extremely low cost of acquisition with a significant ROI. Dental Sleep Solutions provided me with the Powerpoint so all I had to do was spend 10 minutes customizing it with my practice info & I was set. I’m not suggesting this approach will work for everyone BUT it has been successful in my hands and several of my colleagues have experienced similar results.
Contact Cindy Herbert at Dental Sleep
Solutions for a FREE copy of the Powerpoint presentation she sent to me. cindy@dentalsleepsolutions.com 877.95.SNORE
877.95.SNORE
RECAPTURING THE BITE
facial on upper teeth and from the lingual on lower teeth.
Fx Fy By. Dr. Richard Drake
So…now, you’re making Mandibular Repositioning Devices (MRDs) for your patients who have been diagnosed with sleep apnea. They’re sleeping better, feeling better; they visit their doctor and the hospital less often; they’re healthier and happier……but you’re not……..because (insert expletive of your choice here) their bite has changed a little. All treatments have side effects and our MRD’s are not immune. Go back to high school for a moment. For me, the 70’s…..long hair, bell bottomed pants, Rhonda Lee…..and Mr. Anderson, the geeky Physics teacher, talking about force vectors. F = ma. Torque = rf sin theta. The maxilla is attached to the cranial base, and our MRD’s anchor themselves to the teeth which then hold the mandible in a slightly open and forward position. The patient falls asleep, and the lower jaw wants to fall back, closing the airway and starting the downward spiral of negative physiologic events that surround hypoxia. BUT our MRD doesn’t let this happen. As a result, presssure is placed from the
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B
F
As a result, upper teeth can move back, and lower teeth can move forward. We know this; Dr. Alan Lowe from Canada has studies that follow MRD-wearing patients for years. But wait, my device is hard acrylic, and it still fits, how can this be? I’m not exactly sure, but my bet is that the slow and steady force actually moves the acrylic and plastic as well as the teeth. Pure conjecture on my part though… So what tends to happen from long term use of MRD wear, and is there anything we can do to slow it down or better yet prevent it? In a nutshell:
Maxillary teeth shift back Mandibular teeth shift forward Posterior open bites can develop
My partner, Dr. Gy Yatros, and I, have made thousands of devices and followed some patients for decades. We’ve read a few studies and learned a thing or ten along the way. A couple of patient experiences come to mind. Eloise, an elderly sweet lady, swears she has worn her EMA every single night for over
ten years. That’s 7-8 hours a night, for ade, or 3650 nights, or about hours. Her bite has not changed. N single angstrom. Locked in. Solid. Wh bites change? Baaaa humbug!
And then there’s Samantha, a 50 som executive who got her MRD and th week moved to Brazil. She came back years later, thanking me for her increas ergy level and joie de vivre. She, too, ha her device every single night. Bite you together, Samantha…..YIKES! Can you your back teeth touch? They’re not ing? No. In fact, I could get my fat little completely between her po teeth. She was completely WARE her bite had changed. Her teeth ha moved, but her condy not sitting in the fossa; slid down and left he open. There you have it, the tw tremes. Everyone else w somewhere between.
Summary:
AM Aligner or Morning Repositi tongue retruding exercise, and push EVERY day, first thing in morning, until bite feels norm Helps to keep teeth from driftin condyle in place.
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From the top secret vault at Dental Sleep Solutions, we now bring you THE 10 MUST DO’S regarding bites: 1. Every patient signs an Informed Consent. 2. Speak to every patient and make them acutely aware that bites can change. 3. Document their bites / teeth position BEFORE you start. 4. Every patient gets an AM Aligner or Morning Repostioner. 5. Every patient gets coached on how to use the AM Aligner, along with tongue retruding exercise and chin push.
6. Document bites / changes at each follow up visit in DS3. 7. Consider augmenting MRD therapy with PAP therapy for all patients but especially for patients whose bites start to change. Also note that PAP has been shown to change bites.
8. NEVER consider telling a patient NOT to wear his dental device unless he has PAP therapy to fall back on.
9. Remember that it’s easier in most cases to keep bites from changing than it is to try and recapture them after they’ve changed.
10. Do everything you can to keep bites from changing, but if they do, don’t fret. It beats dying. You can recapture posterior open bites, as we did with Samantha. She stopped wearing her MRD, started PAP therapy, and we utilized a Morning Repositioner several times a day, combined with tongue retruding exercises and chin pushes. It took about four months, but we did get her posterior teeth back together.
Learning By Dr. DeWitt Wilkerson
is More Than Watching By Dr. Steve Carstensen
offices every day.
If you are looking for rewards in dentistry, there is nothing like treating sleep patients. People who thank you for making their lives so much better, for giving them energy, and for helping them have hope for a long, fulfilling life are in our
If you treat sleep patients, you already know this. If you are curious about adding services to serve your patients to this level, you have lots of choices. Dental Sleep Solutions has wonderful videos to watch and share with your team. You can attend excellent lectures at a dental conference near you. Or, you can get involved with hands-on learning in a supportive community where participants work side-by-side with 7 experts from medicine, dentistry, and industry who will prepare both novice and experienced sleep
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dentists to treat their sleep disordered breathing patients. At the Pankey Institute, the days are spent learning from Dr. John Remmers, the physician who discovered obstructive sleep apnea, with lectures and hands on training with dentists who have over 15 years each treating patients like yours every day. Dr. Gy Yatros, founder of Dental Sleep Solutions, is there for you every day. Even the evenings are used for less formal story-telling to round out the learning sessions and discuss what’s on your mind. Tuition for this four and a half day course also includes your own custom made appliance, a remoldable professional temporary appliance, and a personal sleep study so you are ready to share your own experience with your patients and your team. You will be ready to make a difference in their lives, and in your practice, right away. The Pankey Institute understands you
don’t maximize the impact of new skills all by yourself, so we include on the faculty lab professionals who have been involved since the beginning of oral appliance therapy and expert team trainers so you know exactly how to lead your team when you get home. We want you to take action, to make a difference in your community health, and to feel the value for the time you spent learning. You will sit with your patients, working hard to hold back your emotions as they share their success with you. That’s what Pankey does. Find out more at www.Pankey.org. Our next Sleep Course starts April 24th.
“I love the A-Z concept. It gave me what I need to fully implement.” Dr. Jorge Angulo
WHEN CE IS SOOO MUCH MORE By Staci Holbrook
“The course was extremely informative and user friendly, very practical information. All speakers gave us a wealth of info that will help our office to move to the next level and build a future in dental sleep medicine with DS3. Thanks to everyone at DS3 for your help and instruction in getting started. Cindy, Staci, & Brandie gave us excellent training and helped us to get set up. The course offered everything we needed and we look forward to working with DS3. Thanks also to Jason for being so accommodating & tailoring the parts of the presentation to meet our needs.” Sharon Camerino
“I can honestly tell you, I was actually dreading this course becauseIthoughtitwouldbe so boring. I am so thankful I came and feel completely different about dental sleep medicineandlookforwardto addingitinourpractice.” KellyMcLane
CE is ubiquitous. It’s online, in your mailbox, at the study club, EVERYWHERE! But, is all CE created equal? When was the last time you sat through a day long commercial masquerading as education? Equally as frustrating can be an overly academic course in which the content has ZERO real world application. Have you been to other Dental Sleep Medicine courses, only to leave feeling a bit smarter but still not knowing how to develop the info into a workable patient flow that actually makes money for the practice? What do you want in a CE experience? Do you want an engaging speaker? An interesting topic about a product or service that could make your practice more efficient, improve patient outcomes, and generate more production? Hands-on experience? Do you want your team involved to solidify their buy-in so you’re not met with the standard “Monday-after- the- course” resistance? I could wax poetic about the quality of Dental Sleep Solutions courses but I’ll just zip it & let some past course attendees tell you what they think. Read on and then CONTACT ME TODAY to register you and the team for an upcoming course.
1.877.95.SNORE staci@dentalsleepsolutions.com
“When you sign up with DSS, you’re not just getting a software package. You are joining a team that provides tremendous knowledge and experience to help you treat your patients. They truly care about you and your success. They will motivate, educate, train, and encourage your team to succeed.”
“Well presented and organized! Best common sense andpertinentinfodeliveredin asleepcoursefordentistsand staff wanting to implement dental sleep into their practice.” Dr.DougJungmann
MEMBER
DSS Office Manager
Contact Dr. Layman at www.GoGobilling.com or call 877-874-GoGo (4646) ext 2
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1.877.95.SNORE
why take the gamble?
cially posted on the Medicare websites for the E0486 code, however we have seen The options are as follows 1) Opt allowables from A $1700.00, B $1321.61, out of Medicare 2) Become a parC $1032.37 and D $1320.00. Medicare ticipating provider 3) Become a will pay 80% of the allowable, if the panon-participating provider. tient, but if the patient has supplemental Let’s break each of these insurance they will pay the additional options down to simpler 20% up to the allowed amount and payterms. ments go to the provider. The upside is case acceptance is 90% to 100% and you The easiest thing can start right away and not have to wait to do is to “opt on a pre-authorization. out” of Medicare. Then Medicare non-participating provider; you’re set for same set of rules but more money, Yatwo years. After hoo! The provider charges full fee and the the two years are up, patient makes payment to the provider. you need to opt out again Medicare pays 70% of the allowable, and or choose to become a provid- supplemental will pay the additional 30%, er. In order to opt out of Medicare both payments being sent to the patient. successfully, a signed ‘opt out affidavit’ is Case acceptance will go down but keep in mailed to your designated office. Once ap- mind you can sign up as a nono what is the answer? There are proved, Medicare will mail a letter to keep participating provider and decide on a three options, and you get to choose one. on file and it can be used as a denial to sub- claim by claim basis to accept the assignBecoming a Medicare provider is a big mit to any true secondary insurance plan. ment or not. decision and can be daunting, but it is When a patient presents for treatment, you something all dental offices will have to must formally inform them that you are not For more information and the complete decide once they delve into the world of a Medicare provider and they will not reguidelines for treating Medicare patients treating sleep apnea. Most ignore the big ceive any benefit or reimbursement for a please email me and I will be happy to looming question and figure they will covered service. The patient must sign the send you the guidelines as well as a list of make a decision at some point. Let me tell opt out patient contract and you keep it on approved devices. GoGo also offers Mediyou why this is not the best strategy. file with their chart. No doubt that opting care DME credentialing services for out of Medicare comes with little hassle, but 999.00 and for guidance in opting out I’ll We all know the saying “we don’t know is this the best decision for your practice? I help…FOR FREE! what we don’t know” but in this case, not suggest you evaluate all your options before knowing won’t act as an excuse or deyou turn your back on the old folks. Let’s Stay tuned for my next article on Medifense to save you from Government fines consider the other options Medicare has to care, Supplemental Vs Secondary. and penalties. Dentists have never had to offer. deal with Medicare because dental work has never been a covered benefit. Treating Medicare participating provider; oh fun! a medical condition such as sleep apnea Lots a rules and not a lot of payment but with an oral appliance, IS a covered bene- you can feel good about helping your comfit and now you fall under the same guide- munity and the referring sleep doctors and lines as medical providers. Did you know physicians love it. Misery loves company, that treating a patient who is covered unthey say! “Participating” means you are der Medicare, and having them pay for willing to accept the allowed amount and services and simply stating “sorry I don’t not balance bill the patient over and above Lesia Crawford, take Medicare” is a federal offense? Yes the said amount. There are four jurisdictions CEO, GoGo Billing folks, it is! Not only could you be forced in the country and each has a different al877-874-4646 ext. 1 to pay the patient back, but you could be lowed amount. The allowables are not offifined as well. The odds may be low, but info@gogobilling.com
S
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Why mess with faxing and keeping track of paper when you can scan it in once and forget it?
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GoGo now has the perfect billing solution thanks to DS3's secure back office. Instead of filling out super-bills, faxing supporting information and emailing. Just request a VOB(verification of benefits) with a click of a button GoGo is notified and has access to all the patient information to get to work.
Using technology to bridge the gap between office and billing team, GoGo can now offer a simple and seamless billing solution using DS3.
Per Patient set up fee ...$40.00 Benefit call.....................Included Pre-auth and GAP..........Included Claim submission...........Included Appeals..........................Included % of claim payment ......9%
www.GoGobilling.com 877-874-GoGo (4646) 8700 E Vista Bonita Dr. Scottsdale, AZ 85255 Contact Lesia Crawford ext 1
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