Dental Sleep Practice Fall 2020 by MedMark, LLC

Obstructive Sleep Apnea and Dental Implants by John H. Tucker, DMD, DICOI, D.ABDSM, and Dennis R. Bailey, DDS, FAAOP, D.ABDSM

Leading the Cross-Coding Movement for Over Three Decades

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INTRODUCTION

Lessons from Antarctica

“P

ut footstep of courage into stirrup of patience.” – Sir Ernest Shackleton

Restless days have turned to sleepless nights. Worrisome weeks morph into mundane months. These months have culminated in a dreary quarter. Now what? Since March, I’ve been unable to get Sir Ernest Shackleton and the crew of Endurance off my mind. You might be wondering what an expedition racing to cross Antarctica more than a century ago has to do with Dental Sleep Medicine (DSM). Fair enough. Shackleton and the crew aboard the aptly named Endurance were attempting to sail to Antarctica and cross the continent on foot. He made an attempt with a different crew a few years earlier. They came within 97 miles of the goal only to turn back because he feared they had insufficient rations to survive the return journey. He could have risked it and continued onward to glory and fame – or death and infamy; just rolled the dice. He didn’t. He took decisive action with the health and wellbeing of his team as the sole focus. Shackleton knew he’d create another chance. And five years later, he did. Not long into this second journey, the ship became moored in ice in the Weddell Sea. The crew spent days chiseling and picking at the ice in futile attempts to create a floe they could travel through back into open seas. Shackleton realized these efforts were for naught. He ordered them to stop and conserve their resources so they could tap them when the ice broke. Unfortunately, bad quickly became worse and that was rapidly followed by the worst-case scenario. Sound familiar? The ice shifted and crushed the boat. The men spent the next several days dragging necessities off the sinking Endurance and onto the frozen wasteland. There, they lived for a year. Shackleton ensured they stayed sharp and focused by continually running through drills. This guaranteed procedures and readiness were ingrained in the crew. He required structured maintenance of equipment and supplies. Morale was kept high with special meals, organized soccer matches, and staged

plays. All of this was done for months. On the ice. In the dark. More than a year later, the moment came. The ice loosened. The crew put their practice and preparation into action. All 28 boarded 3 lifeboats and sailed the world’s most treacherous seas for a week until they reached Elephant Island. For the first time in more than a Jason Tierney year, they were on solid ground, albeit inhospitable, frigid (-20 ºF), and relentlessly battered by sea water. They survived on the shore for some time, eating seals and using their lifeboats as shelter. Eventually, Shackleton and 5 crew members boarded one of the lifeboats and sailed the treacherous Drake Passage for two weeks toward a whaling station over 650 nautical miles away. They were tortured by freezing cold saltwater sprays, towering waves, and …bad quickly stress – lots and lots of stress. They finally landed on the island hous- became worse and ing the whaling station – on the opposite that was rapidly side of the island. They could have succumbed. Instead, they traversed the frozen followed by the mountains, something no human had ever worst-case scenario. done before. To make a long story a little bit shorter, Shackleton and his team made Sound familiar? it to the whaling station and after repeated attempts, they returned to Elephant Island three months later to rescue the other crew members. No one perished. Years later, when they were asked how they were able to survive and remain in good spirits, several of them replied with one word, “Shackleton.” So, here we are. For readers that have been practicing DSM for any substantial period of time, you know that patience, persistence, critical thinking, and endurance are necessary. Sound leadership is, too. The COVID comeback is no different. Sharpen your skills. Hone your processes. Rally your team. Be attuned to emotional states. Coach to success. Empower. Stay connected, continue learning, prepare, adapt, and endure. And don’t eat seals. DentalSleepPractice.com

CONTENTS

Choosing Appliances

An Evaluation of Oral Appliance Therapy Device Volumes: Is Size as Advertised?

Cover Story

Leading the Cross-Coding Movement for Over Three Decades

Rose Nierman is a pioneer in the field of medical billing in dental practices. Learn about her legacy and Nierman Practice Management’s future forward.

by Jerry Hu, DDS, D.ABDSM, D.ASBA, D.ACSDD, and Len Liptak, MBA Size matters and not all appliances are created equal.

Rose Nierman, Founder & CEO, and Jon Nierman, Vice President/Director of Education & Marketing, Nierman Practice Management

Clinical Focus

Obstructive Sleep Apnea and Dental Implants: Sleep Before You Drill by John H. Tucker, DMD, DICOI, D.ABDSM, and Dennis R. Bailey, DDS, FAAOP, D.ABDSM Implants have an elevated failure rate in patients with OSA. What do you need to know before drilling?

2 DSP | Fall 2020

Continuing Education

Get with the Program: Dental Sleep Medicine and Electronic Medical Records by Richard B. Drake, DDS, D.ABDSM, and George S. “Gy” Yatros, DMD, D.ABDSM Electronic Medical Records (EMR) simplify workflow and improve communication. Get the info you need so your practice is programmed for success.

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“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 Join the growing number of dentists who are treating more patients with greater efficiency and effectiveness.

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CONTENTS

44 Laser Focus

Publisher’s Perspective

Thoughts of Business Health, Optimism, Clarity, and Prosperity

LightScalpel 10,600 nm CO2 Laser Procedures in Pediatric Patients

by Lisa Moler, Founder/CEO, MedMark Media

by Martin Kaplan, DMD, and Peter Vitruk, PhD Laser procedures for pediatric patients.

8 Crucial Conversations

Communcations The Elephant in the Operatory: The #1 Struggle in a Dental Understanding the PsychoSleep Practice Isn’t What social Impact of Covid-19 You Think by Pat Mc Bride, PhD, CCSH Everyone – team, patients, even you – walking into your office is a different person now. Communication and engagement count more than ever.

by Michael Cowen Spoiler Alert – Quality communication is the common denominator in successful dental sleep practices. Step up your game.

24 Expert View

52 Product Spotlight

In Your Own Words DSM is a team sport. We asked key team members 3 questions about their positions.

28 Product Spotlight

Protect Dentistry with Panthera Sleep® Night Guard by Diane Robichaud, t.d. Special announcement about a new product for bruxers.

30 Billing Blocks Game Changer

by Randy Curran and Kyle Curran Why are so many dentists only treating one sleep patient each month?

Building Physician Trust with Preferred OAT Designs by Mark T. Murphy, DDS, D.ABDSM What are you willing to sacrifice at the Gold Standard altar?

54 Risk Management Next-Level Strategies to Protect Your Practice by Bre Cohen How will you protect your practice if disaster strikes again?

56 Sleep Humor

...The Lighter Side of Sleep Apnea

Publisher | Lisa Moler lmoler@medmarkmedia.com Editor in Chief | Jason Tierney jason@medmarkmedia.com Managing Editor | Lou Shuman, DMD, CAGS lou@medmarkmedia.com Editorial Advisors Jagdeep Bijwadia, MD Randy Clare Scott Craig Randy Curran Barry Glassman, DMD Elias Kalantzis Steve Lamberg, DDS, D.ABDSM Mayoor Patel, DDS, MS, RPSGT, D.ABDSM Mark Murphy, DDS John Viviano, DDS

Director of Operations Don Gardner | don@medmarkmedia.com Manager – Client Services/Sales Adrienne Good | agood@medmarkmedia.com Creative Director/Production Manager Amanda Culver | amanda@medmarkmedia.com Marketing & Digital Strategy Amzi Koury | amzi@medmarkmedia.com eMedia Coordinator Michelle Britzius | emedia@medmarkmedia.com Social Media & PR Manager April Gutierrez | medmarkmedia@medmarkmedia.com Front Office Administrator Melissa Minnick | melissa@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496

Pediatrics

Sleep Disorders are In Your Face

by Sharon Moore Part 2 in a series on dentistry’s role in pediatric SDB identification and treatment.

4 DSP | Fall 2020

Fall 2020

www.DentalSleepPractice.com Subscription Rates 1 year (4 issues) $149 | 3 years (12 issues) $399 ©MedMark, LLC 2020. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Dental Sleep Practice magazine or the publisher.

PUBLISHER’Sperspective

Thoughts of Business Health, Optimism, Clarity, and Prosperity

s I write this message, COVID-19 is still driving many of the operational aspects of the dental office, and dentists are trying to navigate the challenges and restrictions related to maintaining safety and health. Recently, I attended the ADA’s press conference on reopening — a meeting that gathered dental leaders to discuss CDC guidelines, dentists’ concerns, and the ADA’s direction on how to navigate with “cautious optimism” out of this crisis. Seeing these visionaries of the dental community all working to provide information and guidance to their peers empowered us at MedMark Media as well to work even harder to be advocates for the dental community.

Lisa Moler Founder/CEO, MedMark Media

6 DSP | Fall 2020

In these times, when it seems we are re-inventing dentistry to accommodate new and evolving needs, we need to call upon the strengths and creativity that have navigated us out of other very difficult times in our lives and our careers. As different types of information swirl around us on the news, on social media, and in our own social circles, it is important to keep the team informed and involved in the decisions that will affect their health and safety. Keep those team meetings ongoing so the team is aware of your consistent support. Formulate and be proactive on what steps will be taken if a team member is exposed to the virus, or if a patient with COVID-19 has entered your office. Now is the time to use your social media to show patients your dedication to a safe environment for them and your staff. Keep them apprised of your technologies that will offer them the most comprehensive care, even after COVID-19 abates, and life returns to the “new normal.” Take a look at all of the telehealth options that are possible for the dental practice. This tool can be useful for prescreening patients, as well as scheduling and check-in, to reduce the amount of people at your front desk or in your waiting rooms. Make sure that you have clear instructions on your online presence as well as in the waiting area and any area that requires social distancing or face masks. And, be clear on when face masks are required in your office

(such as removing the mask in the operatory and putting it back on when leaving the room or in the presence of others). In this issue, we continue to provide articles on subjects that can expand your dental sleep practice far into the future. Our CE, by Drs. Richard Drake and George “Gy” Yatros, discusses electronic medical records (EMR), a tool that can streamline and standardize documentation and workflow. Since DSM is a cooperative science that involves various disciplines, team members, and insurance companies, the efficiencies that EMR offers can have a positive impact on your practice. In “Obstructive Sleep Apnea and Dental Implants: Sleep Before You Drill,” Drs. John Tucker and Dennis Bailey discuss identifying and addressing SDB issues before placing implants to increase success rates and avoid potential challenges. Consider these insights for both the pre-treatment phase and when planning for oral appliances. Our Cover Story shines the spotlight on Rose Nierman, who for more than three decades has helped dental practices receive the compensation they deserve. Read about how she pioneered the cross-coding movement and medical billing for the benefit of dental practices. During COVID-19 and after, we strive to keep bringing you ideas and information for clinical and business aspects of your practice. Wishing you and your business health, optimism, clarity, and prosperity in these ever-changing moments we are all facing.

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CRUCIALconversations

The Elephant in the Operatory

Understanding the Psychosocial Impact of Covid-19 by Pat Mc Bride, PhD, CCSH

s we reopen practices and return to the business of providing care for our patients, no one has a clear view of how the Covid-19 pandemic will play out. Mandated closures of many practices across the country have led to unprecedented revenue declines, stress, and anxiety across the field. Dental Sleep Medicine providers, regardless of economic concerns, must focus on the changed emotional and psychological well-being of each patient. Providers and their staffs are presenting care paradigms that include expanded safety precautions and changes in care provision e.g. possibly not polishing at hygiene

8 DSP | Fall 2020

appointments and no contact billing/front office policies. Patients who have been waiting for months to see you are intrinsically different from their last appointments. You are, too. They are eager to reconnect now and share their experiences of the last few months with you. Remember, many people, especially those who have been distancing from others alone, will be eager to engage. It will be a sound investment for you and your practice if you deliver a sincere connection that confers a high level of care and understanding of the struggles individuals have experienced in recent months. While it may take some time, most practices can recover and even thrive in the

CRUCIALconversations post-pandemic world. Covid-19 cannot stop dental decay, periodontal disease, or sleep and breathing disorders from affecting our patients health and wellbeing. However, you can. Unfortunately, while patients need you, many providers must deal with numerous attendant anxieties related to reopening offices – PPE shortages and price gouging by suppliers, patient inability to return to the clinic due to economic reasons or out of fear, and staffing constraints as employees decline to return to work. On top of these urgent concerns, it will be imperative that providers critically evaluate how they are coping as well as assessing how patients and staff are faring psychologically, physically, and emotionally during these turbulent times. No one sees the world as they once did, and it behooves providers to acknowledge this elephant in the operatory. Mandated quarantining meant that every person had to suppress profoundly human and evolutionarily hard-wired impulses for connection and touch. Never in our collective experience have we been forced to forgo basic social interactions such as weddings, school, graduations, funerals, sporting events, and worship and replace them with online substitutes. While physical distancing is intended to protect our physical health and slow the spread of disease, the unintended emotional, relational, and spiritual consequences on individuals and communities is largly unseen. But it is present. Prolonged periods of enforced physical separation are sorely testing our collective capacity for cooperation as evidenced by the “busting out” behaviors observed across the country. The concept of social distancing suggests social isolation which is why we should be mindful to shift the term to “physical distancing.” When we must be physically distanced from others it is imperative that we remain accesible and socially available to them. This is true of patients, staff members, and others in our social spheres. Segerstrom (2010) noted that when faced with illness or infection, human beings and other animals naturally withdraw as an adaptive response to conserve energy. This natural withdrawal is not the same as prescriptive distancing in the absence of symptoms or disease which can actually increase the likelihood that individuals may become ill – not from coronavirus, but from something else like depression

or heart disease. A meta-analysis by Julianne Holt-Lunstad (2015) determined that chronic social isolation increases the risk of mortality by 29%. She also noted that there is a connection between perceived social connectedness and stress responses. As providers reengaging with our patients, we will need to understand that there is an enormous variation in individuals’ abilities to handle the isolation and its related stress. We can begin doing this by recognizing the aforementioned elephant. It’s real. Heather Servaty-Seib’s (2014) loss ...chronic social isolation gains framework may be a means increases the risk of mortality by by which we can conceptualize the unique impact of specific life events such as coronavirus on our own lives and those of our patients. As we reach out and reconnect with patients to reschedule appointments, we should be particularly attuned to tone. Schedulers trained to get people on the book and off the phone in two minutes or less will need to stop and truly listen to the patient. We must remember that grief is not only connected with death. It is a multi-dimensional emotional, cognitive, physiological, social, and spiritual response to myriad types of loss. There has been a loss of community and established routines accompanied by inhibited freedom of movement. Other tangible impacts include access to resources such as food and meal programs for underprvileged kids in schools that are now closed, planned activities and celebra-

29%

Pat Mc Bride, PhD, CCSH, has spent 38 years as a full time clinician, educator, and author in the fields of dentistry, respiratory medicine, and dental sleep medicine. Her extensive experience in clinical, laboratory, research, and educational arenas has led to the development of interdisciplinary care model delivery systems used in collaboration by physicians and dentists around the globe. Pat has a unique ability to intervene in the interstices of global systems, developing protocols which can be translated across demographics and cultures into improved clinical outcomes. In addition to writing and teaching, she is currently a Clinical Sleep and Field Specialist for HNS implants. Serving the underserved and marginalized patient remains a passion and priority for her. She sits on numerous Boards such as the AAPMD and NAAFO. She has one grown daughter who shares her passion for social justice and education, serving as a sixth grade teacher in the inner city Oakland.

DentalSleepPractice.com

CRUCIALconversations tions, increased marital discord, inability to see primary care physicians and dentists in person, and child care disruptions. The occurrences and their severity run the gamut. Postponement of a long-awaited DMV appointment for one 16 year-old aspiring driver was cause for more than a few bouts of hysteria in our neighborhood. As providers, we must be cognizant that any and all of these losses are real. Fortunately, dental providers typically spend more minutes per patient than any other healthcare provider which uniquely positions us to help patients identify gains as well. Recognizing that many professionals work long hours and yearn for more time with their kids, this mandated hiatus can be considered a huge positive. Okay, home schooling your teenager may be ex…now is the time to asperating – and had you Googling implement this ADA- the Pythagorean Theorem caluculator on your phone in the other room, recommended guideline. but in the greater scheme of things, it’ll be totally worth the time spent together. As a new normal emerges, it’s unlikely we’ll have these opportunities again. We will all become “too busy” again. It is vital that we seize these opportunities and reap the benefits while we can. And it is important that we reflect this positive mindset to our patients. Next to touch, the human voice comes second in importance for our well-being. People long for connection right now. Don’t make the mistake of having text or computer appointment confirmations for the foreseeable future. While texting is expedient and asynchronous, nothing can replace the hormonal responses we get from hearing the human voice. Hearing the familiar voice of your scheduling staff may be a healing balm and set the tone for the next visit when you can reconnect in a truly meaningful way. During this initial conversation, provide clear expectations as to what the patient will experience during the visit. Eliminate trepidation and assuage concerns while building trust and confidence. In advance of appointments, prepare patients by sending forms for medical history updates that they can complete ahead of time as they will no longer be allowed to sit in the waiting room. Even if the chart shows that the medical history is current, it isn’t. Every single patient has been exposed to many

10 DSP | Fall 2020

Covid-related psychological and emotional (if not physical) traumas, and their health status may reflect it. Raised sympathetic tone and autonomic nervous system dysregulation are potentially present. Be prepared to talk with patients about how they are actually “feeling.” Medication doses previously effective for their hypertension, depression, and or thyroid disorders may not seem to be working as well, and they may not be able to articulate why. This may be a manifestation of the autonomic nervous system being thrown off by raised sympathetic tone. If an oral appliance patient says they’re not sleeping well anymore, consider whether it is from stress-related insomnia or other manifestation of anxiety before simply adjusting the device. Be ready to connect with their physician with any concerns you may have regarding your patients’ medical or mental health status. And if you haven’t been screening all of your patients for sleep disordered breathing due to time constraints, now is the time to implement this ADA-recommended guideline. Finally, enjoy the additional time you have with patients. You cannot pop out of the operatory and do a few hygiene checks while waiting for a restoration to set anymore. Taking off all that PPE, putting on new equipment, and then going back into the room you just came out of is a costly and impractical venture. Appreciate that the restrictions placed on your movements to conserve PPE may actually work in your favor as you spend time connecting with your patients. Once they get used to seeing you looking like an extra from Contagion, flip up your loupes and let them see how much you care. Honor their effort, reconnect, talk to them, and let them know you are there to support them in any way you can. You will turn the recent months’ losses to gains, connect in a meaningful way, build rapport, and retain patients for many years to come.

Holt-Lunstad, J., Smith, T., & Layton, J. (2010). Social relationships and mortality risk: A meta-analytic review. SciVee. https:// doi.org/10.4016/19865.01 Segerstrom, S. C. (2010). Resources, stress, and immunity: An ecological perspective on human Psychoneuroimmunology. Annals of Behavioral Medicine, 40(1), 114-125. https://doi. org/10.1007/s12160-010-9195-3 Servaty-Seib, H. L. (2014). Perceived impact of life event scale. PsycTESTS Dataset. https://doi.org/10.1037/t48438-000

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COVERstory

Leading the Cross-Coding Movement for Over Three Decades

or many dental offices, the ability to cross-code and bill a patient’s medical insurance for necessary procedures isn’t simply a way to improve the bottom line. It’s the single most important factor for a practice to set themselves apart in the current landscape. This is no surprise to the team at Nierman Practice Management, a company who not only founded the cross-coding movement but has been leading the way to cross-coding success for over three decades. Nierman’s mission to help dental practices receive the compensation they deserve has made them the leading company that offers training, software, and medical billing services to the dental industry. This mission all began with one woman, the company’s founder and CEO, Rose Nierman.

How Rose Nierman Became an Industry Innovator

Although Rose’s name is well known across the dental world today, the story of Nierman Practice Management began in just a single dental practice, where she was employed as a hygienist and office manager. While this may seem like an unlikely begin-

12 DSP | Fall 2020

ning for a company which has served over 10,000 dental practices, it was this beginning that gave Rose unique insights into both the challenges practices face and the potential opportunities medical billing offered. During this time working in a practice that focused on treating TMJ and airway disorders, Rose saw first-hand how many patients were unable to afford recommended care, leaving them without treatment and the practice without revenue. Yet, she knew the types of procedures her office performed “should” be covered under their medical insurance, despite the fact that doing so successfully was practically unheard of. Without anyone to guide her, Rose set out to learn everything she could about medical billing and its nuances, as well as how to obtain approvals and reimbursements. She was told “no” numerous times but didn’t quit until her practice had successfully received payment. Soon, the office’s revenue skyrocketed, and her doctor was singing her praises to other practices who came to her to teach them how to replicate her success. It was then that the cross-coding movement was born, as Rose developed a stepby-step process and helped practice after

COVERstory

Rose Nierman and Jon Nierman

DentalSleepPractice.com

COVERstory practice, personally supporting them in the transition to medical billing for the benefit of their patients and practices. Rose was acutely aware that there were far more offices who needed a system, ones who were languishing with low reimbursements, patients who were unable to afford their services, and a lack of knowledge of how cross-coding could be done. To meet this need, in 1988 she founded Nierman Practice Management to begin assisting dental practices nationwide. Her proprietary process became the gold standard as more and more dental offices began to succeed and achieve coverage for the procedures and services their patients so desperately needed.

The First Ever Narrative Report and Medical Claim Software – A Systematic Approach

Part of the company’s success can be attributed to its continued innovation, illustrated by its 1991 launch of the first software on the market to handle narrative reports and medical claims for dental practices. Rose’s process was captured in the software to create a truly streamlined system. The implementation of Rose’s software served as a rallying point for practices across the country and gave them the ability to easily and efficiently manage the documentation necessary to ensure medical insurance reimbursement. Also of great importance, it allowed offices to improve interactions with and foster referrals from medical practices,

Best Practices for Billing and Physician Communications

1. Electronic claims take precedence over paper claims, so use electronic billing when possible. Electronic claims are often reimbursed within two weeks, instead of the 30 - 90 days commonly found with paper claims. 2. Implement Secure Electronic Fax. E-fax allows you to supply your narrative reports, sleep studies, and prescriptions directly to the insurer, saving time and eliminating excess paper. 3. For practice building and to set yourself apart, forward your SOAP reports to all of the health care providers the patient has seen. DentalWriter automates this as part of the 4-step process. 4. Send the documentation to the insurance carrier at inception to prevent rejections. 90% of claim denials from medical insurance are preventable!

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boosting the number of new patients who set foot through their doors month over month.

The DentalWriter System Today

Nierman’s innovation continues to this day. Their most recent iteration of DentalWriter software is used by thousands of practices to implement a repeatable system using their proprietary 4-step process: Step one: Online Dental Sleep Questionnaire. The data from the online or paper questionnaires informs the insurer and physicians of medical comorbidities related to obstructive sleep apnea. Step two: Input exam data. Dedicated to showing treatment necessity, the DentalWriter Dental Sleep Exam documents the appropriate oral screening, a detailed airway exam, TMJ and periodontal baselines, and other important exam findings. Step three: DentalWriter generates the narrative report in SOAP format (subjective, objective, assessment and plan) from the questionnaire and exam entry for medical reimbursement, physician referrals, and records. Step four: The medical claim is automatically populated with the required fields including ICD diagnosis codes and CPT procedure codes. Practices can choose to submit the claims electronically or utilize Nierman’s integrated medical billing service where a dedicated billing specialist handles benefit checks, pre-authorizations, claim submissions, and status reports. Nierman’s upgrade to a cloud-based solution also ensures that practices stay ahead of the game. What makes DentalWriter truly special is the team behind it. Led by industry expert, Courtney Snow, the renowned NPM support team guides practices throughout their dental sleep medicine journey.

Carrying the Torch and Continuing the Mission to the Next Generation

Today, another Nierman has joined Rose at the helm of the business founded 32 years ago. To ensure the company always stays true to its mission and remains focused on serving its practices with the same dedication Rose has always exhibited, her son, Jon Nierman, has taken his place as Vice President of the organization.

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COVERstory As Rose likes to point out, Jon’s role in the company is incredibly fitting and surely inevitable since Nierman Practice Management and Jon were born the same year. Rose fondly remembers how, from the moment Jon was old enough to sit at a desk, he began testing software. He’s been a part of the company for almost as many years as Rose herself. Jon jokes that the old saying, “If you can’t beat ‘em, join ‘em” is certainly true, and in his case, he’s glad he did. A graduate of Georgia Institute of Technology, Jon joined Nierman full time in 2010. Right from the start, Jon took a special interest in the company’s CE department. His deep-seated passion for providing education helped expand Nierman’s program to where it is today.

Rose’s Rules:

The vast majority of medical insurers cover custom-made oral appliances for OSA. The coverage criteria can vary, so be sure to look up the coverage criteria on the insurer’s website when you start working with a new insurer. • Step #1 is to ALWAYS verify benefits and determine if a preauthorization is required. ¡ Pro tip: Verify benefits prior to the first appointment so you can talk about their insurance coverage expectations at that appointment. ¡ Just as pilots use a preflight checklist, utilize a detailed checklist for verification calls before beginning treatment. • Adopt medical-necessity terminology. “We are providing a medically necessary custom-made oral appliance for the treatment of Obstructive Sleep Apnea (ICD-10 code G47.33)” is better than “we’re making a dental snore guard.” This alleviates confusion as to whether the treatment is dental or medical in nature. • Three key pieces of documentation for sleep patients to get your claim paid are: sleep study report, prescription from physician, and SOAP clinical notes from dentist’s exam. • Assign an official DSM coordinator team member to oversee medical billing (even when outsourcing billing) • Happy physicians are the referral source that keeps on giving – be sure to send SOAP reports to treating physicians to keep them informed of your mutual patients’ progress. • If possible, have the bed partner come in with the patient for the screening appointment • Document your patient’s sleep history, oral and airway exam thoroughly – this can make or break if the medical insurer covers treatment or not!

16 DSP | Fall 2020

In the past 10 years, Jon has hosted over 250 CE programs, providing more than 4,000 CEU’s in dental sleep medicine, TMD, and medical billing education. From mini-residencies and online CEU events to courses all over the country, Jon has made it his life’s work to make this crucial educational content available to dental practices all across the country. To make the courses more accessible, Jon has recently developed Nierman Practice Management’s online learning platform, Nierman CE Plus. Having access to a mentor like Rose, Jon knows what it takes for dental practices to succeed. “We’ve identified 3 key areas for practice growth in dental sleep, TMD, and medical billing – proper education for the dentist and team, scalable systems to streamline processes, and access to ongoing support specialists,” says Jon.

Commitment, Teamwork, and Dedication Make the Nierman Difference

With Nierman, dental practices are never alone. No matter what the issue, Nierman’s team of more than 40 specialists are here to answer your questions, to help practices navigate the ever-changing world of medical billing and dental sleep medicine, and to give you the knowledge you need to level up your success. Nierman’s core values of commitment, growth, dedication, and passion are seen in every client interaction. With Nierman, clients always come first. The company’s world-class products, education, training, and services, combined with Nierman’s client commitment, create unsurpassed value. The company also believes deeply that success is dependent upon the collective energy, skills, and contributions of all of its team members. This allows Nierman to continuously improve, innovate, and facilitate growth for their team and the practices they support. Finally, and not to be missed, the company’s dedication and passion is what has driven it to uphold and advance its mission of helping dental practices implement dental sleep medicine, TMD and medical billing for over 32 years. Rose Nierman founded the cross-coding movement, and today, Nierman Practice Management continues to lead the charge.

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CHOOSINGappliances

An Evaluation of Oral Appliance Therapy Device Volumes: Is Size as Advertised? by Jerry Hu, DDS, D.ABDSM, D.ASBA, D.ACSDD, and Len Liptak, MBA

uring an Oral Appliance Therapy (OAT) consultation, many Dental Sleep Medicine practitioners provide patients with the buffet option. The patient is seated in the consultation room, and they are met with an array of different devices in varying colors, shapes, and sizes. Like the people in the buffet line, they don’t always make the choices that are best for them. In this situation, the wrong choice can be costly. It can lead to discontinuation of treatment, poor compliance, and pricey remakes when changing devices. How can dental sleep providers guide patients to select an OAT device that will be comfortable and increase the likelihood of continual, regular use?

“It is widely accepted that OAT device volume is correlated with comfort and adherence.”

18 DSP | Fall 2020

Volume is one of the characteristics that dental sleep providers and patients consider when selecting an OAT device. It is widely accepted that OAT device volume is correlated with comfort and adherence. Conversely, device discomfort is routinely cited by physicians as a reason they are reluctant to prescribe OAT. OAT device volume may also impact tongue space and posture, the degree of mandibular protrusion, and the expression of intraoral exostoses, which can impact treatment efficacy and side effects. Given the importance of OAT device volume, scant objectively recorded data is available to help providers and patients make informed decisions. To the best of the authors’ knowledge, no studies have systematically evaluated and reported on OAT device volume. Many manufacturers advertise device volume. Some claim that their devices are small. Others claim their devices are smaller. Yet others claim they’re the smallest. Further complicating the challenge is that OAT device samples are made on different sized dental casts. In other words, what the patient sees is not always what the patient gets. There is no standard dental cast baseline for the samples. One manufacturer offers a sample on a pediatric dental cast, for

example. Another uses a full-size dental cast with an ABO base. Another manufacturer’s sample omits the terminal molars on their dental casts and devices. Patients are not always aware of these subtle differences, but these differences can be significant in practice. This leads to the research topic – Are OAT device volumes as advertised? Multiple sets of five different types of custom OAT devices (n=14) were ordered. Each of these devices utilized the exact same set of digital dental sleep records. The intent of holding the dental records constant was to enable an accurate, objective, comparison of OAT device volumes. The five device types were: Nylon Strap (NS, Panthera n=3), Precision Manufactured (PM, ProSomnus n=3), Reverse Dorsal (RD, Respire n=3), Fulcrum Strap (FS, Somnomed Avant, n=3) and Traditional Dorsal (TD, Somnomed Flex, n=2). All

Figure 1: A classic Archimedes displacement method was used to calculate device volumes

CHOOSINGappliances manufacturers were blinded to the intent of the orders. A classic Archimedes displacement method was used to calculate device volumes. Each OAT device was submerged in water. The amount of water displaced was measured (in ml) to determine the volume for each OAT Device. Three cycles of measurements were made for each OAT device to control for measurement error. The data revealed a significant range in OAT device volumes, by device type. The average volume across all devices measured was 2.57 ml +/- 0.79. The PM style devices had the smallest average volume of the devices tested at 1.41 ml +/- 0.17, 55% smaller than the average of all devices measured. The TD style devices had the largest average volume at 3.81 ml +/- 0.17, 149% more volume than the average of all devices measured, and 270% larger than the smallest volume OAT device. Three of the five devices studied utilize a CAD/CAM manufacturing process. Two of the CAD/CAM devices, the PM and NS devices, are on the smaller end of the volume spectrum. The volume differences are statistically significant. However, the average volume of the third CAD/CAM device, the FS device, is not different than the RD type device in terms of statistical significance. Importantly, a visual inspection reveals that the variances in volume appear in three areas of the devices evaluated in this study: the lingual aspect, the anterior aspect, and the titration mechanism. The lingual aspect might be clinically significant as it pertains to tongue space. The anterior aspect might be clinically significant as it pertains to lip seal. The titration mechanism might be clinically significant as it could lead to discomfort in the buccal corridor. This in-vitro study establishes a foundation for additional research. One natural extension of this study would be to evaluate whether these devices, each made from the same dental cast, might result in different OAT device selections in the consult room. Another would be to evaluate whether these differences in OAT volume translate into different treatment results such as adherence, efficacy or side effects. In conclusion, this study provides an objective measurement of OAT device volumes. Different OAT device types exhibit

Figure 2

Figure 3

statistically, and likely clinically, significant differences in volume. Though the smallest volume device utilizes CAD/CAM production, providers should not assume that CAD/ CAM devices are smaller volume. Jerry Hu, DDS, D.ABDSM, D.ASBA, D.ACSDD, practices in Anchorage and Soldotna, Alaska. His practice is focused on Cosmetic, Implants, and Dental Sleep Medicine. He has published clinical research in all of these areas and has also lectured many times both nationally and outside of United States and won numerous awards for his treatment. Len Liptak, MBA, is the CEO of ProSomnus® Sleep Technologies. An award-winning executive with expertise growing and operating innovation-oriented businesses, Len is a founding member of ProSomnus, and co-inventor of the company’s flagship product. Len also serves on the company’s Board of Directors. Len earned an MBA from the University of Minnesota’s Carlson School of Management and a BA from Brown University. A lifelong learner, Len has completed executive education programs at John’s Hopkins, and is a member of the Young President’s Organization (YPO).

DentalSleepPractice.com

CLINICALfocus

Obstructive Sleep Apnea and Dental Implants Sleep Before You Drill

by John H. Tucker, DMD, DICOI, DABDSM, and Dennis R. Bailey, DDS, FAAOP, DABDSM

any patients are presenting for management of their sleep breathing disorder (SBD) that have had restorative procedures utilizing dental implants with subsequent prosthetic rehabilitation. There are specific and special concerns that require consideration, both in the pre-treatment phase and when planning treatment utilizing a mandibular repositioning oral appliance. Obstructive sleep apnea (OSA) is a disorder characterized by repetitive collapse of the upper airway during sleep, with consequences of nocturnal hypoxemia and recurrent arousals from sleep.1 The prevalence of OSA is significant and the incidence is increasing with greater obesity as well as aging of the population.2 In addition to decreased neurocognitive performance from recurrent nocturnal arousals, there exists an increased risk of fatal and nonfatal cardiovascular events as well as all-cause mortality in patients with more severe OSA.3,4 Recent evidence has demonstrated that the risk for cancer mortality and ischemic stroke carry a dose-response association with the severity of SBD.5 The history of dental implants can be traced back to 3000 B.C.6 Implant-borne restorations have become the standard of care in oral rehabilitation.7 The most important factor in implant treatment is the formation of a direct interface between the implant and the bone, without intervening soft tissue, a process called osseointegration. The success rate is now reported to be 92%-97% for implant supported fixed partial dentures.8 However, implants can and do fail. Early failures occur during the period of osseointegration in 40% of cases, while 60% fail after loading.9,10 Excessive biomechanical loading can have a deleterious impact on the implant fixture, abutment, or the implant restoration.11 Unfortunately I have personally treated numerous cases of screw loosening and/or fracture, abutment fracture, prosthesis fractures, porcelain fractures, and the most extreme,

20 DSP | Fall 2020

implant loosening and fractures. These calamitous situations have been documented in the literature.12,13 The International Classification of Sleep Disorders 3rd edition (ICSD3), states that sleep related bruxism (SB), also known as nocturnal bruxism, is a “repetitive jaw-muscle activity characterized by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible.”14 The gold standard for the diagnosis of SB is polysomnography. Bragger, et al. found technical complications associated with bruxism (prosthetic and implant problems listed below). Out of 10 bruxers, 6 had a technical complication. Impaired general health status was not significantly associated with more biological failures, but bruxism was associated with more technical failures.15 Anitua et al. reported 30 complications in 22 prostheses in 16 patients. Complications included porcelain fracture, abutment screw and implant fracture, abutment screw loosening, and de-cementation. Of the 172 patients in this study, 49 were diagnosed with OSA based on a simplified respiratory polygraphy (BTI APNiA, BTI Biotechnology Institute, Vitoria, Spain). OSA was found to be present in 13 of the 16 patients having prosthetic complications. “The highest AHI and thus the severity of OSA was identified in patients with a fracture complication related to an implant, a screw, or a porcelain failure. The frequency of prosthetic complications has been higher in patients with obstructive sleep apnea.”16 Bruxism may significantly increase both the implant failure rate and the rate of mechanical and technical complications of implant supported restorations.17,18 Bruxism has been reported to occur in approximately 12% of the population.19 It occurs predominately during sleep whereas the diurnal activity is mainly clenching. Sleep is comprised of two major phases, REM (Rapid Eye Movement) sleep and NREM (non-REM). NREM sleep has three stages, N1 sleep or stage 2 NREM that is a transitional stage be-

CLINICALfocus tween REM and NREM, N2 or stage 2 NREM a lighter stage of sleep that makes up about 50% of our sleep and stage N3 or stage 3 NREM that is also known as deep sleep or restorative sleep. The relevance of this is that the majority of sleep related bruxism (SB) occurs during N1 and N2 sleep.20 Anything that increases the amount of N2 sleep may also be associated with a greater amount of SB. This is important for a variety of reasons: 1. According to the ICSD3, SB is considered a movement disorder so an increase in sleep disruption may increase N2 sleep 2. This lends credibility to the fact that SB is mediated through the central nervous system 3. Any other sleep disorder, such as SBD, may impact sleep thus increasing N2 sleep that may be associated with an increased risk for SB to be present. The association of SBD and specifically OSA with SB may be 26% based on reports from patients and based on sleep study data SB may be between 33 and 54%.21 The management of SB has historically been the use of an intra-oral appliance often referred to as splint or night guard. It is well known that these devices do not control, reduce, or eliminate the SB but instead, are intended to protect the dentition.22 This is also true as it applies to dental implants as well as the prosthetic restoration of the implant. SB has the potential to increase the occlusal

load on the implant thus resulting in a higher risk for failure.23,24 This failure may be associated with bone loss around the implant similar to that seen in natural teeth.25 Another consideration that cannot be ignored is the health related consequences associated with a SBD, in particular OSA. The related consequences of a SBD that may also come into play and should be considered are: 1. A higher level of inflammation associated with hypoxia and oxidative stress 2. The association of the risk for diabetes with a SBD 3. A proven association between a SBD and periodontal disease26 All of this should be considered prior to any treatment through the use of appropriate screening techniques. Here are a couple points for readers to consider regarding implants, bruxism, and SBD: 1. Is it possible that focusing more on vertical as opposed to mandibular advancement that occlusal load might be reduced? Two studies are worth noting that seem to indicate that vertical opening may be as effective as advancement of the mandible.27,28 2. Clinicians who provide oral appliance therapy should consider that forces associated with the insertion and removal of an oral appliance (OA) on an implant crown may be damaging as well, especially during the removal

OSA was found to be present in 13 of the 16 patients having prosthetic complications

John H. Tucker, DMD, DICOI, D.ABDSM, has maintained a private practice in Erie, Pennsylvania since 1982. He is a graduate of the University of Pittsburgh School of Dental Medicine. Dr. Tucker has a special interest in the treatment of Obstructive Sleep Apnea. As a Diplomate of the American Board of Dental Sleep, he is exceptionally qualified to manage this serious problem with Oral Appliance Therapy. He has been actively treating patients in the Tri-State Erie area for the past ten years. Dr. Tucker founded Erie Dental Sleep Therapy, LLC, in 2007. Erie Dental Sleep Therapy, LLC, became the eighth AADSM Accredited facility in June of 2012. Dr. Tucker is passionate about educating the dental profession; he has presented approximately 1,700 hours of continuing education on treating the PAP intolerant patient with Oral Appliances Therapy nationally and internationally over the past six years. Dr. Tucker has also published numerous articles regarding Oral Appliance Therapy for OSA patients that are unable to tolerate PAP therapy. Dennis R. Bailey, DDS, FAAOP, D.ABDSM, is a general dentist with a practice limited to the management of Sleep Related Breathing Disorders utilizing oral appliances as well as Temporomandibular Disorders, Orofacial Pain, and related headaches. Dr. Bailey frequently lectures in the U.S. and internationally and has authored numerous articles and chapters on the topic of Sleep Medicine and on the use of Oral Appliances by the dentist. He is currently a visiting lecturer in the Orofacial Pain Program and is the Director of the Mini-Residency in Sleep Medicine for the Dentist at UCLA School of Dentistry. In December 2010, the textbook he co-authored entitled â&#x20AC;&#x153;Dental Management of Sleep Disordersâ&#x20AC;? was released and is available from Wiley-Blackwell. He is a past president of the American Academy of Dental Sleep Medicine (1998-1999). He has Diplomate status with the American Board of Orofacial Pain and the American Board of Dental Sleep Medicine and is a fellow in the AGD and the International College of Dentists.

DentalSleepPractice.com

CLINICALfocus

Figure 1: GEMPro

Figure 2: GEMPro data

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28.

of the OA. This may produce undesirable forces that could have a loading effect similar to that found with occlusal loading. To this end adequate block out around the implant crown may be advisable. There is no existing literature to support this topic, however, it is one to consider. Based on the information presented, when a patient presents with extensive wear, it may be another indicator of an undiagnosed SBD. The challenge for the dental practitioner has been how to determine if the bruxism is occurring during sleep, awake, or both prior to starting prosthetic restoration of the damaged dentition. GEMPro (DDME, Inc.) is a unique sleep wellness monitor that can be used in the privacy of the patient’s home for further assessment (Figure 1). This device monitors SpO2, EMG activity of the masseter muscle, snoring, body position, and heart rate (Figure 2). Based on the results obtained from a single night or multiple night screening with the GEMPro, the dental practitioner can objectively determine if the patient exhibits bruxism, SpO2 desaturations, snoring, and increased heart rate. This information can be used to determine if the patient should be sent for further diagnostics such as a sleep

study. The bruxism data can assist the practitioner in determining the appropriate treatment. Follow up studies may also be done to determine treatment efficacy. Rehabilitation of bruxism patients through the use of implants is a feasible alternative with implants of adequate length, diameter, and correct position. These factors can reduce the risk of treatment failure. Control of bruxism manifestations is critical for a successful treatment outcome as well as the longevity of the restoration. Patients need to be informed about potential technical complications that may generate additional fees. Prior to initiating treatment, the patient needs to be instructed about proper daily hygiene and accept this responsibility as well as maintaining appropriate recare (follow-up) appointments. If a patient presents with worn dentition and implants are a consideration in the treatment plan, consider the possibility of the patient being at risk for or having an undiagnosed SBD. Also consider the presence of other potential medical and health related conditions, as well as medications, that may be of concern. Identifying and addressing these issues before placing the implant may increase the rate of success.

Malhotra A, White DP. Obstructive sleep apnea. Lancet 2002;360:237–245. Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997;20:705–706. Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: An observational study. Lancet 2005;365:1046-1053 Punjabi NM, Caffo BS, Goodwin JL, et al. Sleep-disordered breathing and Mortality: A prospective cohort study. PLoS Med 2009; 6:e1000132. Nieto FJ, Peppard PE, Young T, Finn L, Hla KM, Farre R. Sleep-disordered breathing and cancer mortality: Results from the Wisconsin sleep cohort study. Am J Respir Crit Care Med 2012;186:190–194. (ME., 1995) Ring ME. Pause for a moment in dental history: A thousand years of dental implants: A definitive history - Part 1. Compendium 1995;16:1060-1069. Esposito M, Grusovin MG, Coulthard P, Thomsen P, Worthington HV. A 5-year follow-up comparative analysis of the efficacy of various osseointegrated dental implant systems: a systematic review of randomized controlled clinical trials. Int J Oral Maxillofac Implants. 2005;20:557–568. Wennerberg A, Albrektsson T. Current challenges in successful rehabilitation with oral implants. J Oral Rehabil. 2011;38:286–294. Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors contributing to failures of osseointegrated oral implants. (II). Etiopathogenesis. Eur J Oral Sci. 1998;106:721–764. Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factorscontributing to failures of osseointegrated oral implants. (I). Success criteria and epidemiology. Eur J Oral Sci. 1998;106:527–551. Ekfeldt A. Incisal and occlusal tooth wear and wear of some prosthodontic materials. An epidemiological and clinical study. Swed Dent J Suppl. 1989;65:1–62. Brunski JB. Biomechanical factors affecting the bone-dental implant interface. Clin Mater. 1992;10:153–201 Anitua E, Alkhraist MH, Pinas L, Begona L, Orive G. Implant survival and crestal bone loss around extra-short implants supporting a fixed denture: the effect of crown height space, crown-to-implant ratio, and offset placement of the prosthesis. Int J Oral Maxillofac Implants. 2014;29:682–689. Sleep related bruxism. In: International Classification of Sleep Disorders. 3rd ed. American Academy of Sleep Medicine. Darien, IL. 2014:p303-311. Bragger U, Aeschlimann S, Burgin W, Hammerle CH, Lang NP. Biological and technical complications and failures with fixed partial dentures (FPD) on implants and teeth after four to five years of function. Clin Oral Implants Res. 2001;12:26–34. Anitua E, Saracho J, Almeida GZ, Duran-Cantolla J, Alkhraisat MH. Frequency of Prosthetic Complications Related to Implant-Borne Prosthesis in a Sleep Disorder Unit. J Oral Implantol. 2017;43(1):1923. doi:10.1563/aaid-joi-D-16-00100 Chrcanovic BR, Kisch J, Albrektsson T, Wennerberg A. Bruxism and dental implant failures: a multilevel mixed effects parametric survival analysis approach. J Oral Rehabil. 2016; 43: 813-823. Chrcanovic BR, Kisch J, Albrektsson T, Wennerberg A. Bruxism and dental implant treatment complications: a retrospective comparative study of 98 bruxer patients and a matched group. Clin Oral Implants Res. 2016. Ref: Jul;28(7):e1-e9 2017 Manfredin D, Winocur E, et al. Epidemiology of bruxism in adults: A systematic review of the literature. J Orofac Pain 2013;27:p99-110 Lavigne GJ, Khoury S, et al. Bruxism physiology and pathology: an overview for clinicians. J Oral Rehab 2008 35;476-494 Lavigne GJ, Cistulli PA and Smith MT. Sleep Medicine for the Dentists An Evidence Based Overview. Quintessence Publishing 2020 Jagger R. The effectiveness of occlusal splints for sleep bruxism. Evid Based Dent 2008;9(1):23 Deo SS, Singh DP and Dogra N. Bruxism: Its multiple causes and its effects on Dental Implants: A Review. J Oral Health Craniof Sci. 2017;2:057-063 Kate MA, Palaskar S and Kapoor P. Implant failure: A dentist’s nightmare. J Dent Implants 2107;6(2):51-56 Zhou Y, Gao J, Luo L and Wang Y. Does Bruxism Contribute to Dental Implant Failure? A Systematic Review and Meta-Analysis. Clin Implant Dent relat Res 2016 Apr;18(2):410-20 Famili P. Obstructive Sleep Apnea and Periodontal Disease: Review of Established Relationships and Systematic Review of the Literature. J Dent and Oral Health 2018;1(4) Hu JC and Comisi JC. Vertical dimension in dental sleep medicine oral appliance therapy. General Dentistry July/August 2020 p69-76 Anitua E., Duran-Cantolla J, et al. Minimizing the mandibular advancement in an oral appliance for the treatment of obstructive sleep apnea. Sleep Med 2017 Jun;34:226-231

22 DSP | Fall 2020

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In Your Own Words

eamwork makes the dream work, right? It’s often stated that teams play a crucial role in the success or failure of Dental Sleep Practices. This issue we decided to go right to the source, to key team members, and ask them each the following three questions. 1. What does a day of DSM in your life look like? 2. What is (a) most challenging & (b) most rewarding about the role? 3. What are 3 must haves for you to work your magic? Here are the answers in Your Own Words.

Nichelle E. Sutton Clinical Sleep Specialist GoTo Sleep Center

Stacey C. Layman, DDS, D.ABDSM 1. As the lead clinical assistant my day is a constant adventure. Each day is different and brings its own challenges. On a daily basis I am looking at the next day as well as the week ahead. Preparedness is my motto. I’m not a fan of surprises unless they are flowers and chocolate! I make sure I have all of the devices I need for my deliveries as well as the supplies and required paperwork. Once the patients arrive, I bring them back and start by getting to know them or catching up with them. It’s important to me that patients know we aren’t a mill (none of that “get em’ in, get em’ out” crap here). We treat the whole person and care about them as people, not just their disease. I am cross-trained in the office so I have clinic days and front office days. 2. The most challenging part of my job is helping patients understand that the oral appliance is not a magic pill that will make all their sleeping problems go away. Some patients come to us expecting a cure-all, but many of these people have other medical conditions and medications that make quality sleep elusive. I invest a lot of time explaining the process and helping them understand that it may take several weeks to find their sweet spot

24 DSP | Fall 2020

(that point at which their device has normalized their sleep apnea). I ask them to be patient and don’t give up, we will get there. The most rewarding part of my job is the moment when I look in their eyes and “they get it” – when I see an excited, vibrant, and well-rested individual. Those are the moments I go home satisfied and fulfilled! 3. The three must haves in my life are flowers, chocolate and ... oh wait, we were talking about work. Sorry. a. Carestream 3600 scanner. Taking digital impressions instead of analog impressions is a game changer. Devices fit accurately and comfortably, making the delivery process a breeze. b. A software system that is designed for treating sleep apnea and not just a general dental software is hugely helpful. c. And last but not least, I cannot live without is my team!! Having a caring, supportive and encouraging team is the only way I am truly fulfilled.

Jessica Vasquez Director of Operations Sleep Better Austin

Max Kerr, DDS, D.ABDSM & Brandon Hedgecock, DDS, D.ABDSM 1. My role requires me to oversee all operations of the practice. I divide my time to ensure that I am being intentional and productive within the business. 30% of my time is spent overseeing department leads – Administrative, Clinical, Physician Liaison/Marketing. I ensure that each department is taking care of their down line and that every department is taking care of our patients and meeting business expectations. This includes meetings with team leads, looking for training opportunities, coaching and constant communication with leads on day to day operations and areas of opportunity.

EXPERT view 30% of time is spent on auditing each department and ensuring that our systems are being used and protocols are being followed. 30% of my time is focused on “What next?” Projecting and forecasting for the future of the business. Strategizing next steps. 10% of time is dedicated to admin and HR work. 2. The most challenging aspect of my role is balancing my time. Ensuring that I am present for my team and making sure I allow intentional time to look at what our next steps are for the business and patient outcomes to be successful. The most rewarding part of my job is hearing patient success stories. The everyday things we take for granted such as sitting through a movie without falling asleep or getting back in the same bed as your bed partner can be life changing milestones for our patients. Knowing that we are truly saving lives every day keeps our team going. 3. a. Dedicated team b. Supportive doctors & leadership c. Systems & processes

Tanya Bowling Sleep Coordinator Caffaratti Dental Group/ Innovative Sleep Concepts Jason Doucette, DMD, D.ABDSM 1. A regular DSM day for me is seeing new patients, using the Eccovision phayrngometer and rhinometer, taking impressions, delivering appliances and seeing patients for adjustments. Between patients I upload all document images (sleep studies, MD clinical notes, LOMN/RX, etc.), write letters to patient’s doctors letting them know how the patient’s progress is going (sleep MD, PCP, Cardio, Dentist, ENT), fax letters and any information requested, and return any phone calls that come in during the day from labs, patients, and doctor’s offices. 2. The most challenging thing about DSM is dealing with insurance companies. When billing insurance it is very important to make sure you have all documents

26 DSP | Fall 2020

needed to bill. This includes all clinical notes, a current sleep study, and LOMN/ RX from referring sleep physician. Even when you have all this information, some insurances will require additional information such as: lack of TMJ, perio charting, and x-rays. This is why it is nice to have GOGO Billing there to help. The most rewarding thing about DSM is seeing how our patient’s lives improve after wearing their oral appliances. They stop snoring, sleep better, have more energy during the day, headaches go away, anxiety and depression get better, and there are so many other health improvements I wish I could list them all. The best thing is all the hugs I get from patients because they are so happy with treatment. 3. a. Eccovision pharyngometer. This allows us to see the patient’s airway collapsibility and then how we are stabilizing the airway when putting the mandible in different verticals and protrusion. b. ITero Scanner. It is so nice being able to do digital impressions and being able to send them directly to our labs. c. Great sleep team to work with. Everyone in our office has an important role and without all of them our office would not be successful.

Samantha Church Best Sleep Champion Sleep Better Northwest Erin Elliott, DDS 1. Seeing patients, medical insurance documentation, insurance checks, and financials. 2. Troubleshooting when things don’t go as planned can be a real challenge. You know, not all patients’ anatomy is created equally. It’s incredibly rewarding when patients and spouses come back and are blown away by how much better they are feeling. 3. Must haves a. AM Aligners b. Home Sleep Tests c. Quality appliances and supportive lab reps

PRODUCTspotlight

Protect Dentistry with Panthera Sleep® Night Guard by Diane Robichaud, t.d.

ight guards, a sub-category of occlusal splints, are the most widely prescribed orthoses in dentistry. The recognized role of night guards is the protection of natural dentition and restorations from damaging parafunctional forces and, in some cases, headache relief and treatment of muscle soreness or TMJ pain.

The groundbreaking, teethprotecting Panthera Sleep® Night Guard is the smallest fullarch night guard on the market.

Night guards can be used as a permissive splint/muscle deprogrammer (Dawson) and as a muscle relaxation/stabilization appliance (Okeson).1,2 Splints can be placed on either the maxillary or mandibular arches and typically cover all the dentition on the respective arch. Thermoformed night guards are one of the most popular types because they are fast and easy since they can be made in office or inexpensively through a lab. However, they can be difficult to adjust, are usually not very durable, and have a resultant short lifespan. For long-term wear, a hard material is preferred in order to avoid increase in contractures.2

Panthera Sleep Night Guard lower and upper splints

Diane Robichaud, t.d., is a Panthera Dental Research and Development Council Member. She can be reached at diane@pantheradental.com.

Continuing their long-revered trend for innovation in dentistry, Panthera Dental has announced that the Panthera Sleep® Night Guard is now available. It is manufactured using the finest CAD/CAM technology which greatly reduces the need for appliance adjustment and allows for easy reproducibility. Additionally, the Panthera Sleep® Night Guard is comprised of Polyamide 12 (nylon material), the same 3D printed material used in the fabrication of their seminal Panthera D-SAD sleep apnea oral appliances. This medical grade material combines durable rigidity on the occlusal surfaces and comfortable flexibility on the buccal and lingual surfaces, enabling the guard to engage undercuts for retention rather than ball clasps, which can encourage tooth movement. Polyamide does not deteriorate in open air and does not need to be stored in water like hard acrylic splints. Nor does it become brittle or fracture under parafunctional forces as many thermoformed splints do. The splint does not need to be heated before seating like thermal acrylic splints. Also, Panthera Sleep® Night Guard won’t absorb odors, stains, and other gunk after only 30 days of use like dual laminate devices do. The ground-breaking, teeth-protecting Panthera Sleep® Night Guard is the smallest full-arch night guard on the market. It provides greater comfort and more robust protection than anything else available along with the accurate fit of the D-SAD and the laudable service and expertise you’ve come to expect from Panthera Dental. Easier delivery. Higher quality. Extra strength. Your patient’s dentistry will be the true testament to its effectiveness.

28 DSP | Fall 2020

Dawson P.E., A classification system for occlusions that relates maximal intercuspation to the position and condition of the temporomandibular joints, The Journal of Prosthetic Dentistry, 1996, V.76, N.1, 60-66 Okeson JP, The effects of hard and soft occlusal splints on nocturnal bruxism, J. Am. Dent. Assoc. 1987; 114:788-91.

BILLINGblocks

Game Changer by Randy Curran and Kyle Curran

ou have heard a cacophony of opposing views about everything from appliances and billing protocols to fees and accreditation; from sleep testing and sleep physician engagement to purple mountains majesty and amber waves of grain. No matter where you are in your Dental Sleep Medicine career, you have experienced some confusion about, well, about nearly everything. Ten years ago, pioneers in the Dental Sleep Medicine (DSM) field adroitly persuaded Medicare to recognize the importance of Oral Appliance Therapy (OAT) and they subsequently drafted a comprehensive policy. As is customary, private insurance carriers followed suit and consistent medical insurance reimbursement became commonplace. A significant barrier to treating patients was removed, and the number of dentists providing OAT grew significantly. So why, after a decade, do most DSM practitioners, despite their gusto and expertise, only treat one or two patients per month?

1. Greed

With insurance coverage for OAT came exploitation. Dentists were uncertain about what their fees should be. A cadre of willing hucksters took the podium at many weekend courses, and sickeningly took advantage of a system that hadn’t yet defined usual and customary allowable rates. In California, more

30 DSP | Fall 2020

specifically Los Angeles, it was like 1849 all over again. It was a veritable gold rush replete with the same ilk of con artists and unsuspecting marks that you saw back then. These charlatans showed slides featuring EOBs of $9,000 while encouraging attendees to charge upward of $15,000 for treatment. Permit me to put that into perspective; Medicare allowed approximately $1,300 for OAT in California. Unfortunately, that is rather low for quatlity treatment. However, the answer is not to bill an order of magnitude higher. This cash grab created a stereotype that many physicians still hold regarding DSM clinicians. Of course, this doesn’t apply to you, but shaking stereotypes is difficult. Just ask a Cubs fan.

2. Physicians Unfortunately but understandably, many of your physician counterparts bought the stereotypes of DSM practitioners as greedy gougers of the system. This has triggered frustration in the majority of dentists – professional providers with a focus on patient care and wellness. As Mark Murphy, DDS, deftly demonstrated in the last issue of Dental Sleep Practice, many physicians are still ill-informed about the benefits of OAT and how to collaborate with focused DSM professionals. The time must come for physicians to recognize the use of OAT for their PAP-intolerant and mild/moderate patients as the first line

THE RELIABLE HOME SLEEP TESTING SERVICE YOUâ&#x20AC;&#x2122;VE BEEN DREAMING ABOUT

BILLINGblocks of therapy. The onus is on every one of us to help inform, educate, and guide them to this truism. It’s good for them, for you, for the healthcare system, and most important – for the patients.

3. Reimbursement Expectations

Many practices… begin their DSM journey with the preconceived notion that they will collect at least $3,500 on every case.

The national average for OAT insurance reimbursement hovers around $2,300. I want to stress this is a national average and not specific to any region, state, or health plan. Many practices I speak with begin their DSM journey with the preconceived notion that they will collect at least $3,500 on every case. Why are they anchored to this misinformation? It’s an incorrect number that’s been bandied about by unknowing commercial vendors and others for some time. Whether it is done intentionally as a sales ploy or unintentionally despite supporting data, this over-promising leads to disappointment and frustration. Instead of providers doing cartwheels because they successfully treated a patient and received payment north of $2,500, they are disappointed and jilted. They were “sold” one thing but “bought” another. Cognitive dissonance rears its ugly head. I’m going to say this plainly – The #1 reason you should step into DSM is to help patients get the treatment they need. If you focus on that, the revenue will follow. I promise.

Randy Curran is the founder and CEO of Pristine Medical Billing. During the past 12 years, Randy has committed his life to helping those with sleep related breathing disorders obtain prior authorizations for coverage while ensuring providers receive fair compensation for care. Randy has been involved in the treatment of more than 38,000 patients while collecting over $85,000,000 for providers from insurance carriers through both contracting and claim submissions. Kyle Curran has been active in the Dental Sleep Medicine industry for the past five years and is currently the Director of Client Development at Pristine Medical Billing. During this time, Kyle has managed medical billing processes, training, and proper workflows for more than 100 dental practices across the nation. He stays abreast of the ever-changing field of medical insurance by participating in continuing education and practical experience. As a graduate with a business degree, he is able to help dental practices understand and implement practical business solutions to achieve sustainability in the Dental Sleep Medicine arena.

32 DSP | Fall 2020

4. Operations

Dental Sleep Medicine isn’t general dentistry. Protocols are different. A new workflow has to be implemented, but it has to be efficient and compliant with medico-legal and payor guidelines. How are you going to properly screen patients, correctly document treatment, and ensure maximum reimbursement? How are you going to do this when you have a hygiene check in op 3? This can seem daunting, particularly if you’ve been assured by someone selling a product or service that it’d be a walk in the park. Dental practice acts, laws, regulations, and Medicare and private insurance policies constantly change. How do you know if your patient’s plan allows for home sleep testing or if your state dental board permits you to order one? It can take quite a long time to develop that rapport, generate successful shared patient outcomes, and foster sense of mutual trust that is essential for these referral relationships. There is one noteworthy recent change that has at least a tangential effect on each of these four issues, and it’s a favorable shift for the DSM field. It makes implementing DSM and increasing cases easier than ever before. There is a path through this minefield of uncertainty. It’s called telemedicine. Creating strong relationships with local physicians is always the goal, and telemedicine is a desirable solution for many situations. Telemedicine opens doors to connect dental sleep medicine patients, sleep physicians, and dentists via virtual visits. Telemedicine is like the introduction of the iPhone. It will change the way DSM is practiced in a major way. Dentists now have the ability to connect with national sleep physicians to mutually work on driving more care to dental patients while staying 100% compliant. This game-changer is applicable for private insurance patients, and it will also work with Medicare patients, now that Medicare has modified their rules around telemedicine and face to face visits. A streamlined. consistent workflow with each and every patient regardless of the payer is now possible which positively addresses each of the hurdles I detailed. You still have to have an open mind, determination, and the right people and organizations around you. You can do this. Your patients need you.

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PEDIATRICS

Sleep Disorders are In Your Face by Sharon Moore

n part two of this four-part series, author, speech pathologist, and myofunctional practitioner Sharon Moore takes a deeper dive into the role of screening sleep, upper airway functions, and myofunctional disorders in the management of pediatric sleep disordered breathing.

Previously, we saw the ramifications of poor sleep on every aspect of a child’s development and functioning, making poor sleep a global health challenge.1,2,3 Furthermore, compromise can occur during critical periods of brain development in early childhood with a cascade of effects that can last a lifetime.4,5,6 The light at the end of this tunnel is that much of this is both avoidable and treatable, with dental teams playing a key role on the frontline for screening, education, and treatment of sleep disordered breathing. Up to 40% of 4 to 10-year-old children are affected by sleep problems, and they are truly ‘in your face.’ Dr. Peter Eastwood et al demonstrated that facial bone structure is predictive of obstructive sleep apnea (OSA).7,8,9,10 In fact, when a room full of ‘airway-focused’ health professionals gather, it is common to hear them predict potential sleep disordered breathing (SDB) from facial characteristics. Unfortunately, 80% children with sleep problems are missed, dismissed, or misdiagnosed despite existing signs and symptoms.

The Challenges of Identifying and Treating Sleep Problems

SDB is the second most common sleep disorder, and recognized as a contributor to insomnia, the most prevalent, suggesting SDB is under-estimated.11,12 There are several issues contributing to low diagnosis levels: • Not all sleep specialist centers recognize the full continuum of SDB: OSA, snoring, UARS, RERAs, and mouth breathing. • Although the Apnea Hypopnea Index measures apneas, it doesn’t acknowledge other degrees of airway collapse that disrupt sleep.13 • Interpretation of existing sleep tests may not accurately identify SDB. For example, while PSG (polysomnography) measures body and brain signals extensively, SDB that does not lower oxygen levels, may be dismissed. • A team care approach is critical; however, it is challenging to find compatible medical and allied health colleagues with the expertise and willingness to be part of a diagnostic sleep care team. • Nighttime waking diagnosed as insomnia could be related to SDB.14 The challenges of SDB diagnosis raise the question: How can we screen for it? Fortunately, dental teams are in the best seat in the house for the screening, education, and treatment of SDB.

34 DSP | Fall 2020

Sleep Screening

The simplest way to screen a child’s sleep is using validated questionnaires that evaluate sleep health broadly and give insight to the existence of SDB. These are easy to incorporate into the clinical intake process.15,16,17 Some validated questionnaires include: • BEARS (Bedtime Issues, Excessive Daytime Sleepiness, Night Awakenings, Regularity and Duration of Sleep, Snoring) • PSQ-SRDB (Pediatric Sleep Questionnaire – Sleep-Related Breathing Disorder scale) • SDSC (Sleep Disturbance Scale for Children) • CAST (Children’s Airway Screener Taskforce – under development) These questionnaires are predictive of SDB, in particular OSA. Symptom-based questionnaires can also be invaluable serving dually as education tools for patients. The gold standard option for identifying SDB is polysomnography (PSG) and important for some but not all children. It is not easily accessible or affordable for many, nor necessary. Fortunately, there are other useful tools to identify significant symptoms and whether PSG is advisable, like; video, overnight pulse oximetry and even apps like Snore-Lab that track the frequency and intensity of nocturnal audible breathing.

Upper Airway Screening

With SDB, the whole of the upper airway is under scrutiny and any functional disorders of the upper airway (UA) and orofacial

PEDIATRICS

The Dynamic Upper Airway System

wellspoken.com.au

Lifesaving functions:

A dynamic interplay between morphology and function.

breathing, eating, airway dilation and sensory feedback

Frontal Sinus

Upper Airway Zones 1

Nasopharynx

Velopharynx

Sphenoid Sinus Adenoid

Superior Turbinate Middle Turbinate Inferior Turbinate Maxilla

Eustachian Tube Orifice

Soft Palate Uvula Pharyngeal Wall

TMJ

1 2

Tongue

Soft Palate Uvula Palatine Tonsil Lingual Tonsil Vallecula Epiglottis

Oropharynx

Hypopharynx

Glottis Thyroid Cartilage Trachea

Lungs Mode of breathing: nose, mouth, upper chest, diaphragm

myofunctional (MYO) disorders, need to be identified. Multiple studies demonstrate the role of myofunctional intervention in successful management of pediatric SDB.18,19,20 UA and MYO screening go hand-in-hand. In SDB, narrowing or collapse of the UA can occur at multiple points, including collapse or narrowing of orofacial, nasal, pharyngeal or laryngeal morphology. Upper airway function is dynamically integrated with UA morphology and any restrictions or changes in morphology will change function and vice versa. Diagnosable disorders can occur in any part of UA from the front of the face to the larynx. Examples of this include dysphagia, dysphonia, nasal resonance disorder, epiglottis collapse related to laryngomalacia (this occurs in 3.9% of children presenting with SDB).21

Orofacial Myofunctional Screening

A MYO disorder refers to atypical function or rest postures in the mouth, face or throat and any co-existing parafunctional behaviors. To diagnose a MYO disorder, we look at:

Supraglottis

Subglottis

Upper Esophageal Sphincter Cricoid Cartilage Oesophagus

Stomach Gut, microbiome, digestive processes

Palatine Tonsil Back of Tongue Lingual Tonsil Vallecula Epiglottis

Hyoid Bone

Sphenoid Sinus Adenoid Eustachian Tube Orifice

Glottis Cricoid Cartilage Laryngeal Musculature Vestibular Folds Cricoid Cartilage Tracheal Rings

• Function: º Muscle rest postures º Muscle movement patterns: breathing, chewing, swallowing (in infants, sucking), and speech º Range, strength and control of movement of stomatognathic system º Any related parafunctions Then we consider factors that influence, or are associated with, those functions: • Morphology: º Skeletal: the size, shape and structure of the face and upper airway passages º Tissue: health of the soft tissues in the face and upper airway, both extra and intra-oral, nasal, and pharyngeal • Other relevant considerations: º Medical, dental or orthodontic, early developmental history

Sharon Moore is an author, speech pathologist and myofunctional practitioner with 40 years of clinical experience across a range of communication and swallowing disorders. She has a special interest in early identification of craniofacial growth anomalies in children, concomitant orofacial dysfunctions and airway obstruction in sleep disorders.

DentalSleepPractice.com

PEDIATRICS An example of a MYO disorder that exists in conjunction with, or resulting from, discrepancies in skeletal shape or size is a high, narrow maxilla, preventing the tongue resting in its ideal position within the upper dental arch. The maxilla may be distorted by a thumb or finger sucking habit, altering tongue rest posture to a low-fronted position impeding tongue suction to the maxilla during sleep which assists maintenance of an open airway.

Identifying UA and MYO Red Flags

To screen for SDB, it’s important to evaluate UA and MYO red flags. These clinical markers for SDB are considered alongside relevant medical and early developmental history, such as pre- and post-natal history,

Sleep Disorders are in your face

wellspoken.com.au

Myofunctional & Upper Airway Functional Red Flags

DAY

Atypical orofacial rest postures

Lips:

Low tone, low slung

Facial muscle tone and symmetry:

Tongue:

forward head posture, slumped body posture

Atypical/ dysfunctional orofacial functions

Breathing:

Sucking infants:

Saliva management:

Nasal function:

Oro-facial musculature:

Swallowing:

Speech:

Chewing:

Parafunctional habits

Grinding or clenching teeth (bruxism)

Nail biting

Finger sucking

Chewing objects1

UA functional disorder

Dysphagia

Dysphonia

Sialorrhoea

Resonance disorder

Velo-pharyngeal incompetence

Odynophagia

Odynophonia

Chronic cough

Vocal cord dysfunction

UA sensory symptoms

flaccid, open, everted

Velo-pharynx:

low, fronted, dentalized or interdental mouth, upper chest, audible, effortful, tachypnea

• limited range, control and/or strength of muscle movement of primarily: lips, tongue, jaw, soft palate • restricted ability to control tongue movement independent of the jaw • inability to lower or contract base of tongue, inability to elevate or contract anterior, mid- and posterior tongue

1 LM Corradi

Head, neck, and spine:

poor suck-swallowbreathe coordination, inability to latch

tongue thrust/swallow, fronted, dentalized, lateralized or interdental

drooling or xerostomia

fronted or lateralized alveodental or alveopalatal sounds

flaccid or low tone, asymmetrical

hypo- or hyper-nasal resonance, inability to blow nose, external or internal nasal collapse on ingressive nasal breath open mouth, excess lateral jaw motion, inadequate, asymmetrical, audible

- 2019 https://www.intechopen.com/online-first/oral-parafunction-aetiology-implications-and-relation-to-orthodontic-treatment

NIGHT

UA and/or myofunctional disorder during sleep

Lips: lips flaccid, everted, open

Tongue: collapse posteriorly into the pharynx, low, fronted, dentalized or interdental

Jaw: retro position mandible, open

Soft palate: vibrations, expiratory palatal obstruction, low postured contacting tongue

Nose: internal or external nasal valve collapse on in-breath

Epiglottis: laryngomalacia

Body Posture: unusual positions e.g. ‘snail', head extended back, neck extension or flexion

Bruxism

Breathing: • any audible breathing including snoring • any breathing interruptions including; stoppages, waking with gasp or startle, extended in-or out-breath • mouth breathing • signs of increased ‘work-of-breath; retraction (intercostal, suprasternal, costal margin), paradoxical abdominal breathing, accessory muscle use, nasal flaring, sternocleidomastoid contraction (head bobbing), forward posture, tachypnoea

Drooling

Larynx:

Muscle tension, vibration or narrowing at any point of the UA

stridor related to glottis closed or semiclosed, supraglottic muscle tension

As we are talking about function primarily in this article, these diagrams outline key functional features both diurnal and nocturnal, to screen for. However, they stand alongside both skeletal e.g. deviated septum, micro- or retrognathia, dolichofacial type and tissue e.g. venous pooling, swollen uvula, enlarged lymph or lingual frenum restrictions or anomalies that impede function. Other medical markers eg. obesity, hypotonia, reflux, middle ear effusion or laryngomalacia to name a few, must also be taken into consideration to complete the profile.

36 DSP | Fall 2020

PEDIATRICS feeding history, and diagnosed medical conditions or syndromes. This completes the picture of airway dysfunction or dysmorphology. Other medical markers, particularly those relevant to ENTs, form a critical part of the picture. These are covered in more detail in Sleep-Wrecked Kids and Snored to Death for a full discussion on ENT markers relevant to pediatric SDB.22,23

Triaging Medical Severity, Urgency, and Priority

After screening and identifying SDB, examining the interplay of presenting symptoms and their consequences to quality of a child’s life and health, it’s time to determine the urgency and severity of the problem with the aim of organizing earliest possible treatment to mitigate neuro-cognitive and behavioral consequences of untreated SDB. Underlying medical issues impeding dental or myofunctional treatment efficacy need to be prioritized (e.g. untreated allergy with chronic nasal obstruction or reflux that perpetuates a cycle of sinus and nasal congestion, middle ear effusion and enlarged lymph tissue).24 Signs that expedited intervention is required include: • Validated questionnaire scores indicating obstructive sleep apnea. • Any consistent abnormal breathing during sleep. • Poor quality sleep, including waking tired/unrefreshed, frequent unexplained awakenings, parasomnias, anxiety around sleep, extended head or body in odd positions, bed wetting after age 3-4, waking in a tangle of bedclothes. • Poor energy management and self-regulation, including ADHD-like behaviors, excessive fatigue or poor Quality of Life measures. In many cases, a team approach is required with other medical experts; ENT, sleep specialist, allergist, gastroenterologist, neurologist, or oral and maxillofacial surgeon. Untreated, medical issues can undermine any planned dental-orthodontic or myofunctional intervention.

9. 10.

11.

12.

13.

14.

15.

The Role of Education in the Quest for Great Sleep

Given myths and misconceptions that persist around the role of sleep health and SDB, the role of education in a clinical context cannot be ignored. Screening tools that offer opportunities to educate are like gold, and perhaps the most important start-point is to dispel common misperceptions about sleep. Once SDB and any co-existing UA or MYO disorder is identified, there is no time to lose. Normalizing oro-facial and UA functions need to start and continue until resolution and new healthy patterns are fully automated to support ongoing airway, dental, and occlusal health. Fortunately, dental teams are on the frontline of this battle for great sleep. With our ability to screen for and treat problems early, we can ensure children get a great night’s sleep every night.

16.

17.

18.

19.

20. 1.

4. 5. 6.

Karen Bonuck, Ronald D. Chervin and Laura D. Howe, ‘Sleep-Disordered Breathing, Sleep Duration, and Childhood Overweight: A Longitudinal Cohort Study’, The Journal of Pediatrics 166, no. 3 (2015), https://doi.org/10.1016/j. jpeds.2014.11.001. Dale L. Smith, David Gozal, Scott J. Hunter, Mona F. Philby, Jaeson Kaylegian, Leila Kheirandish-GozalImpact of sleep disordered breathing on behaviour among elementary school-aged children: a cross-sectional analysis of a large community-based sample European Respiratory Journal 2016 48: 1631-1639; DOI: 10.1183/13993003.00808-2016 Irina Trosman and Samuel J. Trosman Cognitive and Behavioral Consequences of Sleep Disordered Breathing in Children Sleep Medicine Center, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611, USA Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA Med. Sci. 2017, 5(4), 30; https://doi. org/10.3390/medsci5040030 Philby, M., Macey, P., Ma, R. et al. Reduced Regional Grey Matter Volumes in Pediatric Obstructive Sleep Apnea. Sci Rep 7, 44566 (2017). https://doi.org/10.1038/srep44566 Kheirandish-Gozal L, Sahib AK, Macey PM, Philby MF, Gozal D, Kumar R. Regional brain tissue integrity in pediatric obstructive sleep apnea. Neurosci Lett. 2018;682:118-123. doi:10.1016/j.neulet.2018.06.002 Rosemary S C Horne, Bhaswati Roy, Lisa M Walter, Sarah N Biggs, Knarik Tamanyan, Aidan Weichard, Gillian

21.

22.

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26.

M Nixon, Margot J Davey, Michael Ditchfield, Ronald M Harper, Rajesh Kumar, Regional brain tissue changes and associations with disease severity in children with sleep-disordered breathing. Sleep, Volume 41, Issue 2, February 2018, zsx203, https://doi. org/10.1093/sleep/zsx203 Owens & Chervin, ‘Behavioral Sleep Problems in Children’, https://www.uptodate.com/contents/behavioral-sleep-problemsin-children Sarah Blunden, ‘Behavioural Sleep Disorders across the Developmental Age Span: An Overview of Causes, Consequences and Treatment Modalities’, Psychology, no. 3 (2012): 249–56, https:// doi.org/10.4236/psych.2012.33035. Sharon Moore, ‘Sleep Disorders are in your face’, in The 2nd AAMS Congress (Chicago, 2017). Eastwood P, Gilani SZ, McArdle N, et al. Predicting sleep apnea from three-dimensional face photography. J Clin Sleep Med. 2020;16(4):493–502. Barry Krakow, Natalia D. McIver, Victor A. Ulibarri, Jessica Krakow, Ronald M. Schrader Prospective Randomized Controlled Trial on the Efficacy of Continuous Positive Airway Pressure and Adaptive Servo-Ventilation in the Treatment of Chronic Complex Insomnia VOLUME 13, P57-73, AUGUST 01, Open Access Published: August 07, 2019 DOI: https://doi.org/10.1016/j.eclinm.2019.06.011 Barry J. Krakow, Natalia D. McIver, Jessica J. Obando & Victor A. Ulibarri Changes in insomnia severity with advanced PAP therapy in patients with posttraumatic stress symptoms and comorbid sleep apnea: a retrospective, nonrandomized controlled study Military Medical Research volume 6, Article number: 15 (2019) Irina Trosman and Samuel J. Trosman Cognitive and Behavioral Consequences of Sleep Disordered Breathing in Children Sleep Medicine Center, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611, USA Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA Med. Sci. 2017, 5(4), 30; https://doi.org/10.3390/medsci5040030 Barry Krakow, Natalia D. McIver, Victor A. Ulibarri, Jessica Krakow, Ronald M. Schrader Prospective Randomized Controlled Trial on the Efficacy of Continuous Positive Airway Pressure and Adaptive Servo-Ventilation in the Treatment of Chronic Complex Insomnia VOLUME 13, P57-73, AUGUST 01, Open Access Published: August 07, 2019 DOI: https://doi.org/10.1016/j.eclinm.2019.06.011 Shahid A., Wilkinson K., Marcu S., Shapiro C.M. (2011) BEARS Sleep Screening Tool. In: Shahid A., Wilkinson K., Marcu S., Shapiro C. (eds) STOP, THAT and One Hundred Other Sleep Scales. Springer, New York, NY Chervin RD, Hedger K, Dillon JE, Pituch KJ. Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Med. 2000;1(1):21-32. doi:10.1016/s1389-9457(99)00009-x Oliviero Bruni, Salvatore Ottaviano, Vincenzo Guidetti, Manuela Romoli, Margherita Innocenzi, Flavia Cortesi and Flavia Giannotti, ‘The Sleep Disturbance Scale for Children (SDSC): Construction and Validation of an Instrument to Evaluate Sleep Disturbances in Childhood and Adolescence’, Journal of Sleep Research 5, no. 4 (1996): 251–61, https://doi.org/10.1111/j.1365-2869.1996.00251.x. Camacho M, Certal V, Abdullatif J, et al. Myofunctional therapy to treat obstructive sleep apnea: A systematic review and meta-analysis. Sleep.2015;38(5):669-675A. Guilleminault C, Huang YS, Monteyrol PJ, et al. Critical role of myofascial reeducation in pediatric sleep-disordered breathing. Sleep Med.2013;14(6):518-525. Leto V, Kayamori F, Montes MI, et al. Effects of oropharyngeal exercises on snoring: A randomized trial. Chest.2015;148(3):683-691. Thevasagayam M, Rodger K, Cave D, Witmans M, El-Hakim H. Prevalence of laryngomalacia in children presenting with sleep-disordered breathing. Laryngoscope. 2010;120(8):1662-1666. doi:10.1002/lary.21025 Sharon Moore, Sleep-Wrecked Kids: Helping Parents raise happy healthy kids one sleep at a time. (New York: Morgan James publishing 2019). David McIntosh, Snored to Death: Are You Dying in Your Sleep? (Maroochydore:, ENT Specialists Australia, 2017) Narang I, Mathew JL. Childhood obesity and obstructive sleep apnea. J Nutr Metab. 2012;2012:134202. doi:10.1155/2012/134202 Andersen IG, Holm JC, Homøe P. Obstructive sleep apnea in children and adolescents with and without obesity. Eur Arch Otorhinolaryngol. 2019;276(3):871-878. doi:10.1007/s00405-019-05290-2 David McIntosh, Snored to Death

DentalSleepPractice.com

CONTINUING education

Get with the Program

Dental Sleep Medicine and Electronic Medical Records by Richard B. Drake, DDS, D.ABDSM, and George S. “Gy” Yatros, DMD, D.ABDSM

Educational Aims

Electronic medical records (EMRs) are increasingly common in medical and dental practices. Their use is intended to streamline and standardize documentation and workflows. Dental sleep medicine (DSM) is an emergent market for EMR providers because of the intricate interdependency of documentation across disciplines, team members, and insurance companies. This article will help inform readers, so they understand commonly used terms, the benefits and limitations of EMR use, criteria to consider when evaluating EMR solutions, and how utilization may impact a DSM practice.

Expected Outcomes

Dental Sleep Practice subscribers can answer the CE questions online at dentalsleeppractice.com/ce-articles to earn 2 hours of CE from reading the article. Correctly answering the questions will exhibit the reader will: 1. Define the differences between different types of electronic records 2. Identify common obstacles to electronic medical record (EMR) adoption and utilization 3. Understand rationale for using a dental sleep medicine specific EMR 4. Grasp how an EMR can affect medical insurance claims processing 5. Evaluate common criteria for DSM EMR adoption for sleep testing, consultations, and other appointments

38 DSP | Fall 2020

“I

t has become necessary to develop medicine as a cooperative science; the clinician, the specialist, and the laboratory workers uniting for the good of the patient, each assisting in elucidation of the problem at hand, and each dependent upon the other for support.” – William J. Mayo at 1910 commencement address to Rush Medical College

The implementation of electronic records in medicine and dentistry coupled with workflow redesign create a time-saving, efficiency-boosting leap forward for practices across the country.1 Dentists lag slightly behind our physician colleagues when it comes to electronic records adoption. However, the trend is increasing, and one recently published article showed adoption to be 77% in a dental setting.2 Electronic records adoption trends will continue to increase consummate to federal incentives, improved technical support, and further integration between medicine and dentistry. What impact does this have on dental sleep practices, what considerations should we give to these shifts, and what effects will it

CONTINUING education have on the future of our practices and our profession?

What’s in a Name? EMR, EHR, EDR, DSM, etc.

If you have practiced dentistry as long as we have, you likely remember filing cabinets overflowing with paper charts, peg systems for ledger entries, and countless envelopes containing radiographs that seemed to escape their proper homes and end up in the ‘mystery patient’ box. These cabinets contained sections for patient demographics, progress notes, ledger entries, health histories, personal notes, and insurance claims. We even used red and blue pencils to document our patients’ dental conditions. All the information we needed to treat our patients within our dental offices was contained within these files. They just weren’t easy to maintain. Nor were they standardized for others to efficiently access. It’s difficult to comprehend how we operated over 30 years ago before we had electronic records. So, what is an electronic record? Plainly stated, it is the same information contained within those reams of paper charts but organized into a digital format to improve workflow and patient care. An electronic patient record is loosely defined as an information system designed to create, manage, and store data associated with a patient medical record. Since the 1980s, many terms have been used to refer to these records, including Computerized Patient Record, Computer Medical Record, and Automated Patient Record. Although these

terms are frequently used interchangeably, the two most common terms for electronic records are defined by HealthIt.gov as: Electronic Medical Records (EMRs): “Electronic medical records (EMRs) are digital versions of the paper charts in clinician offices, clinics, and hospitals. EMRs contain notes and information collected by and for the clinicians in that office, clinic, or hospital and are mostly used by providers for diagnosis and treatment. EMRs are more valuable than paper records because they enable providers to track data over time, identify patients for preventive visits and screenings, monitor patients, and improve health care quality.” Electronic Health Records (EHRs): “Electronic health records (EHRs) are built to go beyond standard clinical data collected in a provider’s office and are inclusive of a broader view of a patient’s care. EHRs contain information from all the clinicians involved in a patient’s care and all authorized clinicians involved in a patient’s care can access the information to provide care to that patient. EHRs also share information with other health care providers, such as laboratories and specialists. EHRs follow patients – to the specialist, the hospital, the nursing home, or even across the country.”3 EMRs are typically used in an office or group of offices to digitally maintain patient information for that specialty while also enabling that practice be more efficient through a synchronized, organized workflow. EHRs are designed to include a totality of the patient’s health information from various caregivers, labs, etc. and are designed to be

77% Electronic record adoption in a dental setting is

After practicing general dentistry for 13 years, Richard B. Drake, DDS, D.ABDSM, transitioned to solely practicing Dental Sleep Medicine 20 years ago. A Diplomate of the American Board of Dental Sleep Medicine (ABDSM), he has 2 locations in San Antonio, TX, treats a lot of patients, and catches a lot more fish. At least that’s what he said. Dr. Drake has a passion for teaching other dentists how to successfully implement dental sleep medicine into their practices. He is the co-founder of Dental Sleep Solutions, LLC and DS3 System for Dental Sleep Medicine Implementation. George S. “Gy” Yatros, DMD, D.ABDSM, has practiced dental sleep medicine for over 20 years and is a key opinion leading lecturer in the field of sleep-disordered breathing and dental sleep medicine. He has offices in Bradenton, Sarasota, and Tampa, FL devoted exclusively to the treatment of sleep disordered breathing. He is the co-founder 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), past president of the Manatee Dental Society, visiting faculty for The Pankey Institute and is an Affiliate Assistant Professor of the Department of Internal Medicine with the University of South Florida, College of Medicine.

DentalSleepPractice.com

CONTINUING education shared among caregivers (and even the patient). Most electronic records utilized in dental offices today fit the definition of an EMR.

The American Dental Association

The American Dental Association (ADA) has stated their position on electronic health records. An Electronic Dental Record (EDR) is defined by the ADA as “a combination of processes and data structures, used by dentists, for purposes of documenting or conveying clinical facts, diagnoses, treatment plans, and services provided. For [ADA] purposes, EDR will be used interchangeably with EHR.”4 While there is no deadline or mandate to switch to EHRs for dental offices (unlike our medical colleagues), the ADA does emphasize that since 2015, dentists treating Medicare patients will be subject to payment adjustments if they cannot successfully demonstrate Meaningful Use. What does Promoting Interoperability Programs (PIP), formerly referred to as ‘meaningful use’ mean for dentists and dental sleep medicine (DSM) practices? It primarily relates to reimbursement by federal programs such as Medicare or Medicaid via the Qualified Payment Program (QPP). If your practice is a Medicare or Medicaid provider, you may receive higher reimbursement for certain procedures if you qualify for Meaningful Use. But there is more to qualifying than just simply using a specific EMR. When considering whether to attain PIP certification, providers must weigh the non-trivial effort and cost against the potential increased income from higher reimbursement. In our

A “one size fits all” approach is detrimental to the providers.

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experience coordinating with over 1,000 DSM practices, most find that the additional effort and expense involved with PIP compliance does not offset the additional income they might receive.

EDR vs. DSM EMR; The Choice is Yours

One significant barrier to EMR utilization has been the fact that many EMRs subscribed to a “one size fits all” approach that is detrimental to providers. In these scenarios, practices find the functionality limiting with tabs and features that are not applicable to the specialty or area of practice.5 Anecdotally, this has been reported by innumerable DSM clinicians, including the authors. EDRs were designed to store dental data and improve dental procedure workflow. Theoretically, you could devise a way to treat your patients and appropriately document treatment with an EDR or even a chiropractic EMR, but those methods generally do not provide efficient DSM workflow and DSM-specific patient documentation. A DSM EMR can provide practices with systems, documentation templates, and workflow tabs relevant to compliance and efficiency particular to the field of dental sleep medicine. Examples of these software products include DentalWriter (Nierman Practice Management), imagn sleep software (Devdent), and DS3 (Dental Sleep Solutions, LLC). The following are some applications and functionality that DSM EMRs may provide: • Screening applications – The first step for dental offices getting involved in DSM is to have an effective system to help identify “at risk” patients. More than 22 million Americans suffer from OSA and an estimated 80% remain undiagnosed.6 This makes an effective screening tool a critical function. • Patient portal for sleep and health history – Interactive patient portals streamline patient intake and minimize time in the office; this is especially important as practices strive to mitigate COVID exposure risk. Confirm that any portal you use is compliant with all Health Insurance Portability and Accountability Act (HIPAA) guidelines as expressed by Health and Human Services.7

CONTINUING education • SOAP note creation – SOAP notes, an acronym for “Subjective, Objective, Assessment, Plan” have been commonplace in medicine for nearly 50 years, but this documentation framework is relatively unknown in dentistry.8 Many insurance payors require notes in the SOAP format and your physician counterparts are accustomed to this standard. As the old saying goes, “when in Rome…” A DSM EMR with standardized and customizable SOAP note templates will aid you in multidisciplinary communication and medical claims filing. • Communication facilitation with other providers – As DSM providers, it is our obligation to communicate with our patients’ other healthcare providers. With a typical dental sleep patient our offices generate nearly a dozen communiques with their other providers. This should include template letters and other forms of customizable correspondence so that you can efficiently and effectively articulate patient status to their primary care physicians and attending specialists. • Ability to file medical claims – Many EDRs cannot submit medical claims while others do but the authors could not identify one vendor that promoted this functionality as a core feature. Many insurance payors will only accept electronically filed medical insurance claims, and some such as Aetna and Cigna promise expedited processing compared to manually filed claims.9,10 Most DSM practices rely on medical billing as a large part of their success; an efficient medical billing system is essential. • Communication with third party service providers – One of the most daunting challenges to implementing DSM is that we, as dentists, cannot do this alone. Of course, we must coordinate with physicians. We also frequently communicate with ancillary service providers such as sleep testing companies, medical billers, dental labs, telemedicine platforms, and others. Some DSM EMRs integrate with these other third-party firms which can save you and your team time and

As DSM providers, it is our obligation to communicate with our patients’ other healthcare providers.

money by eliminating the need for unnecessarily redundant software systems or less convenient communication methods. • Cloud-based vs On-premise – While we have an admitted bias toward cloud-based software, it is the result of our own experiences coupled with the trending evolution of Software as a Service (SaaS). On-premise software solutions typically require greater capital expenditures, put the onus for security on the owner, and they can be challenging to scale across multiple locations. SaaS usually involves a relatively low subscription fee, security and updates are managed by the third-party provider, and the service can be readily networked across numerous locations.11 • Ease of use and user support – As with any software purchase, ease of use and continual support are crucial to adoption and effectual utilization. Difficulty navigating digital records and steep learning curves have been cited as reasons for discontinuing use of electronic records by general dentists.12 Robust onboarding support and continued coaching for dentists and teams have been shown to be critical to a DSM practice’s success.

Bad News & Good News – Insurance Audits & Practice Transitions

As mentioned previously, electronic claims submission via a DSM EMR can expedite payments. With the upside of insurance DentalSleepPractice.com

CONTINUING education

A DSM EMR can expedite payments.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

payments is the unlikely but possible downside of a medical insurance audit. Complying with medico-legal and payor guidelines is critical. It is our position that medical records and dental charts should never be mixed. In the event of an audit from either a dental or medical insurance group, it is recommended that the insurance auditor has only the information he or she needs and that it is organized in a familiar and standardized method. Imagine a medical auditor looking through pages of your dental software, confused by radiographs, treatment plans, periodontal charting, and communication from periodontists. A well-organized DSM EMR should ensure any audit processes are conducted smoothly and painlessly for all involved. Another novel reason to separate your dental and DSM records is to increase the future value of these businesses. Once your DSM practice is up and running it will be a distinct business within your business and will have its own value. A growing number of general dentists are opting to leave “bread and butter” dentistry and transition to exclusively practice DSM. Maintaining a separate EMR and EDR will ensure that when the time comes to sell your practice, you can get a valuation for your dental practice while retaining ownership of your DSM practice. That business will essentially live within your DSM EMR. The value of both separately is frequently much greater than combined. We have worked with many offices who give testament that this separation totally changed their practice and economic future for the better. Bill Scheier, DDS, D.ABDSM recently sold his Cape Cod, MA dental practice while

retaining his DSM practice. Dr. Scheier stated, “I am thankful that many years ago I took some good advice and began utilizing software exclusively designed for managing a dental sleep practice. At the time I was just looking for a better way to treat my DSM patients with no vision of the future sale of my dental practice. I realize now that the decision to separate my DSM practice allowed for the smooth transition to my dedicated dental sleep practice.”

Get Started Now!

The single biggest mistake we see is offices delaying implementation of a DSM EMR. These well-intentioned dentists proclaim, “after I start delivering devices regularly then I’ll invest in a DSM EMR”. This is the monody of a fledgling DSM practice. Without the innovative efficiency of a DSM EMR, most dental offices will face mounting frustration, molehills will become mountains, and they will fail to launch or gain meaningful traction. When contemplating the purchase of a DSM EMR there are numerous factors to consider. This article is not intended to be an exhaustive treatise defining the rationale for the use of a DSM EMR. Nor is it designed to provide a comprehensive list of criteria to inform your buying decision. Instead, we are confident this article will make you a more savvy and informed consumer so you can make the leap into the future. With an efficient DSM workflow you can ensure compliance with relevant guidelines, unmoor yourself from archaic documentation processes, and be free to focus on delivery of the care your patients deserve.

“Will Electronic Health Records Help Save Me Time?” HealthIT.gov, The Office of the National Coordinator for Health Information Technology, 9 Apr. 2019, www.healthit.gov/faq/willelectronic-health-records-help-save-me-time. Chauhan, Zain, et al. “Adoption of Electronic Dental Records: Examining the Influence of Practice Characteristics on Adoption in One State.” Applied Clinical Informatics, vol. 09, no. 03, 2018, pp. 635–645., doi:10.1055/s-0038-1667331. “What Are the Differences between Electronic Medical Records, Electronic Health Records, and Personal Health Records?” HealthIT.gov, The Office of the National Coordinator for Health Information Technology, 2 May 2019, www.healthit.gov/faq/what-are-differences-between-electronic-medical-records-electronic-health-records-and-personal. “General Questions About EHR.” ADA Member Center, American Dental Association, www.ada.org/en/member-center/member-benefits/practice-resources/dental-informatics/electronic-health-records/ehr-faq-index/general-questions-about-ehr-not-in-matrix. Kokkonen, E. W. J., et al. “Use of Electronic Medical Records Differs by Specialty and Office Settings.” Journal of the American Medical Informatics Association, vol. 20, no. e1, 2013, doi:10.1136/amiajnl-2012-001609. “Sleep Apnea Information for Clinicians.” SleepApnea.org, American Sleep Apnea Association, www.sleepapnea.org/learn/sleep-apnea-information-clinicians. “Health Insurance Portability and Accountability Act of 1996.” U.S. Department of Health and Human Services, Office of The Assistant Secretary for Planning and Evaluation, 10 Oct. 2016, aspe.hhs.gov/report/health-insurance-portability-and-accountability-act-1996. Podder, Vivek. “SOAP Notes.” StatPearls [Internet]., U.S. National Library of Medicine, 11 Apr. 2020, www.ncbi.nlm.nih.gov/books/NBK482263/. “Electronic Claims.” Aetna Claims Payment and Reimbursement, Aetna, www.aetna.com/health-care-professionals/claims-payment-reimbursement/electronic-claims.html. “Electronic Data Interchange Vendors.” Cigna Healthcare Providers, Cigna, www.cigna.com/health-care-providers/coverage-and-claims/submit-claims/electronic-data-interchange-vendors. Munk, Daniel. “Cloud-Based Vs. On-Premise Servers.” Forbes, Forbes Magazine, 22 Mar. 2019, www.forbes.com/sites/forbestechcouncil/2019/03/22/cloud-based-vs-on-premise-servers/. Thyvalikakath, Thankam P, et al. “A Usability Evaluation of Four Commercial Dental Computer-Based Patient Record Systems.” Journal of the American Dental Association , U.S. National Library of Medicine, Dec. 2008, www.ncbi.nlm.nih.gov/pmc/articles/PMC2614265/.

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CONTINUING education

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Legal disclaimer: Course expires 3 years after publication date. The CE provider uses reasonable care in selecting and providing accurate content.The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

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Get with the Program: Dental Sleep Medicine and Electronic Medical Records by Richard B. Drake, DDS, D.ABDSM, and George S. “Gy” Yatros, DMD, D.ABDSM

1. Electronic Medical Record (EMR) and Electronic Health Record (EHR) are often used interchangeably, but there are differences in their definitions and applications. a. True b. False 2. Practices using Meaningful Use-certified EMRs may qualify for _________. a. Reduced tax liabilities b. Higher reimbursement rates c. Audit waivers d. None of the above 3. The acronym EDR means _________. a. Electronic Digital Recording b. Electroencephalogram Dental Records c. Electronic Dental Records d. None of the above

6. Cloud-based software solutions typically have greater upfront costs than On-premise software solutions. a. True b. False 7. Some medical insurance payors _______. a. Will only accept electronically filed claims b. Process electronically filed claims more expeditiously c. Both A and B d. Neither A nor B 8. A dedicated dental sleep medicine EMR can potentially ___________. a. Simplify the medical insurance audit process b. Provide appliance lab fee discounts c. Empower you to sell your dental practice while retaining your sleep practice d. Both A and B e. Both A and C

4. It is estimated that ____% of OSA sufferers are undiagnosed. a. 20% b. 50% c. 80% d. 94%

9. Reasons cited for discontinuation of EMR use include ___________. a. Difficult navigation b. Steep learning curves c. Both A and B d. None of the above

5. SOAP is a commonly used acronym in medicine which stands for _________. a. Subjective, Obstructive, Apnea, Patients b. Subjective, Objective, Assessment, Plan c. So, Only, Acronyms, Please d. None of the above

10. One recently published report showed dentists’ electronic records adoption rates to be ____________. a. Equal to physicians’ electronic records adoption rates b. 77% c. 38% d. Increasing 3% annually DentalSleepPractice.com

LASERfocus

LightScalpel 10,600 nm CO2 Laser Procedures in Pediatric Patients Martin Kaplan, DMD, and Peter Vitruk, PhD

Why 10,600 nm CO2 Laser?

Soft tissue surgical lasers have many advantages over traditional scalpel surgery, cryosurgery and electrosurgery. However, not all lasers are equally efficient at both cutting the soft tissue and coagulating and hemostasis because light absorption in the soft tissue varies with wavelength.1-3 As illustrated in Figure 1, some dental laser wavelengths (around 1,000 nm, such as diodes and Nd:YAG) are efficient coagulators, but inefficient scalpels since they are poorly absorbed by the soft tissue. Other dental laser wavelengths (around 3,000 nm, such as Erbium lasers) are well absorbed by the water-rich soft tissue and are great at cutting but are not as efficient at coagulating and hemostasis. The 10,600 nm CO2 laser wavelength it is not as good as Erbium laser at cutting (but is a much better coagulator),2 and not as good as diode/ Nd:YAG laser wavelengths at coagulating (but is a much better scalpel).2,3 The 10,600 nm CO2 laser’s coagulation depth closely matches blood capillary diameters.2 The radiant energy of the CO2 laser is used directly to photo-thermally vaporize (cut, incise, ablate) and, at the same time, photo-thermally coagulate the soft tissues. The CO2 laser is a “What You See Is What You Get” surgical soft tissue laser with minimal collateral thermal effects that are sufficient for sealing blood vessels, lymphatics, and nerve endings; the surface bacteria are efficiently destroyed4 on incision/ablation margins. The modern flexible fiber CO2 lasers from LightScalpel, Inc. (Bothell, WA, USA) use scalpel-like ergonomic autoclavable handpiece (Figure 1) for (a) cutting, (b) ablation, and (c) photo-thermal hemostasis and coagulation. The right-angle, pen-sized, tipless LightScalpel handpiece permits easy and convenient access to the soft tissue within the oral cavity of patients of all ages, including infants. An important built-in safety feature is a sub-millimeter superficial depth of laser beam incision5 at low power settings (see Figure 1), which

Figure 1: Laser-tissue incision with focused (0.25 mm spot size) laser beam; incision depth is 0.3-0.4 mm for 2 W SP F1-6 at 3-4 mm/sec hand speed. Defocused beam (> 1-2 mm spot size) with reduced fluence does not incise, but coagulates the tissue. The handpiece is pen-sized, autoclavable and uses no disposables. LightScalpel CO2 laser angled dental tipless handpiece is pen-sized, autoclavable and uses no disposables.

44 DSP | Fall 2020

makes the CO2 laser a gentler and more forgiving tissue vaporization instrument in comparison with a scalpel, electro-surge, or hot glass diode surgery. Also quick switch from cutting to coagulation mode is enabled by simply defocusing the beam (laser beam fluence dropping below the ablation threshold of 3 Joules/cm2).2 For the CO2 laser, its excellent coagulation efficiency is due to the close match between the sub-100 µm photo-thermal coagulation depth2 and the oral soft tissue blood capillary diameters of approximately 20-40 µm.6

Minimized Bleeding for Enhanced Visibility and Precision

The enhanced hemostatic ability and precision of the CO2 laser is especially valuable in visible (esthetic) zones. The CO2 laser surgical removal of the tissue presented in Figures 2-8 illustrates excellent coagulation and hemostasis during soft tissue ablation.2 Incisions with minimal bleeding, or entirely bloodless incisions, provide great visibility of the cut site, and thus higher precision for a minimized tissue trauma and better esthetic outcome.7 For example, Figures 2 shows the use of LightScalpel LS-1005 CO2 laser (2 watts SuperPulse Repeat Mode with F1-6 through F1-8 settings) for soft-tissue crown lengthening of the maxillary incisors and for labial frenum revision. Both procedures were performed during the same visit while the patient received local anesthesia. No sutures were placed. Figure 2 presents the self-correction of a rotated tooth #9 after frenum revision. Laser frenectomies in Figure 3 resulted in spontaneous closure of midline diastemas. In comparison with traditional scalpel surgery, the precision of CO2 laser ablation

LASERfocus allows for sub-millimeter control over tissue vaporization depth, see Figure 1. The CO2 laser accuracy is especially important for highly vascularized areas. For example, the 14-year-old patient in Figure 4 had a CO2 laser lingual frenectomy performed during which a sublingual vein was exposed and coagulated (sealed) with defocused laser beam. As a result, no sutures were needed and the surgical wound was left to heal by secondary intention. Infant frenectomy is another successful range of LightScalpel CO2 laser procedures that drastically improve the quality of life and breastfeeding for the infants and mothers. Figure 5 summarizes the case of 4 weeks old bottle-fed baby, born at 8 lbs. 6 oz., not able to breastfeed and failing to gain weight during first four weeks of her life. The baby exhibited fussiness and gassiness post feeds and choked often during feeds. Oral exam revealed “wrinkled-looking” gingiva (possible sign of dehydration) and a restricted lip frenum that was corded, thick and tight, and an anterior, tight, calloused and short tongue-frenum causing a significant tongue mobility reduction (see Figure 5A). Figure 5B illustrates the clean blood-free laser ablation. Release of tension and ability to flange the lip is now evident. During the tongue tie release the salivary glands were never involved, lasing was stopped once the restrictive tie appeared to be released enough for proper function and thee tongue is easily elevated. There were also two other areas of ablation during tongue tie release: at the anterior tip of the tongue, and at the insertion into the anterior of the lingual aspect of the mandible. At the 7-day follow-up (see Figure 5C) the mother reported feeding times were more efficient and baby’s weight gain was 1 lb. 11 oz. in the 7 days since surgery. At 3 months follow up the baby now weighed 20 lbs. (9072 gm). There were no more feeding symptoms and the baby was doing well. Unfortunately, the baby never returned to breast. The CO2 laser is also an excellent tool to remove the excess soft tissue. Many pediatric patients require banding of molars, but an overlying operculum gets in the way of placing appliances on these teeth. Figure 6 presents the LightScalpel LS-1005 CO2 laser

B. C. A. B. C. A. Figures 2A-2C: A: Diastema and rotation of tooth #9. Pre-op view. B: Immediate post-op. Note excellent hemostasis and clean margins. C: Post-op view final. Diastema closure and self-corrected rotation of tooth #9.

Figures 3A-3C: A: Pre-op view showing thick maxillary labial frenum and diastema. 3B: Immediate post-op view with good hemostasis. No sutures were placed. C: 4 weeks post-op with healed tissue.

Figures 4A-4C: A: Pre-op view. Lingual frenum restricts range of motion. B: Intra-op view. Exposed sublingual vein was coagulated and sealed with defocused laser beam. C: Immediate post-op tongue-tie release. Anterior view with noticeably improved tongue lift

Martin Kaplan, DMD, completed his undergraduate degree at the University of Massachusetts and then attended Tufts University School of Dental Medicine. After earning his D.M.D. degree, he completed a pediatric residency at Montefiore Hospital in New York. He is a member of: American Academy of Pediatric Dentistry, Massachusetts Academy of Pediatric Dentistry, American Dental Association, Massachusetts Dental Society, Academy of Sports Dentistry, Massachusetts Breastfeeding Coalition, Breastfeeding USA. When not practicing dentistry Dr. Kaplan enjoys Ballroom Dancing and Karate in his spare time. Peter Vitruk, PhD, is a founder of the American Laser Study Club and LightScalpel, Inc. in Bothell, WA, and a member of The Institute of Physics, London, UK. Dr. Vitruk can be reached at 1-866-589-2722 or pvitruk@lightscalpel.com

DentalSleepPractice.com

LASERfocus operculectomy (3 watts SuperPulse Repeat Mode F1-7) prior to band placement. Tissue hemostasis allows for banding to happen immediately after CO2 laser procedure â&#x20AC;&#x201C; bands were seated shortly after operculectomy was

Figures 5A-5C. A: Pre-op view of restrictive lip tie (top) and tongue tie (bottom). B: Immediate post-op view of released lip tie (top) and tongue tie (bottom) with good hemostasis. C: 7 day post-op view of healed lip tie (top) and tongue tie (bottom).

Figures 6A-6C. A: Pre-op view of operculum visible on mandibular 1st molar. The bands cannot be seated due to tissue interference. B: Immediately post-op view. Laser ablated the thick interfering tissue. Note lack of bleeding. C: Bands were seated properly and without discomfort during the same visit the operculectomy was performed.

Figures 7A-7C. A: Pre-op view. Gingival hyperplasia due to poor oral hygiene. B: Intra-op view with laser markings prior to incision. C: 2 weeks post-op view shows good tissue healing.

46 DSP | Fall 2020

performed, in the same visit. Local anesthetic may be required in some cases.

CO2 Laser Use in the Presence of Orthodontia Hardware Gingival hypertrophy caused by orthodontic positioning and poor oral hygiene as well as overlying operculum are common problems during orthodontic therapy.7 Drug-induced hyperplasia presents another challenge for some orthodontic patients.7 Additionally, orthodontic devices attract bacteria and thus exacerbate the inflammation; periodontal disease often worsens in adolescents with fixed orthodontic hardware.7 Figures 7-8 demonstrate completely bloodless CO2 laser gingivectomy around the mandibular incisors in the orthodontic patient. CO2 laser gingivectomies, such as the ones presented in Figures 7-8, help improving the esthetics and oral health; they also allow for more ideal bracket placement and quicker treatment with less appointments. Gaining access to impacted tooth or teeth is often necessary in order to place orthodontic braces. With conventional scalpel surgery, many problems occur when placing brackets, such as sutures breaking before brackets are bonded. Brackets will not bond properly if enamel is wet due to bleeding. Clean, bloodless enamel is necessary for enamel acid etching and bonding of the composite resin. Using the CO2 laser to expose an impacted tooth produces dry surgical field thus creating conditions required for immediate bracket bonding. The CO2 laser-assisted cuspid exposure procedure is shown in Figure 9. This quick CO2 laser treatment allows access for bracket placement, saving the patient months of waiting for the tooth to erupt on its own. The CO2 laser provides a clean, nonbleeding border. The CO2 laser straight and angled handpieces, illustrated in Figure 1, permit a convenient reach into areas that may be obstructed by braces. Once an impacted tooth is exposed by laser ablation, the bloodless surgical field is ready for the next step. The orthodontic traction hook can be bonded to the exposed enamel immediately after ablation during the same visit saving time for both the patient and clinician. An important safety consideration is the heating rate of the orthodontia that could be

LASERfocus accidentally exposed to a direct laser beam. Due to the differences in the light reflectance of stainless steel at different wavelengths,8 the wavelengths of approximately 800 nm– 3,000 nm (NIR-diodes, Nd:YAG and erbium lasers) are absorbed 50-250% stronger than CO2 laser wavelengths around 10,000 nm. Such high reflectivity by stainless steel, makes the CO2 laser the safest wavelength around stainless steel orthodontia. When compared to lasers, electrosurgical units present a different safety challenge of conducting electrical currents by orthodontic hardware during accidental contacts with electrosurgical electrodes.

With CO2 laser-assisted oral surgery, sutures are often not necessary, unlike with scalpel procedures. Laser wounds are often left to heal by secondary intention, as presented in Figures 2-8. Studies have shown, that there is a diminished risk of scarring and wound contraction associated with CO2 laser surgery.9 Laser-induced wounds heal with greater fibroblast proliferation, with young fibroblasts actively producing collagen. Laser wounds also have been reported to contain smaller amounts of myofibroblasts (cells responsible for wound contraction), compared to scalpel wounds.9 Secondary intention healing and lack of scarring are especially important for treating lesions located in esthetic/visible zones.

Reduced Post-Operative Pain and Discomfort It is important to avoid charring or causing excessive thermal damage to soft tissue. The experienced CO2 laser surgeon using the proper laser settings and hand speed will have small (sub 50 microns thick) zones of thermal necrosis.5,9 Patients report less post-operative pain and discomfort with laser surgery.9 The healing process associated with CO2 laser surgery is enhanced and less painful than with cryosurgery or electrosurgery.9

Summary The many uses for a soft tissue CO2 laser in pediatric dentistry and orthodontics, such as gingivectomies, frenectomies, exposure of impacted teeth, and others, feature min-

Figures 8A-8C. A: Pre-op view of thick hyperplastic gingiva. B: Immediate post-op view. Note excellent hemostasis. C: 2 weeks post-op view.

Tissue Healing

Figures 9A-9C: A: Laser-marked outline of impacted tooth. B: Intra-op view of CO2 laser excision. C: Immediate post-op view of impacted tooth exposed to assist with eruption.

imal blood loss and reduced discomfort for the patients. In comparison with other dental laser wavelengths (circa 1,000 nm for diode and Nd:YAG lasers and circa 3,000 nm for erbium lasers), the CO2 laser wavelength exhibits the least absorption rate by the stainless steel orthodontia hardware, and the optimum coagulation depth closely matching gingival blood vessel di- The CO2 laser is also an ameters. The CO2 laser ablation depth excellent tool to remove can be controlled to a few tenths of a millimeter, which characterizes this the excess soft tissue. wavelength as a safe and gentle soft tissue removal tool, while the sub-100 micrometer coagulation depth (significantly better than hot glass diodes)2,5 allows for enhanced, scar-free healing of highly vascular oral tissues secondary intention.5,9 The accuracy and precision of CO2 laser surgery are increased by the visibility of the surgical field not being obscured by bleeding.

1. 2. 3. 4. 5. 6. 7. 8. 9.

Jacques SL. Optical properties of biological tissues: a review. Phys Med Biol. 2013;58:37-61. Vitruk P. Oral Soft Tissue Laser Ablative & Coagulative Efficiencies Spectra. Implant Practice US, 2014;7(6):22-27. Vogel A, Venugopalan V. Mechanisms of pulsed laser ablation of biological tissues. Chem Rev. 2003;103(2):577644. Cobb C, Vitruk P. Effectiveness of a Super Pulsed CO2 Laser for Removal of Biofilm from Three Different Types of Implant Surfaces: An In Vitro Study. Implant Practice US. 2015;8(3):14-20. Riek C, Vitruk P. “Incision and Coagulation/Hemostasis Depth Control During CO2 Laser Lingual Frenectomy”, Dent Sleep Practice. Spring 2018:32-38. Yoshida S, Noguchi K, Imura K, Miwa Y, Sunohara M, Sato I. A morphological study of the blood vessels associated with periodontal probing depth in human gingival tissue. Okajimas Folia Anat Jpn. 2011;88(3):103-9. Gama SK, De Araujo TM, Pinheiro AL. Benefits of the use of the CO2 laser in orthodontics. Lasers Med Sci. 2008;23:459-465. Wolfe WL, Zissis GJ. The Infrared Handbook. Office of Naval Research: Washington DC; 1985: 7-81. Glazkova A, Vitruk P. “CO2 Laser Surgery Post-Operative Pain and Healing: A Partial Literature Review”. Dent Sleep Practice. Winter 2019:28-34.

DentalSleepPractice.com

COMMUNICATIONS

The #1 Struggle in a Dental Sleep Practice Isn’t What You Think by Michael Cowen

ow would you answer the question – “What is the #1 Struggle in a Dental Sleep Practice?” Would you cite the challenge of getting your whole team on the same page? Maybe you would quote the astonishing number of times patients say “no” when their quality of life hangs in the balance. In looking outside of the practice, you might mention the chasm that seemingly separates the dental and medical communities from much needed multidisciplinary collaboration.

86% cited a lack of collaboration or ineffective communication for workplace failures

48 DSP | Fall 2020

Well, if you agreed with those answers, we would have been on the same page - until two years ago. With over 17 years personally working in sleep medicine and dental sleep medicine (DSM), I have witnessed these challenges firsthand in many offices across the nation. These experiences have made it abundantly clear there is only one underlying struggle wreaking havoc on dental sleep practices everywhere: The #1 struggle in every dental sleep practice is communication. As humans, we struggle with the strenuous task of communicating effectively with other people. We assume that because those around us speak the same language, they understand us. That couldn’t be further from the truth. The research about workplace communication strikes a familiar chord. In a study performed by Fierce, Inc. and cited by Salesforce, Inc (SFCO), more than 1,400 executives, employees, and educators were polled on the impact of poor communication in the workplace. The statistics are staggering:

• Over 70 percent of individuals either agree or strongly agree that a lack of candor impacts the company’s ability to perform optimally1 • Nearly 100 percent (99.1) prefer a workplace in which people identify and discuss issues truthfully and effectively1 • 86% cited a lack of collaboration or ineffective communication for workplace failures2 Left unchecked, poor communication can cause significant harm to your team culture and practice revenue. Conversely, by identifying effective communication as a pivotal component to every aspect of your dental sleep practice, transformation begins.

Team Communication

Your dental team members are some of the most important people with whom you communicate on a daily basis. You will continue to be the bottleneck in your own practice until your team is able to understand you. When leading your team into DSM, it is paramount that you understand where communication breaks and how to effectively combat that breakdown in a way that is repeatable. The first place to start is understanding the roles that exist in your dental practice and how they sync with the roles needed in a dental sleep practice. While there are unique scenarios (specialists, sleep only practices, etc), these roles (figure 1) accurately reflect the majority of GP offices that have implemented DSM to their current practice structure. Additionally, we

COMMUNICATIONS have found through our VIP data metrics that once teams have clarified their roles, they typically experience more than a 30% increase in the conversion from screening to patients moving forward with diagnostic testing. Once you have clarified the appropriate roles, it is imperative that you find the right people to fill those roles. This is a critical step that requires both your direction as the leader and your team’s buy-in. If either of these components are missing, the result will be a Figure 1 lack of ownership and synergy among team members. If your team is struggling to own their new roles, you’ll want to revisit this point of clarifying and assigning roles. TIP: If you have already started your dental sleep program, ask your team what role they have and what responsibilities they own in that role. You might be surprised by the results. is the estimated number of people Accountability is the next in the United States that die each vital step in communicating year from heart disease with sleep roles and responsibilities with apnea as a complicating factor. your team. What does suc– American Sleep Apnea Association cess look like in your dental sleep practice? Is it the number of patients identified through hygiene? Or the number of treatment plans accepted that month? Better question – does your team know what success is and how it’s measured? According to best-selling author and marketing guru, Donald Miller, “When you confuse, you lose.”3 In following Miller’s lead, keep your goals SMART (simple, measurable, attainable, realistic, time-based). It is your responsibility as a leader to establish the goals for your practice, then clearly communicate them to your team.

38,000

Michael Cowen, CEO and Founder of Awaken2Sleep, started his journey in sleep medicine in 2003 performing in-lab sleep studies as a classically-trained pediatric sleep technician at Loma Linda Children’s Hospital in Southern California. After recognizing his calling to passionately assist others to help their own patients, Mr. Cowen went on to become an expert in the Business of Sleep Medicine, building and developing a network of sleep centers/DME companies across the United States. In 2015, seeing an opportunity to bring testing and awareness to the life-threatening condition that almost took his daughter’s life, he founded Awaken2Sleep, a company whose vision is to empower dental providers and their teams to treat patients with sleep apnea.

Remember you are treating patients with a potentially life-threatening condition. Effecting positive change in their lives is your superpower. Don’t squander it by only measuring dollars. Once you have defined roles, clarified responsibilities, and communicated goals, you are on the right path. Now let’s discuss your workflow.

Workflow Communication

Have you ever been to a weekend course with an amazing presenter? Afterward, all you wanted to do was replicate their workflow, process, and success; then you discovered that it falls apart in your practice. This is a common problem. Multiple factors come into play, including: number of practitioners, size of team, experience level of team members, location of practice, insurance payor mix, and patient volume. But the most consistent, glaring differences in every practice are their team members. People are unique, bringing their own set of skills, abilities, and challenges. Your dental sleep practice is a complex living organism whose ability to thrive is entirely dependent on your team. DSM workflow is comprised of many fairly simple team-led steps such as the screening process, scheduling, testing/diagnostics, case presentation, and billing protocols. While none of these steps are terribly difficult, as an aggregate, they are complex. Due to the number of steps, there are myriad opportunities to get tripped up or experience breakdown. To avoid or overcome these common obstacles, first, you have to know they exist, and then create a plan of action with your team. In his book No-Fail Communication, Michael Hyatt aptly states, “writing your intention produces clarity, increases trust, and enables execution.”4 Spend the time to write down your plan and communicate it effectively to your team. Ameliorate your communication, and the processes will improve. You won’t regret it, and your team will appreciate the newfound clarity and direction. 1. 2. 3. 4.

50 DSP | Fall 2020

https://fierceinc.com/employees-cite-lack-of-collaboration-for-workplace-failures/ https://www.salesforce.com/blog/2012/09/nick-stein-workpost-2.html Miller, Donald. Building a Storybrand. USA. HarperCollins Leadership. 2017 Hyatt, Michael. No-Fail Communication. USA. Michael Hyatt & Co. 2020

What is 02 Day? A day devoted to help all people recognize and address hidden airway / breathing problems to transform their lives and realize their potential. Learn How You Can Help Yourself and Others How We Breathe is How We Live VISIT US NOW AT

www.globalo2day.org #AirwayHealthBestDefense Learn more about airway issues and your sleep at: www.airwayhealth.org 355 Lexington Avenue | New York, NY 10017 | 212-297-2193

PRODUCTspotlight

Building Physician Trust with Preferred OAT Designs by Mark T. Murphy, DDS, D.ABDSM

arning physicians’ trust in OAT requires that we utilize device designs that demonstrate better efficacy, are within the designated precision tolerances, and have exceptional patient comfort and compliance. We could call that the ‘gold standard’ of OAT. A recent survey of prominent Dental Sleep Medicine clinicians exhibited a keen understanding of this. Device Fit, Size, Durability and Biocompatibility, the attributes most closely aligned with preferences of sleep physicians, all ranked significantly higher than attributes that are less aligned with the preferences of sleep physicians such as Ease of Delivery.1 We would all prefer the easiest delivery, but most would NOT be willing to trade Fit, Size, Durability or Biocompatibility for it. Secondarily, yet very important, is that precision milled devices like those from ProSomnus® Sleep Technologies, have fewer adjustments at delivery and at follow up visits. That saves time – chair time and patient time. If we want to earn physicians prescriptions for OAT instead of CPAP, we must evolve from the artisanal handmade varietals to the newer precision designed OAT device alter-

Figure 1: JDSM Abstract Publishing July 2020: An Evaluation of the Starting Mandibular Positions for Oral Appliance Therapy (OAT) Devices Types: Is Accuracy as Expected? Authors: Jerry Hu, DDS, D-ABDSM, D-ASBA, D-ACSDD; Mark Murphy DDS, D-ABDSM; Len Liptak, MBA; Sung Kim; Dave Kuhns, PhD.

52 DSP | Fall 2020

natives. Let us examine the risk and tradeoff values for each of these characteristics.

Fit

Fit does not mean ease of insertion. Rather it refers to the precision approximation of the retainer-like platform. When the fit is excellent, teeth do not move.2 Prevention of this side effect by design is predictable today with the precision milled hard PMMA platforms. Nylon and soft lined OAT devices, even if milled or printed, do not provide the retainer-like fit that prevents unwanted movement.3,4 Fit also refers to how well the device manufacturing replicates the prescribed starting position. A recent comparative series demonstrated variability across most manufacturing that exceeded the standard AADSM guidelines for device design (Figure 1).

Size

If we want to earn more prescriptions, the OAT device must be comfortable to wear. The primary measures of patient comfort have been overall size, bulk, and preventing irritation and side effects. Multiple evaluations of different manufacturers’ devices made for the same patient have yielded data showing that the ProSomnus precision OAT devices are significantly smaller than comparable predicates. Most recently, a late breaking abstract for the 2020 AADSM (Fig. 2), compared volumes using the Archimedes volume displacement test. The precision OAT devices were 30% smaller than their nearest comparable (nylon strap design) and 66% smaller than the traditional dorsal style predicates. Even the new fulcrum strap OAT device design, a milled device platform with an additional soft liner bonded in, was nearly double the volume.

Durability

Simply put, a monolithic material without moving parts or pieces would present as the most durable platform. The ProSomnus [IA]

PRODUCTspotlight

Figure 2: JDSM Abstract Publishing July 2020: An Evaluation of Custom Oral Appliance (OAT) Device Volumes. Authors: Jerry Hu, DDS, D-ABDSM, D-ASBA, D-ACSDD; Len Liptak, MBA.

Iterative Advancement Device has no additional materials than the control cured precision milled PMMA. The strength surpasses other comparable device strength and is still smaller. Even the ProSomnus [PH] Precision Herbst-style Device with two Herbst arms added showed superior strength to other predicates. The arms bent at the failure point while preventing catastrophic failure of the entire device.5 Milled precision fit component parts add strength when mixed materials are present.

Biocompatibility

Monolithic control cured materials are the new standard for OAT devices. The density and lack of porosity appear healthier, harbor less bio-gunk, and are easier for the patients to keep clean. The addition of metal Herbst arms or jackscrews always presents an added material compatibility risk. Printed nylon materials are monolithic, but laser melting is not control cured and they are quite porous. The TAP devices utilize a nickel-free alloy on their attachment mechanism but still have the artisanal handmade acrylic. Dual soft liner materials delaminate, stain more, and the porosity harbors far more biogunk.

Easy Delivery

Some devices are more forgiving at initial delivery and would therefore be considered ‘easier to seat.’ This comes with a price. The ‘forgiveness’ may involve additional flexibility that allows for unwanted tooth movement. One of the main disadvantages of liners is that they mask errors in impressions and bites that that you probably want to know about. Similarly, the presence of ball clasps usually indicates a device that is only retentive at those locations. That leaves the

Figure 3: ProSomnus Platform Devices Size and Strength vs Predicate, Company Data on File.

remainder of the ‘forgiving’ fit at greater risk. The presence of ball clasps may increase the likelihood of unwanted tooth movement. Physician preferences towards OAT is largely predicated on how we treat patients and with what generation of OAT devices. Their concerns are Efficacy, Patient Comfort, Side Effects, Compliance, Insurance Coverage, and our Credential Qualifications. Using better devices, with better efficacy and patient comfort, along with fewer side effects will help cross the chasm between PAP and OAT as first line treatments for OSA. Until some new material comes along with the level of precision, strength, and biocompatibility of milled PMMA, we should not compromise ‘easier to seat’ for the characteristics that physicians want, and our patients need. 1. 2. 3. 4. 5.

ProSomnus Online Customer Survey, April 2020. Vranjes et al, “Assessment of Potential Tooth Movement and Bite Changes With a Hard-Acrylic Sleep Appliance: A 2-Year Clinical Study”; JDSM Vol. 6, No.2 2019. Norhem, et al, “Changes in lower incisor irregularity during treatment with oral sleep apnea appliances” Sleep Breath (2017) 21:607–613. Uniken Venema J A.M., Stellingsma C, Doff MHJ, Hoekema A. Dental side effects of long-term obstructive sleep apnea therapy: A comparison of three therapeutic modalities. J Dent Sleep Med. 2018;5(2):39-46. Internal Third-Party Strength Test, ProSomnus Sleep Technologies (2019).

Mark T. Murphy, DDS, D.ABDSM, is an American Board of Dental Sleep Medicine Diplomate and has practiced in the Rochester area for over 35 years. He is the Lead Faculty for Clinical Education at ProSomnus Sleep Technologies, Principal of Funktional Sleep, serves on the Guest Faculty at the University of Detroit Mercy School of Dentistry and as a Regular Presenter at the Pankey Institute. He has served on the Boards 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. He lectures internationally on Leadership, Dental Sleep Medicine, TMD, Treatment Planning, and Occlusion.

DentalSleepPractice.com

RISKmanagement

Next-Level Strategies to Protect Your Practice by Bre Cohen

OVID-19 has hit the dental industry hard. Closing doors for months is a big blow to any practice and while traditional insurance is great, chances are it didn’t cover your business interruption during this pandemic. So, how will you handle the next adverse event? For many, that thought makes them cringe and for good reason. However, entrepreneurial dental practices are finding ways to protect their business risks that fall outside of traditional insurance through Enterprise Risk Management programs like those from Strategic Risk Alternatives. These programs have been utilized by Fortune 500 Companies for decades and Strategic Risk Alternatives saw a need in the market to make these programs available to small-to-midsize companies and did just that.

“When COVID-19 hit, dental practices that utilize our program were able to recoup cash flow losses in a matter How Does it Work? Much like a 401k helps you use tax-adof days through vantaged dollars to prepare for retirement, their 831(b). ” the Enterprise Risk Management Program – Bill McKernan, President of Business Development, Strategic Risk Alternatives

by Strategic Risk Alternatives helps you use tax-advantaged dollars to prepare for unforeseen risk. It utilizes US Tax Code 831(b), which helps businesses set tax deferred income aside for risks that fall outside of traditional insurance. This serves as a lifeline for companies going through a difficult time and includes COVID-19-type disruptions as well as other cashflow disruptions such as: • Contingent Business Interruption • Political Risk • Supply Chain Interruption

Bre Cohen is the Business Development and Marketing Manager for Strategic Risk Alternatives.

54 DSP | Fall 2020

• Key Employee Loss/Critical Illness • Payroll Protection • and more… “When COVID-19 hit, dental practices that utilize our program were able to recoup cash flow losses in a matter of days through their 831(b). If you own a successful dental practice, consider the advantages of setting pre-taxed dollars aside for unforeseen risks big or small.” says Bill McKernan, President of Business Development at Strategic Risk Alternatives. “Unforeseen risk is real, and it happens every single day. With our program you’re able to make your practice whole again and rest a little easier at night.”

Other Programs for Dental Practices

Strategic Risk Alternatives also offers a Dental Protection Plan program to help practices warranty their work. With a clearly defined warranty you can increase patient retention and use pre-tax dollars to pay for rework. Strategic Risk Alternatives works with the practice to custom design a defined warranty program based on individual practice needs. Through this program, the practice sets aside money from transactions and puts it in their 831(b) Dental Protection Plan to fund warranties for their work. Depending on the terms the dentist sets, the warranty may require a patient to come back once a year to check the work and honor the warranty. This creates customer peace of mind, retention, and loyalty. In addition, you are building a war chest to pay for any issues that do arise. Interested in learning more? Contact Strategic Risk Alternatives by visiting their website, strategicriskalternatives.com/DPP or calling Bill or Ed at (208)424-2249 for a free assessment and to learn more about protecting what you have worked so hard to build.

MITIGATE RISK THROUGH TAX ADVANTAGED DOLLARS

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PROTECT YOUR PRACTICE WITH NE X T LEVEL STRATEGIES info@dentistprotection.com (208)424-2249 www.dentistprotection.com

SLEEPhumor

...The Lighter Side of Sleep Apnea

56 DSP | Fall 2020

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