December 2020 Dental Sleep Medicine Insider Magazine by dentalsleepsolutions

DENTAL SLEEP MEDICINE

Insider

MAGAZINE

December 2020 Issue 37

EVIDENCE THAT DEMANDS A VERDICT BY DR. KEITH THORNTON, DDS

OVERCOMING THE FOUR REASONS PHYSICIANS RESIST OAT

TREATING ALL PATIENTS INDIVIDUALLY

THE HIDDEN VALUE OF SLEEP PATIENT REVIEWS

Mark T. Murphy, DDS, D-ABDSM shares data on why physicians have resisted prescribing OAT more often and why that trend is changing.

Justin Elikofer, DDS, defines success by realizing that there is no “onesize-fits-all” treatment and that each patient needs to be counseled differently for optimum results.

Marc Fowler, Founder at Bullseye Media, discusses the importance of online patient reviews, how to use them and the role they play in promoting your DSM practice.

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FASTTRACK

CALIBRATIONYOUR TECHNIQUES PRACTICE?

You’ve given your patient their dental sleep device ... now what? How do you

know it’s working? What are the follow up protocols and the criteria for success? How do you test the results?

If you send the patient back to the sleep doc and he does a titration study, you only get to test a single position? Few things are more frustrating than testing a patient at 50% of his max and the sleep report says “Dental device is not working; patient needs to return to CPAP.”! This is where many Dental Sleep Medicine (DSM) dentists fall short, but it doesn’t have to be that way! One of the most common challenges for dentists new to DSM is knowing what to do after they deliver a device to a patient. It stands to reason because dentists are accustomed to taking impressions (or today, digital scans) and fitting devices into patients mouths. We are great at grinding on acrylic, making precise margins and fitting restorations to ideal occlusion.

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GY YATROS, DMD

Defining Success At the root of the dentists’ frustration with this step of DSM is the lack of an adequate definition of success for the DSM patients. Each sleep expert you speak with may have a different view on success. Physicians primarily seem to hang their hats on AHI, while dentists and patients may consider success by vastly different benchmarks. This ambiguity and inconsistency understandably frustrate dentists’ meticulous training.

Although there are numerous ways to define DSM success, most everyone involved agrees that success should involve the following three criteria:

You can play with the numbers below, but you should get the idea. Both compliance and efficacy are equally important in treatment success!

1. Treatment Compliance 2. Relief of subjective symptoms associated with their Sleep Disordered Breathing (SDB) 3. Objective Success

TREATMENT SUCCESS = COMPLIANCE X EFFICACY LET’S LOOK AT TWO EXAMPLES: [ CPAP EXAMPLE:

Compliance = 50% and Efficacy = 100%

Treatment Success = 50% x 100% = 50%

[ DSM EXAMPLE:

Compliance = 100% and Efficacy = 70%

Treatment Success = 100% X 70% = 70%

GY YATROS, DMD, DABDSM CO-FOUNDER OF DSS & DS3

Calibration Methods When discussing calibration methods, we focus on the following; with an emphasis on what we call our FastTrack Calibration method. 1. Sleep Lab Calibration 2. MATRx Plus 3. FASTTRACK Calibration While the first two have their advantages, FASTTRACK allows us to test the patient on multiple nights at multiple positions and to utilize that information to obtain the patient’s target position. Once we know the target position, we can have

the patient more slowly advance to that position during weekly adjustments. Once the patient reaches their final position, they should be referred to their other healthcare providers along with all the appropriate documentation. It is the responsibility of the patient’s PCP and other healthcare providers to assess the overall treatment effectiveness and provide any further treatment recommendations. We hope this information provides a pathway for you to help more patients sleep better, live better, and live longer. Our daily goal is to help dentists succeed in Dental Sleep Medicine. Please let us know how we can help reach your goals.

Dr. Gy Yatros has practiced dental sleep medicine for over twenty years and is a key opinion leading international lecturer in the area of sleep-disordered breathing and dental sleep medicine. He has offices in Bradenton, Sarasota, and Tampa, Florida devoted exclusively to the treatment of sleep disordered breathing. He is the founder of New Concept Sleep and the Co-founder and CEO of Dental Sleep Solutions and the DS3 System for Dental Sleep Medicine Implementation. He is a Diplomate of the American Board of Dental Sleep Medicine (ABDSM) and is an Affiliate Assistant Professor of the Department of Internal Medicine with the University of South Florida, College of Medicine.

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DR. KEITH THORNTON

EVIDENCE

THAT DEMANDS A VERDICT: By Dr. Keith Thornton, DDS

Why Standard of Care Should Include the myTAP The diagnosis and management of Sleep Related Breathing Disorders (SRBD) has been changing over the years from Sleep Physician/ PSG/ CPAP centric to one of patient and outcomes focus, independent of the practitioner or therapy.

his trend has certainly been accelerated by the Covid-19 pandemic. Although the sleep physician has been the gate keeper and main source for therapy, the dentist is the practitioner who is best suited to manage these patients for a lifetime. However, an evidenced based standard of care that is a comprehensive management-based approach

rather than marketing, device based one is critical. Three aspects of “chronic disease management” of SRBD need to be addressed 1. Diagnosis 2. Standardized long term management 3. Best practice business model

The diagnosis of sleep apnea has almost become a moot point. The acceptance of HSTs and telemedicine has virtually eliminated the need for the PSG for the diagnosis of OSA. Today, national sleep testing companies are marketing directly to primary care physicians, dentists, and even to the public. Not only do they provide diagnostic services, but some also prescribe and sell devices, and then do the follow up management. All of which is covered by insurance. Recently, the AADSM has advocated that dentists also should be able to order, administer, and titrate appliances with HSATs. The Covid pandemic has led to more directto-patient consumer opportunities for many practitioners, health care providers, DME companies, and HMOs. The demand for the myTAP has increased significantly since patients can fit and titrate themselves with virtual coaching. Also, outcomes have been superior due to objective titration. One large HMO is now offering either CPAP or myTAP as first line therapy, even for severe patients. So where does that leave the dentist? I still believe what I wrote in 1998 in the California Dental Association Journal: “SRBD is a dental problem with a dental

DR. KEITH THORNTON

PATIENT “JS” BEFORE AFTER USING THE myTAP

solution.” However, the dentist must provide the evidence that his therapy is not only working initially, but is a superior and more cost-effective solution over time.

Standard of Care in Dentistry Since the first Tap in 1992, my focus has always been to create the most user friendly, effective, and clinically validated devices available. Our team at AMI has always been proud of the fact that it is an R&D company with a plethora of superb, independent studies in peer reviewed journals. These studies are the basis of the acceptance of oral appliances by Medicare and the features that are required for acceptance. In other words, Medicare based their decisions on the evidence. Physicians generally are interested in the evidence first before deciding on therapy. Unfortunately, that is not true of most dentists and is of very little interest to the “marketing” manufacturers who promote “fit” or “precision” while utilizing mechanics that were designed for orthodontics 50 to 100 years ago. (Lipstick on a 50 year old pig). For universal acceptance as a primary therapy prior to cpap, a strategy that tests both the efficacy and effectiveness of an oral appliance for any individual is necessary prior to fabricating a custom appliance. This is no different than

the requirements for a trial of CPAP. Clearly, the only option today to apply this strategy is the myTAP.

Why myTAP? The myTAP is the culmination of more than 25 years of incremental improvements and developments. It is unique in that it not only positions the mandible protrusively but also vertically and encourages nasal breathing utilizing the proprietary mouth shield. All oral devices have two characteristics in common: they all have a tray system for attaching to the teeth, and all have some kind of mechanism for positioning the mandible. The myTAP is not made on casts. Instead, it is directly fit to a patient’s teeth without any interim steps that can lead to errors with fit and retention. The

Flexible Precision™ unique property of the material allows the trays to fit the teeth precisely with the proper resiliency necessary to maintain appropriate retention with a passive fit. The trays themselves are thinner and take up less space in the oral cavity than any other non-custom device. Additionally, it can be refit an unlimited amount of times to create the correct amount of retention for that patient, which is critical for a patient fitting themselves at home. The myTAP is a modified version of the original TAP. The TAP has over 40 peer reviewed, independent studies and is both the most efficacious and effective device on the market. In the 2015 AASM guidelines, the TAP was the only appliance that was successful in treating all levels of apnea to below 10 AHI.1

DR. KEITH THORNTON

• In three studies by Hoekema, the average AHI before treatment was 3 while the average afterward was 6 – an 85% reduction. All six studies on the TAP met the AASM oral appliance success criteria (greater than 50% reduction, less than 10 AHI.) • In six studies, dorsal-style devices failed to reduce the AHI to below 10, even though the average starting AHI was only moderate. • Herbst had three studies with only mild to moderate patients. One failed to achieve the 10 AHI criteria while the other two only reduced the AHI by 60%. • An Army study (N=497) using TAP, had patients with an average pre-treatment of 30 (severe) while post-treatment it was 8.3, virtually the same as CPAP. The newest feature improvements to the myTAP are vertical adjustments and a mouth shield to encourage nasal breathing. The myTAP has 3 vertical shims available to give a 6mm, 9mm, and 12mm vertical opening. In the studies by both Hoekema and the Army, the “size of the box” of the oral cavity correlated to successful outcomes. Further studies have shown that the size of the tongue is dependent on weight, and it affects the severity of OSA. To compensate for tongue size, a larger vertical opening is necessary. Preliminary data from ACTA (Amsterdam) shows significant outcome improvements utilizing the 6mm for women (9mm for obese) and 9mm for men (12mm for obese). The mouth shield encourages physiologic (nasal) breathing as most healthy sleepers tend to nasal breathe during sleep. The Guilleminault study found that

airway resistance, and the risk for OSA, is significantly lower when breathing nasally. Physiologic breathing, which maintains proper CO2 levels, controls respiratory drive, reduces sympathetic tone, humidifies, heats, and filters the air. It also provides an uptake in nitric oxide. Studies are now underway to evaluate the use of the myTAP and the mouth shield in patients with severe, complex sleep apnea. One patient, JS, was an 80 yo male, with an 18 inch neck and an AHI of 78. On ASV at 18/12 CMW his AHI was 35, 11 of which were centrals. He was not able to wear the CPAP. With the myTAP, 12mm shim, and mouth shield, his AHI was reduced to 20 and he was able to wear the myTAP every night.

MyTAP has changed the way dentists can treat and manage patients. Read Dr. Thornton’s interview about the development of adjustable mandibular positioning devices and the treatment of sleep apnea by dentists. https://dentalsleeppractice.com/clinician-spotlight/ driven-help-world-sleep/ 1. Ramar, Kannan, et al. “Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015.” Journal of Clinical Sleep Medicine, 11, no. 07, 2015, pp. 773–827., doi:10.5664/jcsm.4858.

Future Implications The future is already here – NOW! The opportunity to develop a standard of care for evaluation and treatment of SRBD via telemedicine exists today. The value for the physician and dentist is the added perceived and real, value in the “chronic disease management” of these patients through yearly follow-up to assess efficacy and coach the patient. In-office visits can be minimized to device replacement or repair. In many situations, patients can effectively treat and manage their SRBD at home with a device such as the myTAP; it is the interface with their Dental Sleep Medicine professional for diagnosis, treatment, guidance, and follow-up that will be key in achieving superior outcomes. Clinicians are encouraged to develop a comprehensive approach, utilizing both CPAP and oral appliances, for SRBD evaluation and treatment.

KEITH THORNTON, DDS Keith Thornton, DDS, is a third generation dentist who practiced restorative dentistry for 40 years in Dallas. His practice is limited to the treatment of airway and breathing disorders. He is a member of nine different dental and medical organizations and has had numerous leadership positions. He has been a member of the American Academy of Dental Sleep Medicine since 1993 and was an original Diplomate of the American Board of Dental Sleep Medicine. He is a visiting faculty member at A&M College of Dentistry, and is a consultant to the Army, Navy, Air Force and the VA. He has developed a number of medical devices that treat snoring and obstructive sleep apnea and has 72 issued patents. He is the founder, owner, CEO and chief technical officer for Airway Technologies, Inc.

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MARK T. MURPHY

OVERCOMING THE FOUR REASONS PHYSICIANS RESIST OAT Recent surveys1 have shed light on reasons physicians have resisted shifting their prescription mix to include OAT more often.

he concerns about Efficacy, Patient Comfort, and Insurance Coverage are being remediated through data driven studies, objective compliance sensor development and education about medical and medicare coverages. Side Effects are still a prominent reason. The good news is that current artificial intelligent precision designs, robotically manufactured devices and advancements using

the highest medical grade materials are helping change their perceptions.

Side Effects The AASM website describes the ‘Benefits and Side Effects of Oral Appliance Therapy’. It states, “For mild to moderate sleep apnea, oral appliance therapy offers many of the same health benefits as CPAP.” However, they also go on to warn of the possible side effects and suggest that they can be recognized and managed by dentists trained in Dental Sleep Medicine.

These include: • Excessive salivation or dry mouth • Tooth and jaw discomfort/ movement • Temporary/permanent bite changes • Jaw pain/TMJ symptoms The AADSM consensus paper2 describes a similar categorization of side effects and describes ways to

MARK T. MURPHY

manage the maloccurences to help balance treatment and adherence. • Temporomandibular joint-related side effects • Intraoral tissue-related side effects • Altered occlusal contacts/bite changes • Damage to teeth or restorations • Appliance issues

So, what should we do about Side Effects? Using better devices is mission critical to changing prescription patterns. A 10% shift towards OAT would triple the number of oral appliances prescribed overnight! Surveys also show that 91% of physicians schedule a follow up visit with YOUR patients after Oral Appliance Therapy has been completed. That means, if there are complaints about TMD/muscle pain, soft tissue irritation, occlusal changes, damages, delamination, gunky-ness or breakage of the appliance, your physician will know. That will not help us earn their trust and shift their preferences. They are concerned

about patient discomfort and discontinuation of treatment caused by side effects. Ergo, preventing, mitigating, and designing and selecting devices with less side effects is key. Physicians choose between OAT or CPAP, but qualified dentists own the responsibility and the consequences for device selection. Choosing to use the most advanced materials and designs will yield better results and earn the trust of the broader medical community. Almeida , reported that 46% of compliant and 59% of non-compliant OAT users reported side effects and the most common reason for discon3

tinuation was discomfort (44.9%). Murphy et al. looked at the role of side effects4 on the discontinuation of OAT. Of 136 responses, 76.4% were adherent. Jaw pain, bite changes, tooth pain and drooling were all transient side effects in the adherent group 10.3% changed to CPAP. The non-users (13.2%) reported pain and discomfort as the most common reasons to discontinue treatment. A recent retrospective analysis of patient side effects and discontinuation of treatment yielded far better results5 using ProSomnus® Sleep Technologies devices. Five major reasons were hypothesized for these results. • Tooth movement6 has previously been shown to not occur utilizing this milled, control cured, precision platform. • Patients were trained extensively in Morning Occlusal Guide (MOG) importance, use and responsibility.

MARK T. MURPHY

Side effect

TMD TMJ Muscle Issue

Requiring Post Delivery Intervention

Requiring Warranty or UA Action

Unresolved or Became Permanent

Resulted in Discontinuation of Use

4 2 0 0

0% Soft Tissue Irritation

0 0 0 0

1% Occlusion/Bite Changes

1 0 0 0

Tooth Movement

4 2 0 0

• The use of ProSomnus [IA] Iterative Advancement, ProSomnus [CA] LP Continuous Advancement Low Profile and ProSomnus [PH] Precision Herbst devices assure patients of precise bilateral symmetrical advancement with the ability to retrude if needed to adjust for aggressive initial starting positions. • These designs also include extensive patient comfort features; comfort bumps, low profile, radius posts and patient centric features such as anterior discluder, or elastic non-metallic hooks. • The artificial intelligent design, robotic manufacturing and digital storage and retrieval allowed for quick replacement when breakage occurred without requiring new impressions or bite registrations.

5. Murphy M, Unpublished retrospective analysis of 67 consecutive patient reports of side effects and discontinuation. 6. Vranjes N, Santucci G, Schulze K, Kuhns D, Khai A. Assessment of potential tooth movement and bite changes with a hard acrylic sleep appliance: A 2-year clinical study. J Dent Sleep Med. 2019;6(2).

4% Damage/Removal 3 0 0 0 Restorations 6% Appliance Repair/Break

4. M urphy S, Maerz R, Sheets R, et al. Adherence side effects among patients treated with OAT for OSA. J Dental Sleep Med. 2020; 7;(1).

Earning physicians’ trust and ergo, accelerating a shift in the prescribing patterns will help more patients be treated effectively, feel more fulfilling to dental sleep medicine teams, and expand the income stream in those same practices significantly. Changing HOW and/or WHY we do things or use specific materials always seems to be difficult. Different is not always better, that is for sure. But better, is always different. ProSomnus has innovated a full-service family of oral appliances that will help us bridge the chasm with medicine. Embrace better. 1. Fletcher Spaight International Sleep Physician Survey, 2020 2. Sheats RD, Schell TG, Blanton AO, Braga PM, Demko BG, Dort LC, Farquhar D, Katz SG, Masse JF, Rogers RR, Scherr SC, Schwartz DB, Spencer J. Management of side effects of oral appliance therapy for sleep-disordered breathing. Journal of Dental Sleep Medicine. 2017;4(4):111–125. 3. Almeida FR, Lowe AA, Tsuiki S, et al. Long-term compliance and side effects of oral appliances used for the treatment of OSA. J Clin Sleep Med. 2005;1(2):143-149

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MARK T. MURPHY, DDS, D.ABDSM, FAGD Mark T. Murphy, DDS, D.ABDSM, FAGD, is Lead Faculty for Clinical Education at ProSomnus, serves on the Guest Faculty at the University of Detroit Mercy, is a Regular Presenter on Business Development, Practice Management and Leadership at the Pankey Institute and is the Principal of Funktional Consulting. He has served on the Board of Directors of the Pankey Institute, National Association of Dental Laboratories, the Identalloy Council, the Foundation for Dental Laboratory Technology, St. Vincent DePaul’s Dental Center and the Dental Advisor.

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Dentists can establish OAT as preferred therapy.

ProSomnus devices are designed to help dental sleep providers address physicians’ barriers to prescribing OAT. “With ProSomnus Medical Devices, efficacy is not compromised with simplicity. Less protrusion, no moving parts and a company who listens, makes their devices a winner in the world of Dental Sleep Medicine.” —Dr. Kent Smith, DDS, D.ABDSM, D.ASBA

“ProSomnus is one of my go to appliances because I can depend on the consistency of the fit and its ease of use. My patients who have used other appliances in the past, often comment on how much less bulky ProSomnus feels and how much easier it is to keep clean.” —Dr. Brandon Hedgecock, DDS, D.ABDSM, D.ASBA

“ProSomnus precision engineered devices provide my patients with consistent results. ProSomnus devices are smaller, more comfortable and less porous.” —Dr. Srujal H. Shah, DDS, D.ABDSM

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MARC FOWLER

THE HIDDEN VALUE

OF SLEEP PATIENT REVIEWS

Few will argue the importance of online patient reviews. Numerous surveys have confirmed the influence reviews have on consumer behavior. A few examples:

of consumers trust online reviews as much as a personal recommendations

% of consumers seek out negative reviews

say positive reviews would influence % ofthempatients to go to an out-of-network doctor if their

reviews were better than the in-network doctors.

The concept of Social Proof, coined by psychologist Robert Cialdini, states that people will often copy the actions of others in an attempt to determine the appropriate form of behavior. It’s also been referred to as herd behavior conformity. When unsure of the proper course of action, a common response is to lean on social proof. When it comes to selecting a healthcare provider to treat issues they know little about, most people are hesitant and in many cases they find the reassurance they’re seeking by reading what others have said in online reviews about a practice. What this means, is that the quality and quantity of your online reviews directly impact your ability to acquire new patients. In addition to the obvious benefits of positive patient reviews, let’s look at some unseen advantages of having reviews specifically from satisfied sleep patients.

MARC FOWLER

Consider the following Google reviews for a dental sleep practice:

compatible keywords within your reviews increases your chances of being found by patients seeking sleep solutions.

“For years I’ve suffered from severe sleep

apnea while my wife suffered from my snoring. They evaluated me and he selected a device designed to reduce snoring when I sleep….. My wife said I didn’t snore and I awoke feeling more rested than I had in years.”

“I am almost done with my treatment and already recommend him to all my friends at church who also have sleep apnea and hate their CPAP machine as much as I do. It is a highly recommended investment in your wellbeing.” Not only do these reviews provide tremendous value in the form of social proof for prospective patients, notice the keywords in bold. These are the keyword search terms that generate the majority of the website traffic for dental sleep websites. Reviews for your sleep practice, particularly those left on the Google My Business (GMB) listing for your sleep practice, provide you with a significant competitive advantage online. When Google identifies these keywords in your reviews, they are more likely to show your listing to a prospective patient who conducts a sleep related Google search. Reviews are a significant ranking factor with Google, and having

Additionally, when your GMB listing is linked to your sleep website, having these keyword terms within your reviews helps Google validate and correctly categorize your website, which in turn improves the chances of your website showing prominently in Google search results for critical keyword search terms.

When implemented properly, this approach will double your footprint on the coveted first page of Google by having both your sleep website and your GMB listing show in the search results. This heightened exposure correspondingly increases your chances of being the provider whom patients select when they’re actively seeking treatment for sleep breathing issues.

Your Action Plan 1. Establish and optimize a GMB listing for your sleep practice, separate from your dental practice GMB listing. 2. Develop a proactive strategy for accumulating reviews on your listing. This can be accomplished by sending texts, emails or handing out review request cards to satisfied patients.

3. Link your GMB listing to your sleep specific website. 4. Share patient reviews on your sleep website and social media platforms. Learn more about the importance of patient reviews by clicking here. If you would like to discuss additional strategies for effectively targeting your ideal sleep patients, click here: https://go.oncehub.com/marcfowler to schedule a complimentary 30 minute phone consultation.

MARC FOWLER FOUNDER, BULLSEYE MEDIA Marc Fowler is the founder of Bullseye Media. Since 2006, the team at Bullseye Media has helped hundreds of dental practices across the U.S. and Canada leverage the internet to achieve their practice growth goals. Learn about their turnkey 3 step direct-to-patient sleep marketing program at DentalSleepMarketing.com. Marc@BullseyeDental.com

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JUSTIN ELIKOFER

TREATING ALL PATIENTS

INDIVIDUALLY!

Have you ever had a patient whose sleep study results were unexpected? Maybe not completely to your liking? I certainly have. As I sit here writing I feel somewhat ashamed that I have had these outcomes and feelings. Do I not know enough to help this patient? Could I do better? What am I missing?

aybe it’s my personality or my inner dentite continually striving for that extra percent of Sp02 or AHI point reduction, but the feeling is real and I presume I am not the only one. What if I were to adjust the vertical a little bit more, will that help? I digress. We have plenty of patients who are satisfied and have terrific outcomes from their treatment, but the few that don’t cause more heartache than I prefer. For that reason I often dream of a one-sizefits-all treatment in which I can rubber stamp every patient’s treatment plan. If that were the case, there would be no question as to whether I could have done anything different. An estimated 936 million people are suspected to have obstructive sleep apnea (OSA). Each one of these people drive different cars, have unique ambitions, different wants and needs, and have different medical diagnoses that require different

medications and even different dosages for the same condition. So in hindsight, how would we ever be able to treat them the same? I have found that my secret to success in preventing these feelings and outcomes is rather simple; success should be defined before starting treatment. I am quick to define success in my consultations, as well as have the patient verbalize what success means to them before treatment ever starts. We must individualize each treatment

likely we are to achieve that goal or delay treatment because we don’t believe we can meet their expectation. There are multiple goals we must set for each Dental Sleep Therapy (DST) case. They include the goals of our patients, our referring physicians, and most importantly for ourselves. These goals we set at the consultation will in turn dictate how we proceed with adjustments, evaluate the efficacy of the device, and ultimately the relative success of treatment. 1. What are the patient’s goals? You should specifically ask each and every patient what they want to be different tomorrow. I often hear “sleep quality” and “I don’t sleep well” as primary motivating factors. You should continue to ask more questions and unwrap what those terms mean. It’s

“AN ESTIMATED 936 MILLION PEOPLE ARE SUSPECTED TO HAVE OBSTRUCTIVE SLEEP APNEA (OSA).” plan with what success specifically means to them. The more detailed we become about those successes, the more

important that you document these goals clearly and concisely. I make sure to restate their perceived goals after I

document them and it is a good idea to have more than one goal and subsequently place these goals in order of importance. These goals are posted atop my consultation notes and in my summary page for future visits. It will be important to revisit each goal during each patient encounter into the future. We simply continue with adjustments until we can meet some sort of improvement of our stated goals. 2. What are the goals of the referring physician? How well do you know your referring physician? Do you know their testing preference? What do they consider success? Some of my physicians are ecstatic to see even the slightest improvement. Other physicians are very strict with AHI below 5. We must know how the referring physician will judge success and how they will measure it. I will typically test my final treatment positions with a similar modality in which our referring physician will test. I have referring physicians that are only focused on atrial fibrillation risk. I’m likely going to test those patients multiple nights with a high resolution pulse oximetry to evaluate device success rather than an HSAT. 3. What are YOUR goals? Do yourself a favor and quit expecting that you are going to get every case to below an AHI of 5. At the consultation

I discuss my expectations of change in their sleep study (objective) results with oral appliance therapy as well. Set that expectation and work to meet it. It is important to discuss your goals before treatment as well because you might be surprised how your goals of perceived efficacy differ from the patients’. Does the patient believe that a 50% reduction in AHI is a success? You have to ask. Dental sleep medicine is not a perfect science. It will continue to be a subjectively focused therapy for the near future and therefore defining that subjectivity is crucial to success. It is important to remember that we cannot and should not neglect the seriousness of OSA and its impact on other disease processes due to objective measures. Seriously-ill patients, without question, should have a heavy focus on objectivity, but again these are the goals I set for myself. Establishing these goals and gaining agreement with your patients early and often will lead to tremendous reward in career satisfaction as you journey through dental sleep medicine. I continue to look forward to the future as I amass experience and my goals and expectations evolve and thus my definition of success.

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JUSTIN ELIKOFER, DDS Prior to practicing in Florida, Dr. Elikofer focused his care primarily on oral surgery services and intravenous sedation. Dr. Elikofer’s practice is now limited to Dental Sleep Medicine. Dr. Elikofer also works closely with our own DS360 Premier Tier members so that they can become more successful in Dental Sleep Medicine. Dr. Elikofer has completed extensive training with the help of his partner Dr. Gy Yatros. Dr. Elikofer and Dr. Yatros both lecture for University of South Florida and volunteer their time training sleep physician fellows from the medical school on the potential of dental devices for their patients with sleep disordered breathing.

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LISA FISCHER-HERDT

IF IT’S NOT

DOCUMENTED, If you’ve had the opportunity to speak with me or attend a webinar, I know that you have heard me say this a million times, literally!

’m confident you are tired of hearing it as well, but this is one of the most important steps. I talk often about telling a story or painting a picture for your patient’s care. What type of story or picture are you painting for your patient? Are you a Picasso or stick figure painting? In the September 2020 issue of Healthcare Business Monthly, an AAPC (American Academy of Professional Coders) publication, Dr. Michael Warner provides 7 best-practice approaches to documentation1 in his article titled “Guidelines for Clinical Documentation Improvement. ” 1. Health records must contain accurate information. 2. P atients should answer ALL health history questions in preparation for every medical encounter. 3. A ncillary medical staff members should assist patients in authoring the history component of a medical encounter note in the health history. 4. Medical providers should first read the patient authored history, then ask questions. 5. Medical providers and ancillary medical staff members should view the blocking of a patient-authored history as a HIPAA violation.

IT NEVER HAPPENED! 6. Patients should routinely read their entire health record (history, exam, medical decision making) after every medical encounter. 7. Medical students, as well as all healthcare professionals, should be trained to view health record documentation through the lens of core competencies. a. Systems based practice b. Practice-based learning and improvement c. Professionalism d. Interpersonal and communication skills e. Patient care And, in my humble opinion, you cannot capture too much information. And last, but not least, my dear Dentist, please,

please sign those progress notes. Until the notes are digitally signed the insurance companies deem them INVALID. Insurance companies make frequent requests for medical records and unsigned progress notes will give them one more reason to deny the claim. Paint like a Picasso and tell the patient’s story as if you were an author. I know I’m not one to point out tips for writing skills, if you have received an email from me, I can almost promise there will be a typo. Point being we all need a good proofreader and someone that is very detail oriented to articulate the patient encounter. Happy documenting! 1. These documentation guidelines are based on training delivered in the spring of 2020 at Touro University California – College of Osteopathic Medicine. A full report can be accessed at www. tu.edu and www.PatientAdvocacyInitiatives.org.

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LISA FISCHER-HERDT, CPB Lisa is the Director of Member Communications at Dental Sleep Solutions and 4 Pillar Billing. She has over 25 years of Medical Billing experience, serves on the Manatee Tech College Advisory Board and recently became certified as a professional biller.

Boost Reimbursement. Increase Efficiency. HOW WE HELP YOU: Four Pillar Billing. Medical Billing for Dental Practices

Our Service Includes:

- Application completion - Step by step instructions for the credentialing process - Bi-Weekly follow up for tracking and notiﬁcation

DME Application This application is required by Medicare to be recognized to deliver the appliance and receive payment -Completion of DME application -List of documents required to be sent with application -Bi- Weekly follow up with a status update -Step by step assistance during the process

EFT Application

Electronic Funds Transfer application is required by Medicare to receive payment -Completion of EFT application -List of documents required to be sent with application

- Status updates - Personal support from a credentialing specialist

+ =

*Must be done with DME application, required by Medicare

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Prescribing Application This application allows a provider to write prescriptions to Medicare patients -We complete this application as a courtesy with the DME and EFT application

Part B Application

This application is required by Medicare if a provider would like to bill for other services -Completion of Part B application -List of documents required to be sent with application -Bi- Weekly follow up with a status update -Step by step assistance during the process

CONTACT US TODAY! “We collected less than $5,000 during the ﬁrst half of the year for sleep cases, but since we started using Four Pillar Billing over the past couple months, we’ve collected approximately $30,000.”

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MICHAEL J. LANDRY, DDS

What’s My

WHY?

everal years ago, during some routine blood work, my PCP ordered a test for the APO4 gene. I guess during my family history, the fact my dad and my grandmother both died of dementia or Alzheimer’s must have influenced this decision. When I got the results and it said I have a 75% chance of being affected by Alzheimer’s, I was shocked. I knew it was time to kick into gear and do everything I could proactively to be in the 25% chance of not being affected by Alzheimer’s. I changed by diet. I started using essential oils. I was not going to let conventional medicine dictate my future. I had seen what that looked like and I did not want to be a part. It was in my research that I discovered that memory consolidates in NREM 2 sleep in the form of sleep spindles. As I explain it to patients, the hippocampus is the RAM memory and the cortex is the hard drive. They talk best during NREM 2 sleep. Well, the next step was to have a sleep study. My result came back as mild sleep apnea. No big deal, right? Unless you are trying to be in the 25% group. I needed everything going for me. So, I went through 4 OA’s until I found my favorite. One I made

myself using intraoral scanning, OA prototype software, and 3D printing. But now I am on a mission. I see all the bad things that happen to people with OSA, including death. I know my father had OSA, now I that know what to look for. What if he had been diagnosed and treated in his 40’s, 50’s, or 60’s? I might have had a few more years with him knowing who I was. I now have a gift to give. Better memories, reduced cardiovascular disease, a decrease in GERD which can lead to esophageal cancer, and a host of other benefits. I have created hundreds of smiles in my 39-year dental career, but now I can change people’s lives. I see their faces change as they get better sleep. I hear stories of what they can now do that before treatment was not possible. I hear of husbands and wives who slept in separate rooms starting to sleep in the same bed again after so many years. Grandparents being able to keep up with the grandkids. Happy people now come to see me and hopeful ones too. So, that’s my new why. On December 31, 2020,1 I will put down my handpiece and only practice sleep. I have lives to save!

MICHAEL J. LANDRY, DDS, ABAD Dr. Michael J. Landry attended Lamar University and The University of Texas Health Science Center Dental School San Antonio. After graduating in 1981, he set up a General Dentist practice in Harris County, where he continues to grow, gives back to the community and serves others. He takes a holistic approach in achieving optimal health with his patients. Several years ago, through advanced education and successfully treating patients, I decided to dedicate the future of my practice to Dental Sleep Medicine. I am qualified through The American Academy of Dental Sleep Medicine to fabricate appliances that are FDA approved to treat snoring and obstructive sleep apnea.

RICHARD DRAKE, DDS

When and When Not to

TREAT SEVERE OSA

s a dental sleep medicine practice owner, I often refer to the 2006 AASM Practice Parameters as “the day the earth shook” in Dental Sleep Medicine (DSM). In 2006 the Practice Parameters were updated to essentially say: it’s okay to use a custom MRD [Mandibular Repositioning Device] as a first line of therapy for mild to moderate Obstructive Sleep Apnea (OSA). For those of us practicing DSM at the time, we had been waiting for years to see clinical validation of what we already knew: that custom MRDs work at least as often as they don’t. But what about severe OSA (those with an AHI over 30) -- what to do with them?

Honestly, I’m not sure this was a step forward for Dental Sleep Medicine. But DSM continues to grow; more dentists are getting involved in treating sleep apnea, and oral appliance therapy is gaining market share, albeit slowly. So here is Dr. D’s pseudo-mathematical formula for the situation: (Practice Parameters x 2) + (Increased Market Share) + Increased Efficacy & Better Appliances ––––––––––––––––––––––––––––– Number of Physicians Prescribing Oral Appliances = I ncreased Frustration for Patient AND Dentist!

Fast forward to the 2015 AASM Practice Parameters:

Before you go criticize your local sleep doctor or primary care physician for failure to understand and treat OSA, remember that these docs want easy, predictable, effective, paid-forby-a-third-party solutions for their patients. And custom MRDs don’t always fit their model. Truly, we (as DSM practitioners) and they (as physicians) are looking at the patient from different sides of the same river. So where do we go from here? What has to change? When can we as dentists treat severe patients and when should we not? My mentor from dental school just turned 89; he was recently diagnosed with severe OSA; he showed up the other day wanting a custom MRD. Did I make him one? Not that day. I steered him toward PAP, recommended that he try it for at least a month and see if he could tolerate it. Eventually he failed PAP and we are now treating him with an MRD (successfully, by the way).

“ WE RECOMMEND THAT SLEEP PHYSICIANS CONSIDER PRESCRIPTION OF ORAL APPLIANCES,

RATHER THAN NO TREATMENT, FOR ADULT PATIENTS WITH OBSTRUCTIVE SLEEP APNEA

”

WHO ARE INTOLERANT OF CPAP THERAPY OR PREFER ALTERNATE THERAPY. (STANDARD) – 2015 AASM Practice Parameters

Along the way, I wrote four different letters while treating this severe patient, sent to each of his six physicians:

RICHARD DRAKE, DDS

1. I recommended he try PAP first, which he did, and failed. 2. I started him on custom MRD therapy. 3. We’re continuing to treat him and subjectively he is doing well. 4. We’ve used high-resolution pulse oximetry to show that we are treating the majority of his apnea load. 5. We referred him back to the Sleep doctor to do a formal follow-up Titration Sleep Study. 6. Hallelujah! His numbers look fantastic! We are treating yet another severe patient successfully with a custom MRD! 7. Please consider prescribing a custom MRD for patients who refuse, cannot use or tolerate, or are otherwise not candidates for PAP therapy.

Each of these physicians now know how I personally treat severe patients and that yes, sometimes custom MRDs do work even for severe patients! Severe patients present more challenges and more complexities associated with ongoing care. Use the Practice Parameters as a guideline for how to treat these patients -- MRDs are a useful (but not the only) tool for severe patients, and these patients are a great way to collaborate with and educate your physician colleagues.

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Six physicians are now “better informed” about what a dentist can do for their patients. A less-frustrated dentist. One happy patient.

Changing the world…...one patient and one doctor at a time.

RICHARD DRAKE, DDS Dr. Richard Drake has been exclusively treating snoring and apnea for 20 years. He Co-founded Dental Sleep Solutions and DS3 and has a state of the art sleep practice in San Antonio, TX.

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Welcome to the VirtuSLEEP Program! • Screening materials to help identify patients with OSA • NightOwl© Home Sleep Apnea Testing (HSAT) devices for the dental office. Can be used for both diagnosis and titration of dental devices. • DocViaWeb™ telemedicine platform with access to: • Sleep physicians in all 50 states • Home Sleep Apnea test results from VirtuOx • Sleep physicians’ prescriptions for dental devices • Dashboard to monitor all patients’ testing • Many more additional added benefits

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Dental Sleep Medicine

BILLING FOR

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Lisa Fischer-Herdt, CPB Lisa is the Director of Member Communications at Dental Sleep Solutions and 4 Pillar Billing. She has over 25 years of Medical Billing experience, serves on the Manatee Tech College Advisory Board and most recently received her certification as a professional biller.

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