Dental Sleep Practice Summer 2021 by MedMark, LLC

Struggle of the Juggle Managing More Sleep in a Busy Restorative Practice by Teresa Power with Drs. Jason Doucette, Brandon Hedgecock, and Marc Newman

HealthyStart: Nearly 60 Years of Innovations

New Technology & Plans for the Future SUMMER 2021 | dentalsleeppractice.com

PLUS

Continuing Education

HST, Telemedicine, and the Impact on Dental Sleep Practices Supporting Dentists Through PRACTICAL Sleep Apnea Education

by Jagdeep Bijwadia, MD, and Greg Manning, DDS

INTRODUCTION

Pandemics, Snake Oil, and OAT

ack in the Spring issue of Dental Sleep Practice, my dispatch was from New Orleans – just before I drove home to Arizona. I was still uncomfortable boarding a plane. Still, glimmers of hope shone through the tunnel’s end. Here we are three months later, and I’m embarking on a flight to Utah to run a marathon. We haven’t just turned a corner, we’ve changed lanes, shifted gears, and we’re in hot pursuit of normalcy. The tunnel is no more. We’re awash in the light of a bright future. I am making you a promise. This missive is the last time I reference the pandemic in a letter from the editor. Effective vaccines are available to nearly everyone, and unsurprisingly, dentists have stepped up to help administer them. Vaccination sites are ubiquitous. They aren’t housed in large sports complexes anymore because those facilities are now being utilized for their intended purpose – hosting large, well-attended sporting events. Numerous companies in the dental sleep sphere have seized opportunities during The Great Pause we just lived through to focus on innovation. This led to the creation and launch of several new revolutionary appliances. Some friends just returned from an exhilarating CE event in Las Vegas. More live CE courses are announced daily. We’re hurtling toward a better future. There’s a fount of new papers and posters pending publication that reinforce the effectiveness of OAT. Telemedicine’s adoption has been accelerated, remote patient monitoring is realizing widespread use, and inventive business models centered on sleep health and total wellness are popping up like wildflowers. Public confidence in venturing out is heightening, and safety mandates that are no longer necessary are waning. We’re going to restaurants, ballgames, CE events, and our dental appointments. The most recent ADA data shows that practice production, consumer confidence, and overall patient volume is the highest it’s been in more than a year. This is fantastic news. It’s been a lot of work, but now we can all sleep better. Or can we? The hard work related to dental sleep medicine is not over. We’re still seeing only an iota of the overall prescriptions for OSA treatment. As the recent Agency for Healthcare Research and Quality (AHRQ) report questions the effectiveness of PAP therapy, we must also consider the

paucity of quality longitudinal or cross-sectional studies related to OAT. Failure to do Jason Tierney so will relegate us to an undesirable predicament as the one currently facing the PAP industry. The hard work must also continue on a micro level. Far too often I’ve seen way too many dentists fall prey to snake oil salesmen, false purveyors of golden tickets, or veritable get-rich-quick schemes. Are there products and services that can flatten, shorten, and smooth the trail to dental sleep medicine success? There sure are. Selecting the right appliances for the right patients, incorporating a sleep testing workflow that works for your situation, executing marketing that is targeted to your patient demographic, leveraging coaching services that are customized for your team, and coordinating with capable, experienced billers are all key to ameliorating dental sleep practice processes. But I want to be clear – There is NO frictionless, easy, guaranteed path to dental sleep success. No company can do it for you. You want to effectively treat more sleep patients, boost your production, garner accolades from thankful spouses and referring physicians alike? You have to do the work. You can’t be an enviable dental sleep practice without providing enviable, life-improving dental sleep therapy. You cannot be the noun without doing the verb. It just doesn’t work that way. So go register for that course – learn. Meet with the sales rep that’s been calling you about her appliance – try one. Map a plan. Communicate the plan to your team. Screen your patients. Take action. Execute. Again. And again. One step at a time. Pelé’s words have never been more apropos, “Success is no accident. It is hard work, perseverance, learning, studying, sacrifice, and most of all, love of what you are doing or learning to do.” DentalSleepPractice.com

CONTENTS

Cover Story

HealthyStart: Nearly 60 Years of Innovations, New Technology and Plans for the Future

For nearly 60 years, Dr. Earl Bergersen has given kids a healthy start. Healthy sleep starts even before childhood. See what this could mean for your newest patients.

Practice Management

Struggle of the Juggle: Managing More Sleep in a Busy Restorative Practice

by Teresa Power Team won’t get on board? Don’t have the time? Should you do sleep only 1 day each week? See how prolific OAT providers manage dental sleep in their bustling practices.

Pediatrics

Let’s Face It: Not Just About OSA by Sharon Moore Sharon Moore shares the final installment in her crucial series on pediatric SDB and the vital role dentistry can play.

2 DSP | Summer 2021

Continuing Education

Home Sleep Testing, Telemedicine, and the Impact on Dental Sleep Practices by Jagdeep Bijwadia, MD and Greg Manning, DDS Dentistry, home sleep testing, and telemedicine are coalescing to simplify processes and improve access to care. Get educated. Get CE. Get moving.

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CONTENTS

Publisher’s Perspective

The Roaring 20s by Lisa Moler, Founder/CEO, MedMark Media

18 Bigger Picture

The Great Equalizer: Provisional Oral Appliance Therapy by Randy Clare We don’t need more appliances. We need more dentists treating more patients. Randy Clare provides some ideas about how to make it happen.

46 Marketing

Dental Sleep Marketing… Online or Offline? by Max Kerr, DDS, D.ABDSM and Elias Kalantzis OAT? SEO? ROI? Not all appliances are created equally. Nor is marketing for dentistry and sleep. These marketing trends will surprise you.

48 Clinical Focus

Transcending AHI by Steve Lamberg DDS, D.ABDSM Is AHI really the best measurement for OSA severity? What other criteria should be considered for a more accurate diagnosis?

50 Product Spotlight 22 Medical Insights

The Whole World is Screwed… If All You Have is a Screwdriver by Madan Kandula, MD Madan Kandula, MD shines a light on the failings of sleep professionals, so we can build a better future together.

26 Expert View

In Your Own Words

DynaFlex is Your Partner in Telemedicine The pandemic led many to shift their models to get patients the help they need. DynaFlex helps bring that idea home.

51 Product Spotlight

Tips for Estimating & Presenting Out-of-Pocket Costs to Patients when Billing Medical Insurance by Courtney Snow and Rose Nierman Patients want to know what they’ll have to pay before agreeing to treatment. Here are actionable tips to help boost your case acceptance rate.

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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

Laser-focused to Reduce Snoring

Creative Director/Production Manager Amanda Culver | amanda@medmarkmedia.com

by Dr. Harvey Shiffman OAT and PAP aren’t the only therapies for OSA? Getting laser-focused could help more of your patients.

eMedia Coordinator Michelle Britzius | emedia@medmarkmedia.com

More dentists are making the leap to sleep-only practices. What warnings and advice do they have for you?

38 Billing Blocks

Summer 2021

Marketing & Digital Strategy Amzi Koury | amzi@medmarkmedia.com

Social Media & PR Manager April Gutierrez | medmarkmedia@medmarkmedia.com Webmaster Mike Campbell | webmaster@medmarkmedia.com Front Office Administrator Melissa Minnick | melissa@medmarkmedia.com

52 Clinical Focus

Dental Mental Network by Dr. Brett E. Gilbert and Sue Jeffries Dentistry is stressful. Self-care allows you to better care for others... but how?

56 Seek and Sleep DSP Wordscape

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.DentalSleepPractice.com Subscription Rates 1 year (4 issues) $149 | 3 years (12 issues) $399 ©MedMark, LLC 2021. 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.

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PUBLISHER’Sperspective

The Roaring 20s

ere comes summer – we are already halfway through the year – many of us hit the ground running into 2021 – a robust reboot of the “Roaring 20s!” During this past year, we have all had plenty of time to think about our personal and professional lives, what works and what needs to be changed. It’s definitely time to get back to business.

Lisa Moler Founder/CEO, MedMark Media

6 DSP | Summer 2021

Here are some interesting and positive facts from an ADA Health Policy Institute survey collected in January. • Patients are back! As of the week of January 18, patient volume was estimated at 80% of pre-COVID-19 levels, on average. Staffing in dental offices was at 99% of pre-COVID-19 levels and four out of five employee dentists were being paid fully. • Dentists are realizing their worth! At the beginning of the year, nearly a third of dentists had raised fees. Those who needed some extra help were proactive, taking out loans, reducing their dental team hours, and changing suppliers to those more appropriate to their goals. Retirement rates have not changed due to COVID-19. • Practices are ready to roar! The sector has recovered nearly fully in terms of hiring and employment. Based on vaccine rollout and perceptions, full recovery of dentistry is anticipated by the summer or fall. Research and development continues to bring new products and techniques to dental specialties, and now, it’s time to figure out how to stay ahead in this very competitive marketplace. One valuable way is letting MedMark publications educate you about products, services, and techniques that can add to your armamentarium and boost your patients’ options. The more choices that patients have for treatment, the more ways that you can expand your practice’s scope and profits. This issue of Dental Sleep Practice features a cover story on Earl O. Bergersen, who developed OrthoTain® technology and the

HealthyStart® system. Bergersen’s primary focus has been centered on the technological development and clinical implementation of better diagnostic and therapeutic systems and identifying access to care. Teresa Power’s article, “Struggle of the Juggle,” discusses adding DSM to a busy restorative practice, with stories of three dentists from three different time zones who are building their sleep practices and making an impact on patients’ lives. Drs. Jagdeep Bijwadia and Greg Manning’s CE article titled, “Home Sleep Testing, Telemedicine, and the Impact on Dental Sleep Practices” shows that dentists play a major role in identifying patients at risk and helping manage the epidemic of sleep disordered breathing. They say that despite individual variability, dental devices can be highly effective for patients with mild, moderate, and even severe OSA. Many aspects of traditional dentistry have changed over the past year, and clinicians were pushed to find ways to serve patients better while maintaining safe protocols. Applications like teledentistry, patient texting, and online consultations showed that you can stay connected to your patients and serve their needs with secure options. Patients have embraced new technologies and still want these benefits even as offices return to full business as usual. Methods for scheduling fewer appointments and less chair time, while maintaining the personal connection with patients, have been created with more creativity and success that will continue into the future. While 2020 started out as one of the most unusual in our lives, 2021 promises continued healing and the potential for great success. Let us help you get ready to roar into the future with high expectations!

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PRACTICEmanagement

o f e l t h g g e Jugg u r t S l ging M a n a M

by Teresa Power

here are nearly 200,000 dentists in the United States today, but the American Academy of Dental Sleep Medicine (AADSM) boasts of fewer than 5,000 members. Surveys of the dental industry continuously rank dental sleep medicine (DSM) and implants as the top two subjects of interest for continuing education. Implants are booming and have certainly reached a tipping point among clinicians and the public. DSM hasn’t reached that inflection point yet. We’re not even close. Why? When asked this question, many dentists reply that their general practice demands too much time, with little to no time for screening for sleep disordered breathing (SDB) or implementing DSM. They’re aware of the labyrinthine steps required to meaningfully incorporate DSM – steps such as screening, patient education, obtaining a diagnosis, coordinating with physicians, and medical billing. Many of these same clinicians fervently proclaim their desire to implement DSM because they care about their patients. They believe looking at the airway is within their scope of practice, and they want to abide by the ADA’s standard of care. Unfortunately, the obstacle course inherent to DSM and the dynamic time constraints are non-starters for many.

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ore Sleep in a Busy Resto rative Pract ice

These hurdles are real, but they can be overcome. Great sleep dentists overcome them every day. Adding DSM to a busy restorative practice is possible, and the following three stories feature three dentists from three different time zones. They’ll tell you how they dance with the struggle of the juggle.

Brandon Hedgecock, DDS, D.ABDSM

When dentists say they don’t implement sleep into their dental practices because they’re way too busy, it takes too much time, or they tried it and it didn’t take off, I tell them, “Those are 100% excuses – not reasons.” DSM has a lot of hoops, and the process can be long and convoluted, but it’s definitely not insurmountable. You can’t do it alone. You can’t do it without a solid team. You wouldn’t open a general practice with no assistants, hygienists, or marketing plan and expect it to work. That’s ridiculous. DSM is no different. In a restorative practice, you hire RDHs to do prophys and treatment coordinators to talk about money. The dentist can’t do it all and shouldn’t do it all. You develop a plan, put the right people in the right places, don’t give up, then it becomes easier, and then it becomes sustainable. If You Build It, They Will Come When dentists complain they don’t have time to screen their patients, my response is that it takes 10 seconds to mention that there are signs they brux at night or they were snor-

PRACTICEmanagement ing during a procedure, and then simply hand them off to the right person in the office. Then comes the excuse about team resistance. The team won’t get on board with sleep implementation. That’s a leadership and management issue. They probably pushed back when you brought in a scanner, Invisalign, a new software, whatever it is. People are generally resistant to change – any change, good, bad, or indifferent. Remember though, they are in healthcare, so they care about people and their jobs. If they don’t, you have to look at the team and decide if these are the right people. Next, take an assistant or another team member and develop them into your sleep champ. It’s kind of like the Field of Dreams. “If you build it, they will come.” This is not an expense. That’s flawed thinking. This is an investment in your practice, in your team, in your patients’ health, and in your career. Invest the money into getting the right person. As sleep started to gain momentum in our office, I Initially I had someone from the restorative side help, but issues arose on the dental side because everyone’s focus was too fragmented. In short time, we realized we had to dedicate someone full-time to properly manage sleep patients, the workflow, the documentation, and prevent anyone or anything from falling through the cracks. I remember Jessica, who now runs sleep in our office, telling me that we needed another team member. I told her we could hire that person after we hit our number. A month went by, and we didn’t hit it. She passionately explained that we’d never hit the number if we didn’t have enough people to do the work. We hired the person, and 1 month later we exceeded the goal by 30%. Have a growth mindset, not a scarcity mindset. Do more, be more, and you’ll see more patients. Build it. They will come. Physician Referrals and Maximizing Your Time A recurring question I get during lectures is about whether I see sleep and restorative patients on the same days or if I have days dedicated to sleep. I do see them on the same days, but I have 1 chair that’s dedicated entirely to sleep. This allows me to do a crown prep in one op and then while the assistant packs cord or takes a scan, I can go into the sleep room to do an appliance delivery. With this type of schedule, the most productive use of my time is when we have sleep and implant cases scheduled simultaneously.

Dr. Brandon Hedgecock with a patient

Another common question is about generating physician referrals. It’d be disingenuous to deny that many physicians lack education about sleep, see some stigma associated with You wouldn’t open oral appliances, or have a heavy bias toward CPAP. Sometimes it’s all three. This is really a general practice the biggest friction point for our office, but with no assistants, again, it is an issue that can be overcome. It just requires constant contact. Don’t let hygienists, or patients fall through the cracks. Take physi- marketing plan and cians to dinner to discuss how your practice functions, learn about theirs, and identify expect it to work. commonalities. We had a physician liaison That’s ridiculous. and actually just added a second one. This is all they do all day. They keep us top of mind DSM is no different. with existing referral sources and continually generate new ones, too. If nothing else, please remember first the impact you can have on your patients’ quality of life, their health, and their happiness. You will fall – know that. Pick yourself up and do it again. The only ones that fail are those that quit.

Teresa Power lives in Brooklyn, NY and works for SomnoMed as the Northeast Regional Manager for their Medical Initiative. She has been involved in medical and dental sales for the past 13 years – starting in the operating rooms for orthopedic implants, moving on to dental implants, and settling into sleep. Confident that sleep is her passion, Teresa recently achieved her Certification in Clinical Sleep Health (CCSH) from the Board of Registered Polysomnographic Technologists. Other passions include enjoying the NYC scene with her husband, even in times like this, and a good bourbon or rose’.

DentalSleepPractice.com

PRACTICEmanagement Jason Doucette, DMD, D.ABDSM

We’re busy. Our sleep patients are booked out over two months right now. There’s just so much massive growth in this area. I wish it wasn’t needed, but I’m glad we’re trained and available to provide these patients with the help they need. Managing general dentistry and DSM wasn’t easy at first. I try to keep the restorative dental side less complex, so I can focus on the high volume of sleep patients. We must balance family, too, which is most important. This is the struggle of the juggle. Time Management and the Patient Journey Saying you don’t have enough time to talk to patients just isn’t true. On the subject of time, I provide fantastic care for all our sleep patients. I care about them so much. That doesn’t mean I have to spend hours with them. Between the 5-minute initial discussion with them during the hygiene check, the 10 minutes I spend with them during the consult, 5 minutes during the HST review, and the 10 minutes I spend during the 90-minute records appointment, I have 30 – 45 minutes dedicated to each case. And again, I pride myself on our level of patient care. If you’re doing a hygiene check or the patient is there for a toothache, you just note that they have a Mallampatti of 4 or a scalloped tongue. Ask if they have trouble going to sleep, staying asleep, or snore. Do they have headaches or get up to go to the bathroom during the night? Yeah, it’s true, if you try to have a full sleep consult appointment during a hygiene check, it is going to set you back, and your

Ugly teeth don’t kill people. Collapsed airways do.

Dr. Jason Doucette and his sleep champion Tanya Bowling with a patient

10 DSP | Summer 2021

patient back, and your hygienist, too. Don’t do that. Don’t talk too much. Instead, tell them you want to get them scheduled on another day for a 45 minute no charge sleep consultation. Don’t schedule it for that same day! The hook is that initial screening to get them to come back for the consultation. You help them recognize they have a problem they’ve been dealing with privately. Our patients trust us. They trust that we are here to help them. When they come in for the consultation, we use the pharyngometer (to evaluate the collapsibility of the pharynx) and rhinometer (to evaluate nasal patency) as a visual to help them tie their airway issues to their chief complaints. Most patients actually get somewhat excited at this point, because they’re thankful there may be a solution to the issues they’ve been silently suffering through. Tanya gives them a WatchPAT to take home and manages the majority of the consult. She used to sit in the room with me while I did them. After watching me do dozens of them, she was able to take what she observed, and now, with the exception of the 10 minutes I’m present, Tanya does this on her own. I can’t stress enough the importance of investing in an all-star sleep champion. They also schedule the 1-hour HST review before leaving. 90% of my patients come from MD referrals now, but we still test some of our own patients. During the HST review, we focus on the treatment and avoiding bad health outcomes. We talk about how PAP and OAT can help eliminate the signs and symptoms. At this point, there’s still no talk of money. We want to build value, illuminate how sick they are, and what a healthier future can look like. After this, Tanya hands the patient to the sleep care coordinator who connects with GoGo Billing to work out the insurance and financial details. Then, they come in for the records appointment. Like I said, most of my sleep patients are referred by physicians. This means I’m not their regular dentist. Still, we take a pano, probe, and chart everything. If they’re our own dental patients, this has already been done. Tanya uses the pharyngometer again, I palpate the joint and muscles, check the range of motion, and help determine which device we’re going to prescribe. Tanya scans and sends the case off. All of this is driven by Tanya, our sleep coordinator, except for the parts that legally require the dentist to do them.

PRACTICEmanagement The Importance of a Sleep Champion Tanya has been an assistant for 25 years. It’s true – you don’t have the time to do all this yourself. Shut down the entire office for a day or take everyone to a 2-day course. Get them educated, trained, and coached. If the dentist is the quarterback, you’ll lose the game before it even starts. Find a team member that wants to learn, that gets passionate, and invest in them to lead sleep in your practice. Don’t think about the cost. It’s an investment that’s pretty much guaranteed to pay dividends, but way more important, it’ll save your patients’ lives. You’ve helped patients get out of pain from an abscess, you’ve turned black teeth into white teeth, but nothing is more rewarding than this. Ugly teeth don’t kill people. Collapsed airways do. Saying you have to go get more and more CE or more information is BS. Get to a course. Take what you learn and go. Start screening, consult with your patients, invest in your team, and keep learning. Repeat. Success is not an accident; success is at the intersection of hard work and opportunity.

Marc Newman, DDS

I don’t want to throw our profession under the bus, but I’ve heard a lot of our colleagues say they don’t have the time to treat sleep patients. Fine. Don’t treat them, but you should absolutely follow the ADA’s guidelines to identify patients. Then, just make a referral to another provider. New Patients and Neck Measurements In our practice, every single new patient we have gets their neck measured. This is an excellent icebreaker. The patients almost always ask why we’re measuring their necks. We tell them we’re doing it to comply with the ADA’s position that all patients should be screened for sleep disordered breathing. This kicks the door open, and many patients begin volunteering information about their sleep. Challenges, Opportunities, and HST DSM workflow is complicated due to the amount of documentation. You must allot enough time to properly document cases and remember, MDs are dealing with the same issues – cumbersome EMRs, patients running late, payor records requests. No two cases are the same. We don’t have separate days for sleep only. If a patient can’t come in during an available window, we try to get them in a bit earlier

Dr. Marc Newman taking an impression

in the morning or schedule a telehealth visit during non-production time. We really try to be available for them. One gamechanger we’ve recently benefited from is the use of the NightOwl HST technology. Our front office people no longer have to manage all the HST units. In the throes of Covid, they were uncomfortable cleaning and maintaining the units. The NightOwl is great, turnaround is less than 10 days, and it really simplifies the HST process in our practice.

I’m a sleep It Takes a Team My most significant obstacle has been champion. That standardizing a high level of DSM care into a full team approach. However, in combat- means my assistant ing that obstacle, I must say – one thing I’ve is one, too. Sleep learned in my career, not just as a dentist, but as a leader, is that some challenges are champions breed good challenges to have. We have 5 front sleep champions. office admins, 6 assistants, and 4 hygienists dispersed across two locations. Although it can be a task to implement every single protocol from the wish list, I am certainly blessed to be surrounded by a support staff willing and able to multitask the day-to-day of our busy practice. More than anything, I have the best job in the world, because I get to work alongside some pretty great dentists, who happen to be my brothers – Dr. Mikel Newman and Dr. Don Newman. With that said, I’m a sleep champion. That means my assistant is one, too. Sleep champions breed sleep champions. Just don’t give up. Don’t ever give up. If you’re passionate about helping others, you’ll make it happen. DSM is on the cusp of changing things. I want to be a part of it. DentalSleepPractice.com

COVERstory

HealthyStart: Nearly 60 Years of Innovations

New Technology and Plans for the Future

here were no alternatives to traditional braces, no early treatment of children, and little to no understanding of the linkage between sleep issues and dental issues. This was the 1960s, and Earl O. Bergersen, DDS, MSD, ABO, was ahead of his time – developing, innovating, and looking to the future to provide more predictable orthodontic solutions, better overall health, less mechanics, and more stable results.

More than 500 patents later, Dr. Bergersen’s technology leads the way for providing growth appliances that aid in the ideal eruption of teeth and create better oral foundations. Dr. Bergersen’s first-of-its-kind technology addresses habitual issues, eliminates mouth breathing, promotes nasal breathing, reduces the size and inflammation of the tonsils and adenoids, uses the tongue to create

Dr. Bergersen’s long-time patient, Samnang, started his HealthyStart journey at 5 years old. Samnang struggled in school as a child and accredits his straight As in high school to HealthyStart.

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COVERstory expansion and develops proper swallowing. This technology is Ortho-Tain®, and the system is HealthyStart®. Dr. Bergersen graduated from Northwestern University in both the dental and orthodontic programs. He was elected president of his class and organizes their anniversary meetings. Dr. Bergersen was also assistant professor for 25 years at the Northwestern Orthodontic Department and was a regional editor of the American Journal of Orthodontics (JCO) for many years. He just celebrated his 90th birthday, and he often says, with a smile on his face, “Not many of us are left from my class, but, fortunately, the legacy and the knowledge that was created at this great institution, I can still utilize each and every day.” Dr. Bergersen was honored at Northwestern University’s Lurie Research Hospital for his dedication, innovation, and perseverance over so many years. Family, friends and colleagues, as well as generations of past patients and mentors in the dental community, joined to honor his legacy and his lifetime of contributions to better the health of patients all across the world. Dr. Bergersen recounts the moment when the spark began and the scope of dentistry was changed forever. He explains, “A transfer patient arrived at my practice with orthodontic relapse that resulted from previous orthodontic treatment. I began explaining his relapse condition and how it would take 4 to 6 months to recorrect it. He said to me, ‘Don’t worry about it, Doc. I can have these teeth straightened in three days.’” Dr. B accepted the challenge, and, in 3 days’ time, the patient

came back into his office with perfectly straight teeth, and, when asked how he did this, the patient took a broken black rubber appliance out of his pocket. This is the day that the concept was born to create a device that could straighten teeth without braces, correct improper functional occlusions, and promote proper development and dental eruption in the midst of growth. This appliance would eliminate the need for mechanics, but instead use eruptive and bodily forces, focusing more on achieving sustainable results and providing removable treatment that would not need 24 hours of wear per day. Dr. Bergersen associated with some of the greatest minds in orthodontics to discuss various aspects of growth and their impact on orthodontic treatment procedures. He researched at the Bolton Study of Case Western University and the Denver Growth Study at the University of Colorado Medical School. Dr. Bergersen also worked alongside Dr. Idyl Pyle, Dr. Marion Marish, Dr. Harry Sicher of Loyola University, and Dr. B. Holly Broadbent. He also consulted with Coenraad Moorrees of Harvard University, whose research was the basis of the preventive NiteGuide® technique. The initial invention was created; a preformed orthodontic positioner capable of maintaining the straightness of the teeth, the bite correction, and the intercuspation of the dentition all at the same time. It soon became apparent that the preformed orthodontic appliances could actually straighten teeth and correct overbites, overjets, open bites, crossbites, etc., which led to the introduction

67% of the consonant sounds are initiated in either the palate of the mouth or the lip seal. Both of these areas… are compromised in children with Sleep Disordered Breathing issues.

Dr. Bergersen treating a young patient (left) and Dr. Bergersen was featured on the front page of the Courier-Journal on April 19, 1984 for his revolutionary technology; a cheaper and faster alternative to braces (right).

DentalSleepPractice.com

COVERstory

Dr. Bergersen speaking (above) and Dr. Bergersen’s breakthrough technology was featured on the front page of the Chicago Sun-Times on January 2, 1983 as a new alternative to braces (right).

Dr. Bergersen and HealthyStart are introducing an oral appliance for newborns... This new oral appliance looks like a pacifier but is ingenious in its design, creating a ramp to lift and train the tongue to the proper position, eliminating mouth breathing, creating nasal breathing, and promoting mandibular growth.

The PerfectStart® Pacifier with a Purpose

14 DSP | Summer 2021

of an eruption guidance oral appliance for even younger patients from 8 – 12 years of age. Determined to continue finding solutions for even younger children, the concept of treating during the transition from primary teeth into permanent teeth to guide erupting teeth into their proper positions, rather than straightening through force, became the focus of these earlier oral appliances. The NiteGuide® appliances (now more commonly referred to as the “C” appliances) focused on preventing malocclusion by guiding incoming teeth, correcting the functional issues, expanding the arches, addressing improper habits and intercuspation of the dentition all at the same time, while also allowing the fiber bundles to be formed in the ideal position, creating a lifetime of stability. Dr. Bergersen continued to push the envelope and address issues present in children as young as two years of age with the Habit Corrector®, the Class lll and the Max A appliances. These appliances promoted growth, instilled proper habits, eliminated detrimental conditions and provided internal myofunctional habits activated by mouth breathing, thumb-sucking and abnormal swallowing, only requiring nighttime wear. Continuing with the focus on innovation and growth nearly 60 years later, Dr. Bergersen and HealthyStart are introducing an oral appliance for newborns to promote proper habits and to guide the dentition as early as possible. This new oral appliance looks like a pacifier to the average individual but is ingenious in its design, creating a ramp to lift and train the tongue to the proper posi-

tion, eliminating mouth breathing, creating nasal breathing, and promoting mandibular growth. The PerfectStart® Pacifier with a Purpose begins the conversation with families regarding the benefits of proper sleep and breathing, the importance of airway development and the value of preventive care. When Dr. Bergersen was asked what was coming next, he laughed and said, “I already have plans on improving the overall health of the fetus, and it comes in the shape of a Habit Corrector® for the expecting mother. So often, pregnancy brings with it a lack of sleep and exhaustion, hence the importance of mothers assessing their own sleep. HealthyStart® has a solution for expecting mothers via the Adult Habit Corrector®, which assists with better sleeping and breathing, allowing for more oxygen and ideally a healthier baby. It all comes full circle.” In regard to the continuation of his legacy, Dr. Bergersen says, “Fortunately, I have many very capable minds working with me, including the HealthyStart® Development, Research and Advanced Technology Departments.” Dr. Bergersen explains the crucial role of patient education in this conversation, emphasizing that “providing resources to help families is imperative to shedding light on this very important topic. The fact that 9 out of 10 children exhibit one or more of the outward signs and symptoms of Sleep Disordered Breathing is unacceptable. It is a statistic I cannot accept. I have never met a parent who does not want the best for their child. We see many parents who are Dr. Google, which is fine, but it is crucial for accurate

9 out of 10 children suffer from one or more symptoms of Sleep Disordered Breathing. This represents over 40 million children in the US.

The HealthyStart® System addresses children's dental and overall health issues in ONE simplified treatment. Irritability & Aggressive Behavior Swollen Adenoids & Tonsils Daytime Drowsiness Restless Sleep Bedwetting Open-Bite

Mouth Breathing ADD/ADHD Snoring Teeth Grinding Chronic Allergies Overbite

Night Terrors Dark Circles Under Eyes Frequent Morning Headaches Arrested Growth & Development Low Grades in Math, Spelling, etc. Overjet / Thumb-Sucking

The Benefits of HealthyStart®: Learn how to identify, screen and treat the root causes of Sleep Disordered Breathing in the pediatric population Learn tools to help with parent and patient education Encourage proper jaw, facial and dental growth and development Facilitate natural arch expansion Open and develop a proper airway Oral appliances with built-in myofunctional therapy Correct most orthodontic conditions Scan the QR code for more resources on HealthyStart®!

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COVERstory

The fact that 9 out of 10 children exhibit one or more of the outward signs and symptoms of Sleep Disordered Breathing is unacceptable.

education to be available. Many illnesses are identified first in the oral cavity, and, interestingly enough, Sleep Disordered Breathing (SDB) is connected to the oral cavity in various ways as the origin of these issues. I provide parents with comprehensive sleep questionnaires that not only offer 30 of the most significant sleep and breathing issues, but also allow them to assign a numeric severity score to those issues, aiding them in understanding the severity of these problems.” When asked about the inclusion of speech as an area of assessment in his questionnaire, Dr. Bergersen explained that speech is another area that is linked to various oral issues and habits. He says, “67% of the consonant sounds are initiated in either the palate of the mouth or the lip seal. Both of these areas are needed for oral competency and are compromised in children with Sleep Disordered Breathing issues. It is not the dentist’s job to become a speech pathologist, but it is a condition that can improve concurrently with HealthyStart® therapy.” Dr. Bergersen has also created a comprehensive digital assessment to evaluate a patient’s growth and development. Determining the areas of deficiency is critical due to the urgency of addressing those deficiencies during a child’s growing years. These proprietary digital assessments will address growth, dental arch and profile deficiencies, as well as face height and malocclusion of the early dentition. They will assist with diagnosis and establish a new protocol and clinical evaluation standard. While Dr. Bergersen’s primary focus has been centered around the technological development and clinical implementation

Dr. Bergersen giving an interview

16 DSP | Summer 2021

of these better diagnostic and therapeutic systems, he also identifies increasing access to care as a major component to improving the lives of more patients. Dr. Bergersen has traveled the world providing treatment and appliances to children in need, and he has found astonishing adoption rates amongst countries with socialized healthcare programs, such as Estonia, Italy, Russia, and Finland, to name a few. What these countries have in common is a prioritization of clinical efficacy and resource management with an overall goal to improve patient outcomes; and this proven Ortho-Tain® technology allows for just that. In societies comprised more of patients and practices using private insurance, Dr. Bergersen has developed the “Bergersen Assessment”, which is a pediatric guide and scale to determine cranial anomalies for the evaluation of severity of conditions and corresponding medical insurance reimbursement for a patient. He is hopeful that his Assessment will shed additional light on the needs of pediatric patients as related to sleep and airway health, which for too long have been overshadowed by the adult protocols in this field. When asked about the future of sleep, breathing and airway issues in dentistry, Dr. Bergersen says, “The future has never looked brighter. Sleep and breathing will be, in my opinion, one of the most important and impactful additions to dentistry. Over my lifetime, I have seen the impact of high speed procedures, implants, and now sleep and breathing. I find dentistry and orthodontics as exciting now as I did when I first graduated. I am blessed to have found a passion associated with such an amazing group of specialists, treating a lifetime of patients, creating innovative technology and seeing the impact these innovations have had on dentistry and now on other disciplines, as we’ve seen more interest from and collaboration with pediatricians, otorhinolaryngologists, and speech and myofunctional therapists to better support these patients with a more comprehensive solution. I wish for each and every person involved in this exciting career path to cherish every minute. It goes quickly, and you never want to miss a minute or find yourself not thinking to the future. I look to all of you to bring better health and a lifetime of bright smiles to your patients and their parents. Sleep and breathe well, my friends.”

䌀伀䰀䰀䄀䈀伀刀䄀吀䤀伀一䌀唀刀䔀匀㈀㈀㄀㨀

䰀椀渀欀椀渀最䴀攀搀椀挀椀渀攀 ☀ 䐀攀渀琀椀猀琀爀礀琀漀䐀攀氀椀瘀攀爀伀瀀琀椀洀愀氀䠀攀愀氀琀栀匀䔀倀吀䔀䴀䈀䔀刀㈀㌀ⴀ㈀㘀Ⰰ ㈀㈀㄀䠀夀䄀吀吀刀䔀䜀䔀一䌀夀

䔀堀䠀䤀䈀䤀吀伀刀刀䔀䜀䤀匀吀刀䄀吀䤀伀一一伀圀伀倀䔀一䄀吀圀圀圀⸀䄀䄀倀䴀䐀⸀伀刀䜀䄀吀吀䔀一䐀䔀䔀刀䔀䜀䤀匀吀刀䄀吀䤀伀一伀倀䔀一䤀一䜀匀伀伀一

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匀䄀吀唀刀䐀䄀夀Ⰰ 伀䌀吀伀䈀䔀刀㈀Ⰰ ㈀㈀㄀

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BIGGERpicture

The Great Equalizer: Provisional Oral Appliance Therapy How to fit sleep therapy into a general dental practice by Randy Clare

f all 150,000 dentists in the United States screened 100% of their patients for SDB as suggested by the ADA, the way we understand the condition would be transformed. Key to the discussion, however, is that dental office procedures are not designed to identify patients who do not receive treatment. Historically, dentists screen, diagnose, and treat. When it comes to sleep, it’s unclear if they can or how they should do any of these three. So, in most cases, they don’t. And do you know who suffers? It isn’t just the drowsy propane truck driver. It’s the family in the car in the next lane. In a recent position paper by the American Academy of Dental Sleep Medicine (AADSM) governing the ordering and administration of home sleep testing equipment in their practices, it was noted that there are potentially 43 million American adults with undiagnosed obstructive sleep apnea (OSA).1 In 2017, the ADA clarified the role that dentists should take in screening their patients for OSA as part of their comprehensive medical and dental history during annual recall appointments.2 As a community health effort, this represents a vital opportunity since over 50% of adults see their dentist twice a year. Once these patients are identified, they are to be referred to a physician for diagnosis and, I would postulate, medical management. The

Dentists surveyed who offer sleep treatment services...

38% 18 DSP | Summer 2021

with approximately 5% treating more than 5 sleep patients per month3

position paper is vague on this aspect of treating these patients. It seems likely that patients who suffer from undiagnosed OSA will also suffer from a wide variety of other medical conditions that will require medical oversight. I was very excited about the ADA policy when it was released in 2017. The real impact so far has quelled some of my initial enthusiasm. An Inside Dentistry survey found that only 38% of dentists surveyed offer sleep treatment.3 The more alarming number was that only 5% of respondents treated more than five sleep patients per month. Let’s rely on the clarity of simple math to connect some dots and underscore this reality. If we can agree that there are 140,000 dentists in the country, and 38% (53,000) have an interest in dental sleep therapy, then only 2,660 make five appliances or more. This may be a bigger issue than the oftreported shortage of board-certified sleep physicians, estimated to be only 5,700 throughout the country. Glidewell has been identified by Frost and Sullivan as the nation’s largest sleep therapy dental lab, producing about 30% of the sleep therapy appliances that are delivered in the U.S. every year. Our internal records show that some 90% of the dental practices involved in dental sleep treat three or fewer patients per year. This seems to confirm, on a larger scale, the findings of the Inside Dentistry survey regarding the current state of oral appliance therapy treatment. On a side note, it is striking that often the first patient has the same last name of the dentist who prescribed the appliance. On average, the second appliance comes in many months later. This may not be just a screening issue. Perhaps the treatment of sleep apnea in the dental office, as currently envisioned, is just too complicated, particularly in a postCOVID world.

BIGGERpicture I completely agree with Dr. David Schwartz’s comment in Dental Sleep Practice that the last paragraph of the AADSM position paper on HST is central to the whole discussion about the role of dentistry in sleep care.4 That paragraph reads, “As health care providers who live by the ethical code ‘do no harm’ and understand the harmful consequences of OSA, we owe it to the public to implement models of care that reduce barriers to diagnosis and treatment, ensure that sleep apnea is diagnosed, and treatment efficacy is verified by physicians and maximizes the training and skills of qualified dentists.” HST is an invaluable tool for the titration of oral appliances. John Viviano, DDS, D.ABDSM told me once that “a dentist titrating sleep appliances without an HST is like a nutritionist not owning a scale.” However, some state dental boards do not support dentists dispensing HST. The critical point in all of this is that we don’t want to create a barrier to meeting the need of the patients or to the dentists who are now required to screen for sleep-disordered breathing (SDB). This screening can easily be accomplished with an Epworth Sleepiness scale or a STOP-BANG questionnaire. These documents can readily be added to standard health history forms. U.S. Census department estimates there to be 255,369,678 adults in the United States in 2021. Dentists will have conversations with approximately 125 million of them twice this year. We know that 62 million will have some form of sleep disordered breathing (SDB), including the 9% to 38% of the population that suffers from the OSA group that the AADSM is largely focused on.5 Philips Respironics, one of the worlds largest manufacturers of CPAP and CPAP accessories, published a report on the state of sleep therapy for World Sleep Day. In this report, they highlighted that patients do not seek a diagnosis for SDB because they believe CPAP is the only treatment. Of the patients surveyed: • 27% will not take a sleep test because they do not want to know if they have OSA • 24% of the patients screened do not believe treatment is necessary • 30% of the population believes treatment is worse than sleep apnea itself.

Sleep apnea patients are struggling. Despite the prevalence of sleep apnea and the variety of solutions to treat this condition, sleep apnea patients struggled to adhere to CPAP therapy over the past year, and previous negative attitudes around the condition are more common. Compared to 2020, people who say sleep apnea impacts their sleep are significantly:

2020

2021

36% 18% t Less likely to use CPAP

48% 57% s More likely to say they were never prescribed CPAP

10% 16% s More likely to have never used the CPAP they were prescribed

Among those who do not suffer from sleep apnea, consumers are more likely to agree:

21% 27% s Are afraid to take a sleep test because they do not want to know if they have OSA

18% 24% s It is not necessary to be treated for OSA

20% 25% s If diagnosed with OSA, they would not use a CPAP machine

23% 30% s Treatment is worse than sleep apnea itself

DentalSleepPractice.com

BIGGERpicture Of what benefit to patients or dental practices is a screening that requires a multi-step sleep apnea diagnostic process the patient has already decided they do not want? What most people want, is to alleviate their chief complaint – snoring. It is clear that the dental treatment for snoring is highly effective (so effective Glidewell has a money back guarantee), and not all snorers have OSA, but all OSA patients snore. The treatment of snoring does not require a physician’s prescription or an objective diagnosis and can be started immediately. At Glidewell, where the fundamental motivation is to improve patient access to quality care, we believe that patients of the population that present symptoms of snoring should believes treatment is be treated provisionally for that primary worse than sleep apnea itself. complaint. They will be treated with an inexpensive oral appliance (Silent Nite, EMA) using materials and techniques that are found in a general dental practice and pay out of pocket for the care provided. The appliance should be titrated and managed as is usual and customary. The one caveat is that the patient must sign an informed consent document attesting to the fact that they have been advised about OSA and the importance of seeing a physician for medical management and sleep diagnostics if required. A downloadable copy of an informed consent document is available on the Silent Nite

30%

page on Glidewell’s website.6 Any approved appliance will suffice for this care. The document was prepared by Dr. Ken Berley, a dentist and attorney with an extensive background in dental sleep medicine. This document has been downloaded several thousand times. The response has been excellent. The ADA has made the screening of SDB a dental mandate. The AADSM has opened the door for the use of sleep testing for appliance titration. This should give general dentists the confidence that OAT is a service that patients can expect to be available, like tooth whitening, occlusal guards and clear aligners, in any practice from every dentist. The focus on the medical model, medical reimbursement, pre-treatment diagnostics, and medical referrals can be a barrier to entry. It affects the patient and the dentist and is just too difficult for most practices. This has limited the practice of OAT to a very few practitioners whose practices tend to be limited solely to sleep therapy. Therefore, OAT should be provided on a provisional basis for a low price in order to introduce OAT to the wider patient population. This will build confidence in the general dentist that the ADA’s screening policy will lead to revenue in the practice. Patients will return to the practice, after their physician consult, and some of them will have a diagnosis of OSA but most of them will be happily snore-free. All of them will tell their friends and family, and that will help the YELP review…and that is a good thing. 1.

Schwartz, D., Adame, M., Addy, N., Cantwell, M., & Hogg, J., et al. (2020, October 10). American Academy of Dental Sleep Medicine Position on the Scope of Practice for Dentists Ordering or Administering Home Sleep Apnea Tests. Special Article 1, Issue 7.4 - American Academy of Dental Sleep Medicine. https:// aadsm.org/journal/special_article_1_issue_74.php.

Burger, D. (2017, October 31). Sleep-related breathing disorder treatment outlined in new policy. https://www.ada.org/en/publications/ada-news/2017-archive/october/sleep-related-breathing-disorder-treatment-outlined-in-new-policy.

Mazda, J. (2019, January). Trends In Dentistry January 2019 Page 16. Inside Dentistry. https://lscpagepro.mydigitalpublication. com/publication/?m=7169&i=551575&p=18&ver=html5.

Schwartz, D. (2021). How Do Dentists Tackle the 54-million-pound Elephant Called Sleep Apnea? Dental Sleep Practice Spring 2021. https://issuu.com/medmark/docs/dsp_spring2021_ issuu/10.

Senaratna CV, Perret JL, Lodge CJ, Lowe AJ, Campbell BE, Matheson MC, Hamilton GS, Dharmage SC. Prevalence of obstructive sleep apnea in the general population: A systematic review. Sleep Med Rev. 2017 Aug;34:70-81. doi: 10.1016/j.smrv.2016.07.002. Epub 2016 Jul 18. PMID: 27568340.

Glidewell Dental Lab. (n.d.). Silent Nite Sleep Appliance. glidewelldental.com. https://glidewelldental.com/solutions/ sleep-dentistry/mandibular-advancement-devices/silent-nitesleep-appliance.

Silent Nite by Glidewell

Randy Clare, Glidewell’s director of business development in dental sleep medicine, brings more than 25 years of experience in the sleep therapy and pulmonary function fields. He has held numerous management positions throughout his career and has demonstrated a unique perspective of alternate care diagnostic and therapy models. Clare is considered by many to be an expert in the use of oral appliances such as the Silent Nite Sleep Appliance to treat snoring and sleep apnea in the dental office. For more information, follow thesleepandrespiratoryscholar.com.

20 DSP | Summer 2021

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Clinicians Report® is an independent, nonprofit, dental education and product testing foundation, Clinicians Report®, September, 2019. For the full report, visit glidewell.com/essential-product.

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MEDICALinsight

The Whole World is

Screwed… By Madan Kandula, MD

bstructive Sleep Apnea (OSA) is the Rodney Dangerfield of medical conditions. It gets no respect, and it gets mistreated more often than it gets appropriately treated. It’s no wonder that 80% of Americans who suffer with OSA aren’t being diagnosed. And, the 20% who are diagnosed are likely to be shoved into a one-size-fits-all box they’re not meant to fit in. And do you know who’s doing the shoving? You (dental), me (ENT), and the man behind the tree (sleep medicine). The current standard of care The reality for all these patients for OSA patients is a one-sizeis that their throats are too fits-none approach. narrow for their bodies If an OSA patient walks into a sleep center, they will be walking out with a CPAP machine (probably with a full facemask) – guaranteed. If an OSA patient walks into of the time. a dental sleep practice, there is a high probability they will walk out with an oral appliance. If an OSA patient walks into a typical ENT practice, they will walk out with a head buzzing full of information, and a body still suffering with a broken airway. The reality for all these patients is that their throats are too narrow for their bodies 100% of the time. 70-80% of these same patients have noses that aren’t adequately patent during sleep. No oral appliance or CPAP machine can work properly and efficiently without a well-functioning nose. Yet how many dental

100% 22 DSP | Summer 2021

If All You Have is a Screwdriver sleep and sleep med docs properly evaluate and correct nasal airway obstruction prior to placing a patient into a treatment modality? I think we all know the true answer. Why is this? OSA is an ENT issue that is seldom adequately addressed by an ENT. Because of medical turf battles and ENT apathy, OSA has been almost abandoned by the ENT community at large. Who suffers? Certainly, dentists and sleep med docs looking to collaborate. Sadly, those who suffer the most are patients who are being sent down a one-way street to frustration and failure. To put it bluntly: if a patient is tossed an oral appliance or CPAP machine and wished, “good luck,” they either learn to live with the frustration of the device or the misery of their OSA. With a malfunctioning nasal airway, they are destined to fail. This is a band-aid approach, not a root cause solution. What’s worse, patients are left feeling dismissed and hopeless. Like they’re the failure. But there’s something even bigger at play here. Bigger than quality of life issues — I’m talking about years of life left to live. OSA is like a ticking time bomb. Every time you brush off another patient by providing them a remedy not primed for success, you’re nudging them one step closer to detonation. Every mistreated case is one more daughter who loses her father to a heart attack before he gets to walk her down the aisle. It’s one more grandchild who will never know his grandmother because she died from a stroke before he was born. It’s one more parent who loses their battle with diabetes before their kids even graduate from high school. Tick. We’re failing our patients. Tick. They’re paying the price.

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MEDICALinsight Tick. Because the solution is all too often doomed to fail. Millions of people are suffering and dying from OSA and its comorbidities, but dental sleep, sleep physicians, and ENTs are so caught up in their own ways of thinking that they’ve got blinders on. They’re unwilling to give up a little ground in order to bring to light a better way. As dentists, you literally stare into the broken airway abyss all day long. I …dental sleep, sleep commend your willingness to step in and help, but you must physicians, and ENTs understand the true nature of are so caught up in their each individual’s issue to treat it properly and effectively. own ways of thinking that Many dentists, maybe even you, think of ENTs as the “throat they’ve got blinders on… surgery guys” yet it’s unlikely you have a firm grasp on the clinical aspects of what we now offer to OSA patients. And it’s even more unlikely you have a productive partnership with anyone in our field. At ADVENT, a practice I founded in 2004, we’ve pioneered a much different model than the typical ENT practice that you grew up with. In fact, throat surgery is what we do the least. Our paradigm starts with getting the nose working properly first, most often with simple, in-office procedures. Only then do we clear a patient to move into an oral appliance or other OSA treatment. As ENTs and sleep dentists, we must make a shift and approach OSA more holistically on behalf of our patients, together. Rather than treating a singular part of the issue — the collapsing airway — with our limited resources,

ADVENT® CEO, Madan Kandula, MD, takes an iron fist in a velvet glove approach to combat the conventional constructs of a failed healthcare system. Board certified in Otolaryngology – Head & Neck Surgery, Dr. Kandula is a pioneer in developing new techniques and treatments for patients with nose, sinus, snoring and sleep apnea issues. His visionary approach is demonstrated by being the first surgeon to perform Balloon Sinuplasty in Wisconsin and developing a new model of care to evaluate The Breathing Triangle®. Long wait times, dismissal, and uncertainty define the healthcare experience in America, and Dr. Kandula knows that he can not only reinvent the experience for his own patients, but for patients all over the country with ADVENT’s simple in-office solutions to effectively treat the root cause of chronic sinus and sleep apnea conditions.

24 DSP | Summer 2021

let’s instead focus on solving the upstream issue, the obstructed nose, prior to treating the throat issue. Let’s put the murky animosity between our two professions to bed and focus on healing our patients. Put yourself in your patient’s shoes and imagine the ruthless cycle of getting poor sleep every night: waking up day after day with a sore throat or throbbing headache, battling insomnia, irritability, and depression. Consider, the emotional and psychological strain it can put on you and your relationships because your partner is dealing with the same lack of rest due to your OSA. Meanwhile, all your symptoms are leading to the hidden, ticking time bomb underneath — hypertension, heart disease, erectile dysfunction, diabetes, and anxiety to name a few. Imagine this is your daily life, and the only options for treatment are just as uncomfortable and have lousy success rates. It’s not just the misery of OSA we are up against… it’s this! The dental track is too often broken. The ENT track is broken. The sleep med track is undoubtedly broken. All solutions too often lead to despair and an inability of getting patients over the goal line. Our patients are stuck in this broken system and frankly it’s our fault. Until all participants acknowledge the limitations of the tools in our toolboxes, we will continue to fail … and our patients will continue to feel the brunt of it. This is not to say that oral appliances and CPAPs never work — I’m not writing them off at all. It’s just that they’re working against an issue that remains often unidentified and massively untreated. You cannot address an airway problem downstream with an oral appliance or CPAP if upstream the airway is restricted. The bottom line is this: oral appliances cannot work adequately if nasal airway obstruction is not addressed first. Solutions must be built around addressing the anatomical problems at multiple levels. This problem will continue to be unidentified and undertreated if there is a lack of communication and coordination between dentists and ENT surgeons. It must be our mission to treat OSA in a way that works for the patient. Appliances can be a highly effective solution when coupled with a properly working nose. Let’s use our power together to change the trajectory of this highly mistreated disease and deliver an undeniable improved quality of life to the people that desperately need it.

EXPERT view

In Your Own Words

n increasing number of practitioners are transitioning from restorative dental practices that provide dental sleep therapy to exclusively practicing dental sleep medicine (DSM). These are two very different practice models with unique challenges, considerations, and rewards. We asked several dentists that have made this transition 3 questions about their leap to dental sleep practices. Here are the questions and the answers IN YOUR OWN WORDS: 1. What two things do you wish you would have done differently when transitioning to a DSM-only practice? 2. What has been most challenging and most rewarding about the shift? 3. What words of advice do you have for any colleagues considering making this leap?

Todd Morgan, DMD, D.ABDSM

1. Transitioning to a full-time dental sleep practice was a dream for many years. I just had to find the right timing and sell the GP practice. I divided the GP practice and sleep into two separate corps for a few years to establish value for the sale. I loved dentistry but was ready for a change. I should have done it sooner. DSM was my passion, and it can sustain you if you are considering this transition, provided you have developed the DSM component of your practice into a referral relationship with physicians. The key is getting a relationship with top docs in your neighborhood. 2. A real challenge was acting like a specialist in the sense you must maintain and nurture relationships with referring doctors. Staff must be trained regarding the importance of sleep. DSM assistants do not grow on trees, so selecting the right team is paramount. The rewards are plentiful. Once a strong team is in position, you can truly relax and enjoy doing DSM with confidence that records are complete and thorough. My assistants record all of the notes and then I edit when needed. I enjoy the ergonomics! Now, I can sit up and save my back from stress. I enjoy the interaction with my patients tremendously.

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No two cases are the same. Each has a unique history that keeps me coming! How cool is that? 3. Ask yourself, “Can I afford to go all DSM?” Make sure it makes economic sense for you. Trust me, you cannot find a cooler way to “retire” from dentistry. Be sure you have a passion for saving lives – sleep patients are some of the most grateful. I have no regrets and after 33 years of general dentistry, I welcome this change. It is a privilege to continue to serve and share your knowledge with your fellow man.

Stacey Layman, DDS, D.ABDSM

1. I wish I would have done it sooner. Once I made the decision to practice sleep only, I was able to focus, improve patient care, and my referrals skyrocketed. The other mistake I made was trying to do DSM exclusively within my general dental practice. Instead of seeing more sleep patients and focusing on building that practice, I spent most of my day answering questions in the dental office and socializing with dental patients. 2. Let’s begin with most challenging - setting up systems, i.e. software and front office flow. Without the right person in the front office and the right systems, you will fail. And most rewarding? My stress level has gone from an 8 to a 2; and that’s on a ‘bad’ day. Most days feel like a party. I don’t have emergency calls or any unhappy patients. OK, there is an occasional dissatisfied patient, but it is extremely rare. I will NEVER give another injection as long as I live:) 3. It takes time. PERIOD. Start building your referral network and getting your name out in the community. Once you feel comfortable treating sleep apnea and billing appropriately, just do it. Don’t overthink it, just DO IT.

Kent Smith, DDS, D.ABDSM

1. I really wish I would have transitioned earlier. There was a natural dip in income when I finally went cold turkey, but it righted within a year. I could have saved

EXPERT view some aches and pains that have stayed with me from contorting myself to see the distal-buccal root caries on #16. The second would have been to have bought technology earlier. It pays for itself and patients appreciate us being on the leading edge. 2. It’s difficult to recall ten years ago when I made the shift, but the challenge was in explaining why I was making the move to a group of longstanding, loyal patients. The rewards are many, but if I must choose one, I would pick the dizzying decrease in number of stressful moments per day. I find much more time to work ON the practice instead of IN the practice. 3. The biggest problem dentists have is thinking that whoever takes over their dental patients will not treat them as well as they have. You MUST let go of that attitude, or you will struggle more than you should. You also can’t do this alone. Ask for suggestions from others who have gone through it. It takes just as much work to build a dedicated DSM practice as it did to build your dental practice.

Bill Scheier, DDS, D.ABDSM

1. I wish I would have properly staffed and sufficiently separated the sleep practice from the dental practice. It’s critically important that you establish a well-qualified care-coordinator that is SOLELY responsible to oversee the DSM portion of the practice – all phases, both administrative and clinical. Ideally this person is an exemplary communicator and someone who can grow. Second, immediately isolate DSM numbers and track them before transitioning. This will make your life so much easier during sale negotiations. 2. The biggest challenge has been practicing DSM versus restorative dentistry and thinking like a physician rather than a dentist. Successful treatment in DSM is accomplished and defined differently than with dentistry. It takes some time to shift your thought processes. Rewards? Reduction of physical demands of treating dental patients and mental/emotional demands of working with a large staff. The pace of DSM is much more enjoyable. DSM feels like a hobby compared to the rigors of a den-

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tal practice. Patients value DSM therapy more. For me, as with dentistry, DSM provides a venue to establish and advance a passion for the confluence of science and art. 3. JUST DO IT!! Plan for the short- and longterm. Don’t “dabble”. Be proactive. Don’t hire out of need; create that care-coordinator position and help it flourish. Obtain a practice software and use consulting services. Use the dental practice to initiate and fund the sleep practice.

Krissy Connor, DDS, D.ABDSM

1. One thing I would have done differently during my transition is focus on relationship building with physicians in the airway therapeutic area. It is so important to work closely with medical colleagues as it offers more comprehensive care, and it improves patient outcomes. The second thing I would have done differently is taken a high intensity crash course in medical billing. Oral appliance therapy (OAT) is a medical treatment for sleep apnea and patients expect to use their medical benefits to cover the cost. Medical billing is a great service to be able to offer to patients. 2. The most challenging thing was changing the mindset of medical providers about oral appliance therapy. It is a viable medical treatment for many patients, but many medical providers still do not know the benefits of OAT. The most rewarding aspect of the shift has been the trust that my referring providers have in the service that I provide for their patients. Through the years I have been treating patients, I have been able to witness the change in mindset in the medical community about OAT. I would like to believe that the change happened because of the collaborative effort between myself and my medical colleagues. As I have worked together with them to treat their patients, they have witnessed the tremendous benefits OAT has offered. 3. Work as a team with your medical providers. Do not try to be the medical provider. Create value for your services to your medical colleagues by offering consistently quality service, treatment protocols, and constant communication with them and their staff.

CONTINUING education

Home Sleep Testing, Telemedicine, and the Impact on Dental Sleep Practices by Jagdeep Bijwadia, MD and Greg Manning, DDS

ata shared at the 2018 American Thoracic Society International Conference indicated sleep apnea prevalence to be just under 1 billion people worldwide.1 Home sleep testing (HST) is a disruptive technology that has changed the management of sleep apnea and reduced some of the barriers to care. While not appropriate for diagnosing many of the more complex sleep disorders, HST is safe, effective, and it provides valid data for the diagnosis of uncomplicated obstructive sleep apnea. Home sleep testing has improved access to care, expedited diagnostic pathways, and provided a wider reach to the population. This is particularly significant when one considers the roughly 80% of patients with sleep apnea who remain undiagnosed.2 The technology for testing continues to evolve with increased accuracy and reduced cost. There are several different ways dentists currently incorporate HST into their practices. Telemedicine allows dentists and physicians to collaborate in the care of the patients in real time further amplifying the power and ease of home sleep testing while meeting quality guidelines. Background

Educational Overview

In 2020, the American Academy of Dental Sleep Medicine published their position paper on dentistry’s role in home sleep testing (HST). This statement was a welcome advancement for dental sleep practices as part of a multi-disciplinary solution to the growing number of undiagnosed apneics in the United States. In this self instructional course for dentists, Jagdeep Bijwadia, MD and Gregory Manning, DDS, describe the most common HST models employed by dental practices; their benefits and challenges, how the advent of telemedicine improves access to care for sleep patients, and what key criteria dentists should consider when evaluating a model that works for their practices.

Learning Objectives Dental Sleep Practice subscribers can answer the CE questions online at dentalsleeppractice.com/continuing-education to earn 2 hours of CE from reading the article. Correctly answering the questions will exhibit the reader will:

1. Understand the 3 most common home sleep testing models 2. State the required number of channels for each type of HST 3. Explain how telemedicine can facilitate HST in a dental sleep practice 4. Determine an HST model that is appropriate for their practice 5. Be familiar with various medico-dental professional organizations’ unique positions regarding HST and dentistry

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In March 2016, the Centers for Medicare and Medicaid Services (CMS), whose reimbursement rules are generally adopted by private insurers, dropped its long-standing opposition to home studies.3 According to the National Coverage Determination that was released that month, a diagnosis of obstructive sleep apnea (OSA) could be made, and the cost of therapy covered on the basis of a clinical evaluation coupled with a home study. The guideline specified that the home study must be ordered and supervised by the treating physician. CMS also specified the types of HST devices that would be reimbursed. CMS guidelines define 4 categories of sleep testing: • Type 1: Attended studies performed with the oversight of a sleep technologist with full sleep staging and that must include the following channels. EEG, EOG, ECG/heart rate, chin EMG, limb EMG, respiratory effort at thorax and abdomen, airflow from nasal cannula and pulse oximetry, and additional channels to monitor CPAP, PH, CO2, et cetera. • Type II: Home sleep test with type 2 monitor with a minimum of 7 channels that must include EEG, EOG,

CONTINUING education

From left: ApneaLink Air (Resmed, San Diego, CA); Alice NightOne (Philips, The Netherlands); and WatchPAT (Itamar Medical, Israel)

ECG/heart rate, EMG, airflow, respiratory effort and oxygen saturation. • Type III: HST with Type III portable monitor, unattended with a minimum of 4 channels. Type III devices must include the following channels: 2 respiratory channels (flow and effort) ECG/ heart rate and oxygen saturation. • Type IV: A sleep testing device measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone is covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility The most commonly used home sleep tests are type III and type IV devices. In the next section we will review how these HST devices work and how the sensors are used to detect OSA. Since Medicare’s adoption of HST, many private payors followed their lead. It is a truism that where payers go, clinicians follow and although the American Academy of Sleep Medicine (AASM) was initially opposed to the use of home sleep tests, it subsequently endorsed them with detailed guidelines for their clinical use.3

Polysomnography Versus Home Sleep Testing

Polysomnography (PSG) or an in-lab sleep test records numerous physiologic signals simultaneously during a patient’s sleep period. Signals recorded include EEG or brainwaves allowing sleep time to be directly accurately during the study period, airflow, abdominal and thoracic effort during breathing, as well as oximetry which allows diagnosis of various kinds

of sleep disordered breathing (SDB). Electromyography of the chin and limbs is recorded. A video is recorded, and a trained sleep technician directly observes the sleeping patient. Type 1 testing (PSG) can be used for the diagnosis of sleep apnea and many other complex sleep related breathing disorders like central apnea syndromes, hypoventilation, and Cheyne-Stokes respirations. The detailed physiologic data collected also allows diagnosis of several other sleep disorders like periodic limb movements, parasomnias, and nocturnal seizures. PSG can be combined with daytime sleep testing called multiple sleep latency test-

Dr. Jagdeep Bijwadia is board certified in internal medicine, pulmonary and sleep medicine. He is founder and CEO of a national sleep telemedicine practice (Sleepmedrx) serving all 50 US states. He also serves as Chief medical officer for Whole You. He currently holds a faculty position as Assistant Professor in the Department of Pulmonary Critical Care and Sleep Medicine at the University of Minnesota and has a private practice in Saint Paul, Minnesota. Dr. Bijwadia has been named top doc by the Minneapolis magazine as well as US News and World Report. He served as president for the Minnesota Sleep Society from 2016 to 2018 and is active in promoting sleep health in Minnesota. He also has an MBA from the University of St. Thomas in Minneapolis. Dr. Gregory Manning earned his Bachelor of Science in microbiology at Weber State University in Ogden, UT and his Doctor of Dental Surgery from The Ohio State University in 2006. He has been practicing dentistry in the Phoenix-area since 2008. Dr. Manning vigorously pursues continuing education in dental technology and sleep apnea treatment. He lectures extensively on these topics. He is a member of the American Dental Association, the Arizona Dental Association, the American Academy of Dental Sleep Medicine and is a diplomate of the American Sleep and Breathing Academy.

DentalSleepPractice.com

CONTINUING education ing to look for disorders such as narcolepsy and primary hypersomnia. Polysomnography is also used to initiate treatment with CPAP, BIPAP, or even oral appliances. This is called spilt night polysomnography. For all these reasons, PSG is often considered the gold standard sleep test. Disadvantages of PSG include cost and the logistics of performing the complex testing. Since the patient is not in their own environment, natural sleep patterns may not be accurately reflected in the single night test. Additionally, significant backlogs can occur due to bed scarcity. PSG can be prohibitive in rural areas or geographical areas with an insufficient number of sleep clinics, too. Given the high-cost burden, many insurance companies now require the clinician to specify why a polysomnography is needed and why a home sleep study is not sufficient. Specifically, when there is significant suspicion of OSA, most insurance companies will require an HST to be completed prior to authorizing an in-lab polysomnogram. Type II portable monitors are unattended sleep studies that are performed without the oversight of a sleep technologist, with a minimum of 7 channels including EEG allowing for more accurate sleep time and sleep staging information. As previously mentioned, the most widely used home sleep tests are type III and type IV tests. These HST devices typically record fewer signals that are specifically focused on the diagnosis of sleep apnea. For example, EEG signals are not available on Type 3 and 4 home sleep tests so sleep time is derived indirectly and is therefore less accurate. Additionally, as the name indicates, the study is done in the patient’s own home and there is

Alice NightOne (Philips, The Netherlands)

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ApneaLink Air (Resmed, San Diego, CA)

no technician monitoring the patient. While HSTs have been extensively validated for the diagnosis of OSA and are extremely reliable, it is important to recognize that they are not useful for making diagnoses of more complex SDB. Home sleep tests are most useful when one is trying to confirm the diagnosis in a patient with whom you have a high clinical suspicion of OSA. It is important to recognize that home sleep tests are not very accurate in ruling out sleep apnea and a negative test in the setting of a high clinical suspicion for sleep apnea should prompt additional testing. The obvious advantages of HST are the lower cost and higher convenience. Newer, disposable HST units can be used multiple times, further reducing associated costs and increasing clinical usefulness. Since the tests are conducted in the patient’s home environment, they may more accurately reflect natural sleep patterns. Patients often express reluctance to undergo polysomnography but are generally more amenable to home sleep testing.

How Home Sleep Testing Works

Type 3 home sleep tests such as the Alice NightOne (Philips, The Netherlands) or the ApneaLink Air (Resmed, San Diego, CA) detect apneas and hypopneas through simultaneous analysis of airflow measured by a nasal cannula, effort measured by a respiratory impedance plethysmography belt, and an oximeter that detects changes in oxygen saturation. If airflow drops by 90% along with continued breathing effort, the event is identified as an obstructive apnea. If the airflow drops by at least 30% along with a 4% drop in oxygen saturation, then the event is detected as a hypopnea. By counting the number of apnea and hypopneas occurring every hour (called the apnea hypopnea index or AHI) the severity of sleep apnea is determined. Type 3 devices are

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WatchPAT (Itamar Medical, Israel)

also able to detect central apneas, occurring when there is an absence of airflow accompanied by absence of breathing effort. In addition to airflow, effort belts, and oximetry, many type 3 devices also offer actigraphy, heart rate, and body position monitors. Type 4 home sleep tests such as the WatchPAT (Itamar Medical, Israel) and NightOwl (Ectosense Belgium) use alternate signals to assess the AHI. Numerous peer-reviewed studies have been conducted to confirm that the AHI calculated using these devices is comparable to polysomnography. With these devices, peripheral arterial tonometry (PAT) is used in combination with heart rate and oxygen saturation. When the airway narrows it causes a brain arousal which triggers arterial vasoconstriction causing the blood volume in a peripheral blood vessel such as in the finger to fall. This is usually accompanied by a rise in the pulse rate. Using different wavelengths of light and sophisticated algorithms, a sensor placed over a finger can detect the changes in peripheral blood volume as well as oxygen saturations. AHI is calculated by the simultaneous analysis of these signals. It is difficult to separate apneas from hypopneas with this technology and manual scoring is typically not performed as there are no published scoring guidelines for these signals. Newer methods of assessing AHI include acoustic signal analysis of breathing patterns and snoring and ballistocardiography. Devices using this technology are commercially available but aren’t widespread clinical use. Nor are they reimbursed by payors, and further clinical validation is needed. Traditional HSTs require initial investment in the device as well as some recurring disposable costs for each test. Additionally, there are logistics associated with deploying and monitoring the return of devices which adds

NightOwl (Ectosense Belgium)

some operational complexity for practitioners. A significant recent advance has been the introduction of disposable HST devices. With the safety concerns brought forth by the Covid pandemic, adoption of disposable HST Peripheral Artieral Tonometry (PAT): Through an indevices like the WatchPAT One nervation of the digital artery by α-adrenergic recep(Itamar Medical, Israel) and the tors, increased sympathetic nervous system (SNS) acNightOwl has increased signifi- tivity results in digital artery vasoconstriction, which cantly. The patient pairs the dis- can be observed as an attenuation in the amplitude posable home sleep test device of the photoplethysmogram (PPG). with a cell phone. Once the study is completed, the sleep test data is transmitted immediately via the cloud to a portal accessible to the interpreting physicians. One feature which is especially useful for a dental sleep practice is the availability of disposable multi-night home sleep testing. The NightOwl provides not only the diagnostic testing but also several more nights of additional testing with the same small disposable device. This facilitates testing for multiple nights over several weeks as the dental device is titrated to its optimal position allowing objective assessment of treatment outcomes. While these devices have a higher per test cost, they have less upfront costs than other devices, and are now widely used.

Regulatory Issues and Professional Guidelines

To address the OSA epidemic, the American Dental Association weighed in with a policy statement in 2017.4 It stated that dentists are encouraged to screen patients for sleep related breathing disorders as part of a comprehensive medical and dental history to recognize symptoms such as sleepiness, choking, snoring or witnessed apneas and an evaluation of risk factors such as obesity, retrognathia or DentalSleepPractice.com

CONTINUING education hypertension. These patients should be referred as needed to the appropriate physicians for proper diagnosis. There is widespread agreement in the regulatory guidelines that sleep studies including home sleep tests must be interpreted by board-certified sleep physicians. There is however controversy surrounding who can order a home sleep test. The American Academy of Dental Sleep Medicine (AADSM) recently published a statement strongly in support of allowing It is within the dentists to order home sleep tests.5 The statement, co-authored by the AADSM president scope of practice David Schwartz, DDS, D.ABDSM states, “It for a qualified is within the scope of practice for a qualified dentist, defined by the American Dental Asdentist, defined sociation (ADA) as a dentist treating sleep-reby the American lated breathing disorders who continually updates his or her knowledge and training of Dental Association dental sleep medicine with related continuas a dentist treating ing education, to order or administer home sleep apnea tests (HSATs).” sleep related Further cementing this position, Dr. Schwartz wrote in the Spring 2021 issue breathing disorders of Dental Sleep Practice, “This position who continually statement makes it clear that the AADSM updates his or her believes that: 1. It is within the scope of practice for a knowledge and qualified dentist to order or administer HSATs. training of dental 2. Licensed medical providers should sleep medicine with be diagnosing and verifying treatment efficacy.”6 related continuing This statement is in stark contrast to the education, to order AASM’s position statement on the CliniUse of a Home Sleep Apnea Test7 and or administer home cal the Clinical Practice Guideline for Diagnossleep apnea tests. tic Testing for Adult Obstructive Sleep Apnea8 which clearly outline that a home sleep apnea test is used as a medical assessment, and its use must be preceded by a comprehensive sleep evaluation by a medical provider. This medical evaluation should include an assessment for chronic diseases and conditions that are associated with increased risk for obstructive sleep apnea, including hypertension, stroke, and congestive heart failure. An evaluation by a medical provider also is necessary to rule out conditions that place the patient at increased risk of central sleep apnea and other forms of non-obstructive sleep-disordered breathing. This medical evaluation is essential for identifying appropriate candidates for sleep testing and minimizing unnecessary tests.” In the aforementioned Dental Sleep Practice editorial, Dr. Schwartz states his agree-

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ment with this ideal model but challenges its logistical capacity to meet the needs of the 54 million Americans who remain undiagnosed. He opined, “Would it be ideal for every patient in the country to have a face-to-face evaluation with a board-certified sleep medicine physician, have a polysomnogram, be presented with a variety of treatment options, get proper education on how to appropriately use their therapy, know who to contact when they have issues with their therapy and receive the appropriate follow-up care? Absolutely! And it’d be even better if all of this is done within seven to ten days. But the reality is that this is impossible – for a bevy of reasons – for most of the 54 million Americans with sleep apnea. The American Academy of Sleep Medicine (AASM) has acknowledged that there are too few board-certified sleep medicine physicians; approximately 5,700 throughout the country, many of whom are in metropolitan areas and affiliated with academic institutions, to manage the obstructive sleep apnea patient population.” The controversy centers mostly on whether ordering an HST is within the scope of dentistry. Standards for minimum training in dental sleep medicine and well-defined patient-centered collaborative practice protocols are needed and would go a long way to resolving some these ongoing discussions.

Incorporating Home Sleep Testing into a Dental Practice

Due to these seemingly conflicting guidelines, incorporating home sleep testing into a dental practice can seem challenging. There are different approaches that a dental office can use. Each of these approaches present unique advantages and challenges. Purchase a Home Sleep Testing Unit A dental practice dispenses home sleep tests directly to patients while they are in the office. In most cases, the patient returns the unit to the practice the following day and the data from the sleep study is transmitted to a sleep physician for interpretation of the sleep study. Estimated Time of Completion: < 1 week It is important to note that a dental device is durable medical equipment and subject to Stark and anti-kickback laws. Advantages: • Higher patient acceptance as testing occurs at the same time as they are screened

CONTINUING education • Revenue potential by charging patients for testing • Decreased barrier to entry for patients as testing occurs with a trusted provider • Tests are able to be dispensed by staff members and do not require the dentist’s direct contact Challenges: • Capital expenditure for HST units • Recurring cost of disposables • Risk associated with possible loss or damage to HST units • Coordination of sleep physician interpretation • Training team to dispense and maintain the units Use a Home Sleep Testing Service An option that’s seen exponential growth over the past few years involves 3rd party companies that manage home sleep testing for dentists. The dentist submits a prescription and necessary documentation for a home sleep test, and the company contacts the patient to ship a home sleep test to them. The service sends the test to the patient and upon the completing the test, the patient ships the test back to the company. These 3rd party services typically charge the patient a cash fee or works through their medical insurance and compensates their sleep physicians to interpret the sleep studies. Estimated Time of Completion: 2-4 weeks Readers should consider that once the studies are interpreted, the dentist must still to find a physician to write a prescription. If the dentist has a local physician who has seen the patient, and is amenable to writing the prescription, this model can work rather well. Advantages: • Eliminate upfront costs • Avoid potential loss or damage of HST units • Access to larger volume of HST inventory • Reduce impact on dental staff time • Increase patient acceptance compared to an in-lab polysomnography Challenges: • Patient non-compliance when company attempts to schedule test • Reduced patient sense of urgency due to timeframe between screening and testing • Loss of control in process and patients “falling through the cracks”

Refer to a Sleep Specialist The dentist refers patients to a local sleep physician who can perform a face-to-face consult with the patient, order sleep testing, and prescribe treatment such as PAP or a dental device. Importantly, the sleep physician can address non-OSA related issues contributing to the patient’s symptoms. Estimated Time of Completion: several weeks Advantages: • Minimal staff time required for referral to a sleep specialist • Comprehensive testing and treatment coordinated by the sleep phyThe American sician • Meets all currently recommended Academy of Sleep practice guidelines for demonstratMedicine (AASM) ing patient-physician relationship and will return a prescription for has acknowledged therapy (when clinically approprithat there are too ate) • Fosters a collaborative relationship few board-certified in which the sleep physician may refer future patients when oral appli- sleep medicine ances are indicated physicians; Challenges: • Possibility the sleep physician will approximately order more expensive testing (poly- 5,700 throughout somnogram) • Extensive wait times for both consult the country… and testing • Many sleep physicians are skeptical of oral appliances and may order CPAP or alternative treatments

Key Considerations

When pondering an approach to home sleep testing, additional consideration should be given to criteria that doesn’t fit within the binary confines of the advantages and challenges juxtapositions covered thus far. A brief list of these considerations includes: • State Dental Boards – A few states have limited the dentist’s scope of practice to explicitly prohibit ordering or dispensing HST. Verify your state board’s position prior to purchasing home sleep test units. • Sleep studies interpreted by a sleep physician without a consult do not meet all currently recommended practice guidelines for demonstrating patient-physician relationship. A prescription for treatment requires a faceto-face evaluation with the provider prescribing treatment. DentalSleepPractice.com

CONTINUING education • Custom-fabricated oral appliances are classified as durable medical equipment and are subject to Stark and anti-kickback laws. Sleep physicians may have concerns with payment directly from a dentist to interpret sleep studies when there is an implicit expectation that the physician will write an oral appliance prescription for that same patient if clinically indicated. • Most medical insurance companies mirror CMS guidelines and require that the HST and corresponding treatment are prescribed by a physician after an initial face-to-face consult with the patient.

Telemedicine and Home Sleep Testing

With the onset of the Covid pandemic there have been significant changes to the regulations governing the use of telemedicine. Telemedicine allows wide access to medical expertise without the risks of close contact both for patients and caregivers. Prior to the pandemic there were significant geographic barriers to using telemedicine. As an example, a physician could not see a patient via telemedicine unless the patient resided in a rural or underserved area. In response to the Covid pandemic, CMS made sweeping changes that allowed clinicians to use telemedicine across state lines and get reimbursed for the visits with the same payment scale as an in-person visit. Regulatory changes such as these have enabled dentists to refer patients to sleep physicians for telemedicine consultations as well as follow up on their own patients via these virtual platforms. Most sleep physician offices now offer telemedicine consultations. Several third party HST companies including Awaken2Sleep, Better Night, SleepTest.com, and VirtuSleep offer integrated telehealth physician consultations as well.

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

In some models, physician online consultations are followed by a process of non-disposable HST devices mailed to the patients and results and prescriptions are communicated back to the dentists. The workflow is coordinated by the third party making the process easy and fairly seamless for the dentist. Alternate models of care allow patients to leave the dentist’s office with a disposable HST. Online consultation with a physician is followed by test interpretation and dental device prescription in under two weeks. Additionally, the dentists can then use the same multi-night disposable HST to objectively optimize the dental device titration. These are examples of extremely efficient, cost-effective workflows that meet all regulatory guidelines and encourage close collaboration between dentists and physicians across the entire OSA care pathway.

Final Thoughts

There is widespread recognition that obstructive sleep apnea remains underdiagnosed, and patients are seeking treatment option alternatives to CPAP. There is strong evidence that despite individual variability, dental devices can be highly effective in the right group of patients with mild, moderate, and even severe OSA. Dentists play a major role in identifying patients at risk and helping manage the epidemic of sleep disordered breathing. There are numerous home sleep testing models available to drive collaboration between physicians and dentists. Innovation and advances in technology are rapidly changing the way dental sleep medicine will be practiced in the future. Dentists should be on the front lines in this fight to impact the 80% of undiagnosed sleep apnea sufferers. Home sleep testing and telemedicine should be a part of a dental sleep practitioner’s armamentarium.

New Findings from University of California at San Diego Yields New Data on Sleep Apnea (Estimation of the global prevalence and burden of obstructive sleep apnoea: A literature-based analysis). (2019). Health & Medicine Week, 3060. Lee, Won, et al. “Epidemiology of Obstructive Sleep Apnea: a Population-Based Perspective.” Expert Review of Respiratory Medicine, U.S. National Library of Medicine, 1 June 2008, www.ncbi.nlm.nih.gov/pmc/articles/PMC2727690/. Kapur, Vishesh K et al. “Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline.” Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine vol. 13,3 479-504. 15 Mar. 2017, doi:10.5664/jcsm.6506 Council on dental practice - dentistry’s role in sleep related breathing disorders. (2017, October). Retrieved April 10, 2021, from https://www.ada.org/en/member-center/leadership-governance/councils-commissions-and-committees/dentistry-role-in-sleep-related-breathing-disorders?utm_medium=VanityUrl Schwartz D, Levine M, Adame M, et al. American Academy of Dental Sleep Medicine position on the scope of practice for dentists ordering or administering home sleep apnea tests. J Dent Sleep Med. 2020;7(4) Schwartz, David. “How Do Dentists Tackle the 54-Million-Pound Elephant Called Sleep Apnea?” Dental Sleep Practice, MedMark Media, 2021, dentalsleeppractice.com/how-do-dentiststackle-the-54-million-pound-elephant-called-sleep-apnea/. Rosen IM, Kirsch DB, Carden KA, et al; American Academy of Sleep Medicine Board of Directors. Clinical use of a home sleep apnea test: an updated American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2018 Dec 15;14(12):2075-7. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017 Mar 15;13(3):479-504.

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Home Sleep Testing, Telemedicine, and the Impact on Dental Sleep Practices by Jagdeep Bijwadia, MD, and Greg Manning, DDS

1. According to the article, approximately ______ percentage of sleep apnea is currently undiagnosed. a. 50% b. 60% c. 70% d. 80% 2. According to the Centers for Medicare and Medicaid Services (CMS), a Type II home sleep test must have a minimum of _______ channels. a. 3 b. 5 c. 7 d. 9 3. The most commonly used home sleep tests are type III and type IV devices. a. True b. False 4. Which of these home sleep testing (HST) models is not addressed in the article? a. Purchasing and dispensing an HST unit out of the dental practice b. Using a 3rd party HST service c. Using a smart watch with pulse oximetry capabilities d. Referring to a sleep specialist 5. Dentists and physicians collaborating on sleep testing should be mindful of ________ and __________ laws. a. Stark; anti-kickback b. Stark; RICO c. Chicken; egg d. Medicare; parity 6. Benefits of referring patients to a sleep specialist for a sleep test

include ________________. a. Minimizes dental staff time required for HST b. Testing and treatment coordinated by the sleep physician c. Satisfies all recommended practice guidelines for demonstrating patient-physician relationship d. Fosters a collaborative relationship in which the sleep physician may refer future patients when oral appliances are indicated e. all of the above 7. In response to the Covid pandemic, CMS has lifted restrictions that previously prohibited telemedicine visits across state lines while also reimbursing for telemedicine with the same payment scale as an in-person visit. a. True b. False 8. When using a 3rd party Home Sleep Testing service, the approximate completion time is _______. a. 2 – 4 days b. 2 – 4 weeks c. 2 – 4 months d. None of the above 9. Home sleep test results must be interpreted by a _______. a. Nurse practitioner b. Board-certified sleep physician c. Qualified dentist d. None of the above 10. According to the article, __________ has the shortest estimated time to completion. a. Purchasing and dispensing an HST unit b. Using an HST 3rd party service c. Referring to a sleep specialist d. Referring to an orthodontist

DentalSleepPractice.com

BILLINGblocks

Tips for Estimating & Presenting Out-of-Pocket Costs to Patients when Billing Medical Insurance by Courtney Snow and Rose Nierman

“H

$ $ $$ $

ow much is this going to cost me?” Sound familiar? Financial discussions do not need to be a difficult or dreaded conversation for the dental practice team but can be an opportunity to gain trust and confidence with your patients. You can help your patient understand their medical insurance benefits (which have probably never been explained to them before).

is processed. We will share some tips from Nierman Practice Management to help this conversation go smoothly, stay on track, and ensure the information gathered during the benefit verification can be used to provide the patient with an approximation.

For dental practices billing their patient’s medical insurance as out-of-network providers, the answer to this question may not be as straightforward as one would hope; especially for the first few claims filed. The reason for this is because commercial medical insurers do not typically reveal the Usual, Customary, and Reasonable (UCR) fees. UCR is the maximum dollar amount a medical plan will consider or the “allowed amount” for services. When billing medical insurance as an in-network provider, this figure is already known because the provider has a contracted allowed amount determined while enrolling in the insurer’s network. However, this leaves the out-of-network dental practice saying, “Ok, the medical benefits verification we performed revealed coverage at 80% – so the real question is – 80% of what?” That “of what,” paired with a bit of simple math, is the key to estimating out-of-pocket costs as accurately as possible. The good news is, estimating out-of-pocket costs when billing medical insurance as an out-of-network provider becomes easier over time. Although medical plans vary, you can estimate future allowed amounts after having processed a claim or two. Why? The elusive allowed amount is on the Explanation of Benefits (EOB) received after the claim

When you verify the benefits before the appointment, you have the information to begin this discussion. Although you may not yet know precisely what the medical insurer allows for the services you render, you will be able to confirm the remaining deductible amounts and co-insurance percentages.

38 DSP | Summer 2021

1. Verify medical insurance benefits before the appointment when possible.

2. Use positive language confidently. When a patient asks if the service is covered by insurance, use positive language such as “Great news! – Yes, many patients can use their medical insurance benefits to help cover the costs of treatment. This means you can save your dental insurance benefits for dental procedures not covered by medical insurance.”

3. Break the costs down into bitesized pieces.

Break fees down into a monthly or even daily cost! For example, for a custom-made oral appliance for sleep apnea, when estimating out-of-pocket expenses of $1200, you can let the patient know that “these appliances often last for five years, so for the equivalent of about $20 a month, or about $0.66 per night, this therapy can help you sleep and breathe better.”

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BILLINGblocks 4. Be sure the patient understands the deductible.

No one likes deductibles, but if the patient still has a deductible remaining, it can only be waived in cases where there is a genuine, documented financial hardship. Even if a large amount of your treatment fee applies Figure 1: Example Estimate (Out-of-Network) Service Fee:

$3,200

Remaining Deductible

$500

Co-insurance

20%

Estimated allowed amount

$2,500

Patient pays

$700 (difference between your fee and insurers allowed amount) $500 (remaining deductible) $500 (20% of the allowed amount) Total: $1700

Insurance pays

Total: $1500 (80% of the allowed amount less remaining deductible)

Figure 2: Example Estimate (In-Network) Service Fee:

$3,000

Remaining Deductible

$600

Co-insurance

10%

Known allowed amount (in-network)

$2,200

Contractual provider write off (in-network)

$800 (difference between your fee and your contracted allowed amount

Patient pays

$600 (remaining deductible) $220 (10% of the allowed amount) Total: $820

Insurance pays

Total: $1380 (90% of the allowed amount less remaining deductible)

As Director of Training and DentalWriter™ Software Implementation at Nierman Practice Management, Courtney Snow is well-known in the Dental Sleep Medicine industry for her work with medical insurance reimbursement for Oral Appliance Therapy for obstructive sleep apnea, temporomandibular disorders, oral surgery and other medically necessary services performed in the dental practice setting. As founder & CEO of Nierman Practice Management, Rose Nierman is a pioneer and icon in establishing systems, education, and training for dentists. For 33 years, Nierman’s Crosscoding; Medical Billing in Dentistry courses, DentalWriter Software, and billing services have helped thousands of dentists implement Dental Sleep Medicine, TMD, and medical billing. For more information: contactus@dentalwriter.com or 800-879-6468.

40 DSP | Summer 2021

to the deductible (meaning the patient pays you that amount out-of-pocket), you should present this as a positive to the patient. “Once this claim processes, your deductible is met for the remainder of the year!”

5. Pull it all together (do the math)

You’ll need four main things to make the estimate happen: the remaining deductible amount, coverage percentage, your fee, and the estimated allowed amount. For example, let’s say you are an out-of-network provider and your fee for a custom-made oral appliance for sleep apnea (HCPCS code E0486) is $3200. On a claim you previously filed to this medical plan, the allowed amount for E0486 showed as $2500. When you verified the patient’s medical benefits, you found there is $500 remaining on the deductible, and the patient is covered at 80% of the allowed amount once the deductible is met. See figure 1 for an example estimate. As another example, this time, let’s say you are an in-network provider, and your fee for E0486 is $3000. Your contracted allowed amount for this insurer is $2200. When you verified the patient’s medical benefits, you found $600 remaining on the deductible, and the patient is covered at 90% of the allowed amount once the deductible is met. See figure 2 for an example estimate. We would be remiss if we didn’t mention that it is essential that the patient understand that you are only estimating the reimbursement vs. out-of-pocket costs. Many factors play into the ultimate results of the claim being processed – many that are not within your control! For example, a claim may process from another provider the patient has seen between your verification & your processed claim. Part (or all) of the deductible you estimated the patient still owed is now satisfied. Or the plan may pay a different allowed amount this time around. So, a lot can happen in the interim. The moral of this story is: although you don’t have a magic crystal ball to predict the exact amount your patient’s medical insurance will reimburse, we hope you apply these tips and tools to make your patients feel confident that you are dedicated to helping them maximize their health benefits while providing an approximation of benefits that is as accurate as possible.

DENTAL SLEEP

MEDICINE Mini-Residency 2021-2022

Module I: Live-Streamed Online October 14-16, 2021

Intermodule 1: Live-Streamed Online December 12, 2021

Module II: On Campus January 20-22, 2022

Intermodule II: Live-Streamed Online February 27, 2022

! s e

Module III: On Campus April 7-9, 2022

Registration open! Space is limited.

dental.tufts.edu/CE

e h t

t a d

Pediatric e v Dental Sleep a S Medicine Mini-Residency Module I: Live-Streamed December 10, 2021 February 11, 2022 March 11, 2022 Module III: On Campus June 3-5, 2022

TMD & Orofacial Pain Mini-Residency

Further questions, please contact dentalce@tufts.edu or 617-636-6629 The Dental Sleep Medicine Mini Residency program meets the accreditation standards to be an AADSM Mastery Program Provider; however, the AADSM does not endorse, recommend or give preference to this program; faculty; or any product, device, or appliance discussed within this program. Any opinion expressed or communication regarding any product, device or appliance is solely the opinion of the individual(s) expressing or communicating that opinion, and not that of the AADSM.

Module 1: Live-Streamed - September 11, 2021 Module II: On Campus - November 18-20, 2021 Module III: Live-Streamed - December 11, 2021 Module IV: On Campus - February 24-26, 2022 Module V: Live-Streamed - March 26, 2022 Module VI: On Campus - April 21-23, 2022

PEDIATRICS

Let’s Face It: It’s Not Just About OSA by Sharon Moore

n the final installment of this four-part series, author, speech pathologist, and myofunctional practitioner Sharon Moore shares critical information about sleep disordered breathing, an under-recognized disorder taking a toll on children’s health, development and quality of life.1 When children’s sleep and breathing improve, they are happy, alert and better behaved within days, and having a healthy airway from a young age can save kids (and parents) from a lot of trouble later in life. Sleep is a global health challenge, which is why we should screen every child for sleep health and sleep disordered breathing (SDB) specifically. By doing so in my clinic, we frequently encounter families whose children have disrupted sleep, wake frequently or consistently, have signs of insomnia, wake unrefreshed, have nightmares, wet the bed and more. Yet many parents say, in the face of these reported sleep behaviors, they think their child is getting good sleep, despite accompanying daytime ‘shenanigans.’2 They feel confident

42 DSP | Summer 2021

that if their child spends the right number of hours in bed, their sleep must be sufficient. Meanwhile, others acknowledge worrying sleep and daytime behaviors but dismiss these as part of the norm when raising kids. Why is this? Sleep myths and misperceptions persist among the public, my dental colleagues, and medical professionals. This interferes with sleep health being taken seriously, leading many to believe that poor sleep is to be endured in the trenches of parenting. It does not need to be this way. Any signs of sub-optimal sleep beg the big question – Why? When it comes to breathing during sleep, in the absence of obstructive sleep apnea (OSA), other breathing challenges along the spectrum of SDB may be responsible.3-5

The Spectrum of SDB

SDB is a broad term for breathing difficulties occurring during sleep. Consequently, there is a range of disorders on the spectrum, including, OSA, snoring, upper airway resis-

PEDIATRICS tance syndrome (UARS), respiratory effort related arousal (RERA) and even mouth breathing. While snoring and mouth breathing often aren’t seen as serious issues by parents and professionals, the truth is that any breathing difficulties will lead to disruption of the sleep architecture that is fundamental to the brain cleansing and restoration (glymphatics) that must happen every single night for the brain to fully restore and regenerate to be ready for the next day.6 This then leads to a range of developmental and behavioral consequences. Knowing that sleep-disordered breathing is on a continuum, and that problems do not cease simply because of a numerical measurement like the Apnea Hypopnea Index (AHI), raises questions about how to recognize and treat upper airway issues that are deemed ‘less severe’ on the SDB continuum, or indeed not recognized at all.

The Importance of Screening for SDB Currently, validated pediatric sleep questionnaires are designed to identify OSA.

This is very important because OSA is a life-threatening disorder with serious consequences. However, what happens when kids don’t have OSA but they still have a problem like UARS? That’s why I use a signs and symptoms questionnaire as it adds to the clinical picture and also provides a mechanism to discuss sleep and breathing with parents, including what’s normal and what’s not. The clinical questions raised include: What if there is airway narrowing, collapse or obstruction at some point in the airway that makes breathing laborious? What if there is fast or noisy breathing, raising body

Sharon Moore is an author, speech pathologist and myofunctional practitioner with 40 years of clinical experience across a range of communication and swallowing disorders. Sharon 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 temperature and heart rate, but not actually lowering oxygen? Breathing issues activate the sympathetic nervous system, disrupt sleep architecture, fragment sleep, and may be the reason why kids wake at night.7 Kids with these problems can suffer the same daytime physical, mental, emotional, and social consequences as a child with OSA, but they may be misdiagnosed as having anxiety or ADHD, oppositional defiance, depression, autism, PTSD, aggression, emotional fragility, or learning problems. They may wet the bed or have unexplained waking and the wrong treatment may be prescribed. If the problem is due to SDB, no amount of psychological support, bells, whistles, or pharmaceuticals will fix this problem. Fixing the airway and breathing will.8 This illustrates an important point: Generally, insomnia is placed into the basket of stress and emotional issues. However, Dr Barry Krakow’s work on complex insomnia clearly demonstrates the underlying reason for waking can be related to breathing events that rouse a person out of the normal sleep phase and stage, activating the

44 DSP | Summer 2021

sympathetic nervous system, elevating heart rate and blood pressure. Dr. Krakow found that 90% of awakenings experienced by insomniacs were preceded by a disruption in their breathing while asleep, demonstrating a physiological breathing problem in thousands of insomnia patients over two and a half decades.9-12

The Kids’ Sleep Puzzle There is a roadmap we can use to guide our clinical decision making and discussions with parents, including evaluating whether medical, dental or allied health or myofunctional interventions may be necessary. Here is a framework to guide decision making about the next steps:

The Sleep Formula & Sleep Screening Simply start: Screen every child for 1. sleep problems 2. SDB 3. triage symptoms for treatment urgency

The Patient Pathway Provide patient education to improve, sleep health practices, optimizing envi-

PEDIATRICS ronment, behavior & routines, and tips for upper-airway health like keeping the nose clear, managing allergies, middle ear effusion, food intolerances or reflux. Furthermore, being ‘airway fit’ is critical i.e. ensuring the muscles systems that support healthy airway are optimized. Myofunctional therapy is an important feature of upper airway health and function.

Medical, Dental, and Allied Health Treatment Pathway The American Dental Association’s 2017 Policy Statement on the Role of the Dentist in Sleep Disordered Breathing specifies that recognition of SDB is now a part of the dental profession and recommends that every dental practice screen for SDB, even if patients are subsequently referred for treatment elsewhere.13,14 If a patient requires expert medical, dental, or allied health assessment & treatment, decide: • When: Triage the urgency • Who: Decide who needs to be involved and make referral(s) • What: And if your dental practice is a treatment provider, a detailed ‘airway’ structural and functional assessment and treatment plan can be activated. Dental practices can offer sleep education, screening, and treatment with the aim 1. 2. 3. 4. 5. 6. 7. 8.

9. 10. 11. 12. 13. 14.

…a child with OSA…may be misdiagnosed as having anxiety or ADHD, oppositional defiance, depression, autism, PTSD, aggression, emotional fragility, or learning problems. of treatment as early as possible. Remember, myofunctional interventions sit alongside dental treatments until upper airway muscle functions are ‘normalized or ‘optimized’. Being on the frontline, dentists are in the best position to encourage the whole family to think about sleep health. We have a window of opportunity to guide families so that every child gets the sleep they need every night (and parents, too)! It has been such a pleasure write these four articles dedicated to pediatric sleep with a dental and myofunctional focus. Time and time again, we see the essential role of dentists in screening, education and treatment of SDB. If you would like to learn more about sleep issues in kids and how to address them, please read my book Sleep Wrecked Kids and look out for part 1, 2, & 3 of a new publication coming: Well Slept Kids: A step-bystep guide to transforming your child’s sleep before they start school. For queries: email projects@wellspoken.com.au or visit http:// www.wellspoken.com.au.

Sharon Moore, Sleep-Wrecked Kids: Helping Parents raise happy healthy kids one sleep at a time. (New York: Morgan James publishing, November 2019). Sharon Moore, Sleep-Wrecked Kids: Helping Parents raise happy healthy kids one sleep at a time. (New York: Morgan James publishing, November 2019). Guilleminault C., Stoohs R., Clerk A., Cetel M., Maistros P.A cause of excessive daytime sleepiness: the upper airway resistance syndrome. Chest1041993781787 Arnold WC, Guilleminault C. Upper airway resistance syndrome 2018: non-hypoxic sleep-disordered breathing. Expert Rev Respir Med. 2019 Apr;13(4):317-326. doi: 10.1080/17476348.2019.1575731. Epub 2019 Feb 6. PMID: 30689957. Guilleminault C., Black J. E., Palombini L., Ohayon M.A clinical investigation of obstructive sleep apnea syndrome and upper airway resistance syndrome patients. Sleep Med 1200016 Plog BA, Nedergaard M. The Glymphatic System in Central Nervous System Health and Disease: Past, Present, and Future. Annu Rev Pathol. 2018;13:379-394. doi:10.1146/annurev-pathol-051217-111018 Lopes MC, Spruyt K, Azevedo-Soster L, Rosa A, Guilleminault C. Reduction in Parasympathetic Tone During Sleep in Children With Habitual Snoring. Front Neurosci. 2019 Jan 10;12:997. doi: 10.3389/fnins.2018.00997. PMID: 30686970; PMCID: PMC6335331. Di Carlo, G.; Zara, F.; Rocchetti, M.; Venturini, A.; Ortiz-Ruiz, A.J.; Luzzi, V.; Cattaneo, P.M.; Polimeni, A.; Vozza, I. Prevalence of Sleep-Disordered Breathing in Children Referring for First Dental Examination. A Multicenter Cross-Sectional Study Using Pediatric Sleep Questionnaire. Int. J. Environ. Res. Public Health 2020, 17, 8460. Krakow B, McIver ND, Ulibarri VA, Nadorff MR. Prospective Randomized Controlled Trial on the Efficacy of Continuous Positive Airway Pressure and Adaptive Servo-Ventilation in the Treatment of Chronic Complex Insomnia, The Lancet, EClinicalMedicine 13 (2019) 57–73 Krakow B, McIver ND, Ulibarri VA, Nadorff MR. Retrospective, nonrandomized controlled study on autoadjusting, dual-pressure positive airway pressure therapy for a consecutive series of complex insomnia disorder patients. Nat Sci Sleep 2017;9: 81–95. Krakow B, Melendrez D, Sisley B, Warner TD, Krakow J, Leahigh L, et al. Nasal dilator strip therapy for chronic sleep-maintenance insomnia and symptoms of sleep- disordered breathing: a randomized controlled trial. Sleep Breath 2006;10(1): 16–28 March. Krakow B, McIver ND, Ulibarri VA, Nadorff MR. Frequency and accuracy of “RERA” and “RDI” terms in the journal of clinical sleep medicine from 2006 through 2012.  J Clin Sleep Med. 2014; 10: 121-124  ADA Policy Statement: The Role of Dentistry in the Treatment of Sleep Related Breathing Disorders. Adopt ed 2017 American Association of Orthodontists. (2019). Obstructive sleep apnea and orthodontics [White Paper]. https://www1.aaoinfo.org/ wp-content/uploads/2019/03/sleep-apnea-white-paper-amended-March-2019.pdf. Accessed June 21, 2019.

DentalSleepPractice.com

MARKETING

Dental Sleep Marketing… Online or Offline? by Max Kerr, DDS, D.ABDSM and Elias Kalantzis

lmost 90% of the U.S. population uses the internet on a daily basis. This spawned a nutrient-dense landscape for online marketers over the past ten years. But as industries are apt to do, they overworked the once fertile soil, leading to ignored, ineffective ads and spam filters working overtime. We’ve been inundated with online ads and online SEO companies that reiterate this astounding phenomenon. Juxtapose this with the U.S. Postal Service (USPS) which has experienced annual decreases totaling a 33% decline in business over the past decade. Most people we speak with think direct mail is dead. A 2017 Forbes magazine article estimated most Americans are exposed to 4,000–10,000 ads each day. This may seem difficult to believe, but most people see hundreds of brand impressions before even leaving their house in the morning. As our lives are increasingly uploaded and online, what role does offline marketing play for dental practices? Is it an archaic artifact or a fiery phoenix? Most online dental marketing companies spend very little time promoting the online response rates they deliver. Why? Because those numbers are in a precipitous downfall. According to several internet research company studies, the Click-Through Rate (CTR) of email marketing has been on a steady decline for the last decade. Some analysts have postulated CTR rates have declined to a mere 2.6% average in 2019. Inversely, direct mail’s total volume has decreased over time. However, studies from the Association of National Advertisers have shown that when targeting client lists with direct mail, response rates have significantly increased from 3.4% in 2010 to 5.3% in 2016. There is a differ-

46 DSP | Summer 2021

ence between marketing to your patients of records compared to prospective patients, e.g. non-patients in a 5 mile radius of your practice. The aforementioned stats apply to both segments. Let’s zoom in on Dr. Max Kerr’s approach to marketing for his general dentistry office and his 4 dental sleep practice locations in Austin, TX. He habitually reinvests 5% of total gross revenue into marketing, with a 50/50 split of his budget going to online ads vs. direct mail. “For years, online advertising was king for our practice. Over the past 2 years, it’s plateaued at best. Realistically, we’re seeing dramatically diminishing returns,” claims Dr. Kerr. He continues, “The online marketplace is just so noisy. It’s nearly impossible to differentiate yourself, and it’s so competitive in Austin. We had to figure out a way to stand out and stand apart.” One of the key reasons for the success of direct mail is its undeniable tenacity. You can delete a promotional email in a second, or worse for online marketing companies, report it as spam. And you can do this faster than Usain Bolt ran the 40 yard dash in 2019. Most people seldom – if ever – open promotional emails in their inbox. Conversely, we are all forced to open our mailbox on a regular basis. There could be a check, a bill, a greeting card. To get to those coveted items, you have to physically touch each of the other items. Direct marketing is tactile. Unless you’re like Kramer from Seinfeld when he decided to refuse his mail from the post office, you look at and briefly engage every piece of direct mail you receive. You are not only reading the advertiser’s name and seeing their logo but potentially absorb-

MARKETING ing the promotional message itself. This is very different than ignoring or deleting an unopened email. However, not all direct mail is the same. Dr. Kerr qualified this, “I touch a lot of junk mail, so do my patients. We tried a couple postcard pieces and didn’t get a gangbuster return. Then I received a sample product kit from one company, and I thought, “THIS is quality that reflects our practice and will be embraced by a lot of patients.” One of the most frustrating issues with online patient engagement revolves around the subjectivity of patient reviews on sites like Yelp and Google. “You’re at the mercy of someone’s bad day, whether a patient or a team member. Google and Yelp has us held so far over the barrel,” Dr. Kerr declared. If one patient out of your last fifty treatment plans thinks your prices are too high, hundreds of potential patients can hear about their subjective experience. Heaven forbid you choose not to advertise with Yelp, as they are currently in litigation with several companies for the placement of ‘bad reviews’ on their page. Some of the claims against Yelp are that negative reviews from years ago suddenly pop up at the top of the page when businesses decide to stop advertising with them. Seriously. So, how should you decide where to advertise and how much to spend on marketing? “Unfortunately, most dentists don’t view marketing as a strategic method to help guide patients into their practice,” Dr. Kerr states. You have to take a broad approach to marketing by utilizing different advertising media. However, highlighting your strengths and uniqueness to a specific, target demographic is absolutely necessary. The U.S. Post Office offers a program called the “every door campaign” which basically takes the shotgun approach by having the mail carrier deliver to every house on their route. There are superior options though. Similar to some online advertising platforms like Facebook, you can strategically select potential patient demographics with direct mail. Your marketing expenditure should deliver a desirably return on investment (ROI). The ROI can be maximized by laser-focusing your marketing activities. Rather than mailing to every residence in a 5-mile radius, you should coordinate with a firm that can facil-

itate hyper-targeting of your ideal patients. In this situation, you’d deliver high quality, low cost, compelling, engaging promotional items to prospective patients based on age, marriage status, and household income like Dr. Kerr does. “We use Viva Concepts for all of our tactile marketing. Their marketing collateral has depth and promotes curiosity,” Dr. Kerr states. Viva offers direct mail to patients and prospective patients and a patient referral system to track every single encounter. If you don’t have a systemized method of obtaining patient referrals, you should strongly consider one as soon as possible. All of this guarantees new patients, ROI trackability, and a way for your practice to stand up, stand out, and stand apart. “Viva sets up a domino and cascade effect that is unique in the dental market.” Whichever direct mail company you choose to assist your practice, make sure they will target your exact demographic, provide you with beautiful marketing pieces that stand out, and have the ability to track every single piece of marketing that you pay for. Lastly, it’s important to reiterate that an effective marketing campaign should focus on a combination of online ads, email marketing, and tactile marketing. Even though online response rates have decreased, and direct mail responses have increased, they are all crucial to the overall success of your practice’s growth. Complementary marketing is crucial to capture patients’ scarce attention wherever they are.

Google and Yelp has us held so far over the barrel…

Max Kerr, DDS, D.ABDSM is a dental entrepreneur who owns a successful restorative dental practice, 4 dental sleep medicine offices, and is a coach\lecturer focused on building healthy, thriving practices. He devotes time and energy towards philanthropic dentistry and understanding efficient business models. Dr. Kerr also has one of the most enviable beards in dentistry. Elias Kalantzis is the founder/co-founder of numerous businesses that have become household names in the Dental Sleep Medicine industry including OSA University, Pristine Medical Billing, Transform Dental Sleep, and SleepTest.com. He is a graduate of the University of Illinois at Urbana-Champaign. Off hours, Elias enjoys fishing, cooking, practicing ninjitsu, playing chess, and spending time with family and friends.

DentalSleepPractice.com

CLINICALfocus

Transcending AHI by Steve Lamberg DDS, D.ABDSM

ulie has an AHI of 32. Her apnea is far worse than Steve’s because his AHI is only 12, right? What if Steve had events lasting 47 seconds and O2 desaturations to 63%? Does his disease still seem mild to you? Does Julie’s apnea seem as severe in comparison? For more than 50 years the existence and severity of sleep related breathing disorders (SRBD) such as obstructive sleep apnea (OSA) have been quantified using the apnea hypopnea index (AHI). The AHI is based on data derived from an overnight sleep test such as a polysomnograph (PSG) or home sleep test (HST). SRBDs are conditions of abnormal and disordered breathing during sleep and include a spectrum of airway problems such as snoring, upper airway resistance syndrome (UARS), mild/moderate/severe OSA, central apnea, and hypoventilation syndrome.1 Because OSA presents with variable amounts of oxygen deprivation and sleep interruption, these scored events do not always correlate with levels of disease. Some patients with very few scored airway events may have more significant disease than others who have a higher number of “scored” events.2 This disparity between the number of events and levels of disease necessitates more revealing metrics beyond the constraints of AHI, so clinicians can more accurately assess the actual disease level and its risk of progression for an individual. In recognizing the broad spectrum of clinical and pathophysiological features that OSA covers we may be able to take advantage of this opportunity to promote precision medicine and focus on various treatable traits that constitute this heterogeneous disease. Looking through this new lens also offers a more meaningful approach to evaluating the efficacy of treatment(s). Other reasons to transcend AHI include the following: the lack of standard definitions for hypopneas and apneas, competency gaps of scorers create inconsistencies, missing information which includes the duration, depth, and distribution of oxygen desaturations, and an appreciation that variable patient phenotypes may lead to disparate consequences. The best-practice in sleep medicine requires that we evaluate both the severity of the disease process as well as the disease activity level which quantifies the risk of progression. Our new understanding of the connections between SRBDs and overall health and wellness leads us to appreciate the advantages of recalibrating our diagnostic approach to include the “Staging and Grading” of SRBDs. Staging is a way to classify the severity and extent of the systemic effects to an individual based on the measurable extent of destroyed tissue and or damaged systems which are attributable to airway problems. It is a measurement of how sick the patient is currently. Staging also assesses

48 DSP | Summer 2021

the complexity of controlling current disease as well as management of long-term consequences. Grading is utilized to classify the risk of future progression of the airway disease and is based on disease activity levels in combination with the individual risk factors of the individual. Grading helps estimate the potential impact of airway problems on the individuals’ systemic disease going forward. Data collection to score grading is introduced below. The proposed novel system advocates for the diagnosis of SRBDs to be reported as a stage and grade. As an example, a patient who has been previously diagnosed with severe sleep apnea in the presence of multiple comorbidities, could now be diagnosed as Stage 3 or 4 OSA; Grade A, B, or C depending on the risk of progression of the disease. This diagnostic system is superior at flagging a patient with a barely detectable airway disorder but a high disease level, such as in UARS, and exposes the need for treatment. Staging and grading will help us identify our patients’ disease profiles more fully and inform us of the appropriate treatment approach and its efficacy.

Staging and Grading of SRBDs

Staging: Disease “staging” criteria address which system(s) of the body have problems, the etiology or cause of the problems, and the pathophysiologic changes that have already occurred conferring a severity level or a degree of risk of disease complications. Data is collected from a patient’s history, the Lamberg Questionnaire v14, physical examination, and laboratory findings in order to more definitively diagnose the problem, prescribe appropriate treatment, and ultimately estimate the patient’s prognosis. Additionally, data indicating the presence of morbidity biomarkers, endothelial dysfunction, hor-

CLINICALfocus monal deficiencies, and negative response to treatments would factor in. The Lamberg Questionnaire v14 can be used for screening and staging.3 It is segmented into medical categories, each representing a body system. Each medical category that has at least one symptom checked within it indicates the involvement of a body system affected by the SRBD. The recommendation for stage designations are as follows (see table 1). Grading: The purpose of grading is to establish quality-assured screening for people with SRBDs based on activity levels of the disease. Grading is based on evidence of current disease activity and the rate of disease progression conferring a risk for the future. Activity of the disease can be based on subjective reporting, changes in recent medical history, and the presence of systemic inflammatory biomarkers. An example of systemic inflammatory biomarkers that could be used to evaluate the disease activity include the following: hs-CRP, fibrinogen, erythrocyte sedimentation rate (ESR), uric acid (UA), TNF α, IL-6, IL-8, ICAM, and VCAM.4 The recommendations for grade designations are as follows. • Grade A slow or no progression • Grade B moderate progression • Grade C rapid progression Risk factors, or grade modifiers, may include anatomic features, physiologic profiles, behavioral problems, or preexisting medical conditions. For example, BMI, craniofacial profiles, smoking, diabetes, and decreased amount of slow wave sleep would contribute to the risk assessment of disease progression. Additional physiologic risk factors include: high Pcrit, low arousal threshold, high loop gain, and poor muscle recruitment. Data collection for these features will aid in the risk assessment of disease activity.

Discussion

The current diagnostic protocol for diagnosing SRBDs solely using AHI does not take into account the impact of the disorder on the individual patient. For example, patients with UARS may have a higher stage and grade designation than patients who have mild, moderate, or severe OSA, and sadly these patients are frequently overlooked due to the incorrect assumption by insurance companies that their low AHI confers a decreased medical necessity for treatment.

Table 1: Staging for SRBDs

No body systems symptomatic (see LQ)

1-3 body systems symptomatic (see LQ)

4 or more body systems symptomatic (see LQ)

Responsive to Treatment

Stage 1

Stage 2

Stage 3

Non-Responsive to Treatment

Stage 4

It should be accepted that because all patients have a unique profile of medical risk to their body’s systems, based on genetic and epigenetic factors, staging and grading will establish a more complete picture of the SRBD and could even aid clinicians in establishing the most appropriate treatment choice(s) while also defining the efficacy of therapy.5,6 Evaluating success of treatment should include parameters such as quality of life and health outcomes as much as multiple objective metrics.7 Staging and grading classifications will evolve and become more useful to clinicians as our knowledge of the relationship between SRBDs and systemic disease is expanded.

1. 2. 3. 4.

5. 6. 7.

Guilleminault, C., Stoohs, R., Clerk, A., Cetel, M., Maistros, P., A cause of excessive daytime sleepiness. The upper airway resistance syndrome. Chest 1993 104(3), 781-787. Bouloukaki I, Grote L, McNicholas WT, et al. Mild obstructive sleep apnea increases hypertension risk, challenging traditional severity classification. J Clin Sleep Med. 2020;16(6):889–898. Lamberg, S., DDS. (2021). Lamberg Questionnaire Version 14. Retrieved March 30, 2021, from https://drlamberg.com/storage/app/media/seminars/lq-14-final.pdf Izolde Bouloukaki, Charalampos Mermigkis, Nikolaos Tzanakis, Eleftherios Kallergis, Violeta Moniaki, Eleni Mauroudi, and Sophia E. Schiza, Evaluation of Inflammatory Markers in a Large Sample of Obstructive Sleep Apnea Patients without Comorbidities, Mediators Inflammation. 2017; 4573756. Published online 2017 Jul 31 Pevernagie DA, Gnidovec-Strazisar B, Grote L et al. On the rise and fall of the apnea-hypopnea index: A historical review and critical appraisal. J Sleep Res 2020;29(4):1-20. Won CHJ When will we ditch the AHI? J Clin Sleep Med 2020;16(7):1001-03. Sutherland K, Vanderveken OM, Tsuda H et al. Oral appliance treatment for obstructive sleep apnea: an update. J Clin Sleep Med 2014;10(2):215-27.

Dr. Steve Lamberg has been practicing comprehensive restorative dentistry in Northport, NY for 40 years. Always passionate about sleep and wellness, he became a Diplomate of the American Board of Dental Sleep Medicine in 2011 and has served on their board review faculty. He holds several patents, and is the inventor of the Lamberg SleepWell Appliance, which is FDA-cleared for the treatment of OSA. Dr. Lamberg also launched and serves as the director of the Pediatric and Adult Airway Network of New York (PAANNY), to provide a local platform where dentists, physicians, orofacial myologists, and other related professionals learn and collaborate on treatment patients of all ages. Additionally, Dr. Lamberg serves as a Scientific Advisor at the Kois Center in Seattle. His recently published book for the general public, “Treat the Cause…Treat the Airway” correlates many common medical conditions to airway and sleep and is available on Amazon.

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PRODUCTspotlight

DynaFlex is Your Partner in Telemedicine

ynaFlex® is your partner in telemedicine. Whether your sleep practice is looking for a telehealth platform or you have been using telemedicine since the beginning of the pandemic, DynaFlex® is making it easier than ever with our new At Home Impression Kit. Now, more than ever doctors are turning to telemedicine in order to treat patients. This includes the treatment of Obstructive Sleep Apnea (OSA). Since the beginning of Covid-19, DynaFlex has been working to make our At Home Impression Kit a seamless integration into any office workflow.

“DynaFlex pivoted during Covid when other labs were shutting down. My patients and company never skipped a beat. They helped me tremendously by developing an all-inone impression box mailed to patients; where patients still felt safe and we could help them with their sleep apnea needs.” – Chad Denman, DDS Sleep Cycle Center

50 DSP | Summer 2021

The At Home Impression Kit is now available on our new Anti-snoring and Sleep Apnea Lab Rx and through our proprietary software, DynaFusion®. It’s a simple process that delivers real impact.

At Home Impression Kit • Rx Ordered • Easy to Follow Instructions • Device Can be Delivered to Home or Doctor’s Office • Exclusively at DynaFlex® During an initial consultation, the doctor can order the At Home Impression Kit and at the same time, select the type of device which is best for their patient. DynaFlex® ships the At Home Impression Kit directly to your patient at no additional charge through UPS. Within two to three business days the patient receives the At Home Impression Kit with instructions or video conference provided by the prescribing doctor. The patient can then take their impressions and protrusive bite registration in the comfort and safety of their own home. Once all of the records are taken, the patient uses the provided sticker to seal the At Home Impression Kit box. A Business Reply Label is provided on the box for patient convenience. Once DynaFlex® receives the At Home Impression Kit we begin fabrication of the device. Our patented Accu-Fit™ material

fits first time, every time making it optimal for an in-home delivery of an OSA device. Once the OSA device is fabricated, DynaFlex® will ship the device to the office or to the patient to be delivered with instructions through video conference with the prescribing doctor. Provided in the DynaFlex® At Home Impression Kit are size medium, large and extra-large impression trays. Also included is one edge to edge bite fork used to obtain a bite registration along with four putty packs, one for each arch, one for the bite fork, and one extra for ‘just in case’ situations. We’re innovating to provide you solutions so you and your patients can sleep at night. Alicia R. Jackson, DDS, of BlueSleep states, “Since I have partnered with DynaFlex for my telemedicine platform, I have been able to seamlessly and successfully expand and grow my Telemedicine practice. Not to mention how much my patients love being able to take their impression in the comfort of their own home. I would recommend reaching out to DynaFlex if you are interested in implementing or expanding a Telemedicine platform of your own.” For more information, call 800.489.4020 or visit www.dynaflex.com.

PRODUCTspotlight

Laser-focused to Reduce Snoring by Dr. Harvey Shiffman

noring affects millions of Americans, and the signs and symptoms are the results of a partial or complete collapse of the upper airway during sleep. The NightLase therapeutic protocol is a unique approach to treatment for snoring when using Fotona’s LightWalker dental laser. Of the commercially available hard and soft tissue lasers, only the LightWalker combines 2 proven wavelengths; Nd:YAG and Er:YAG. These wavelengths have unrivaled power and precise pulse control resulting in high efficacy levels for a wide range of procedures. With this advanced level of performance also comes significant patient comfort.

Before (left) and after (right) NightLase therapy

Dr. Harvey Shiffman is in general practice at the Laser Dental Center in Boynton Beach, Fla. He is a graduate of Georgetown University School of Dentistry and completed a general practice residency at Georgetown University Medical Center with an emphasis on treating medically compromised patients. Dr. Shiffman completed certification with the Academy of Laser Dentistry (ALD) in three types of Laser systems and was recently awarded a Fellowship in the ALD. He is personally involved in the use and development of cutting-edge technology and has performed thousands of laser dental procedures over the past 14 years. Dr. Shiffman has lectured on advances in Laser Dentistry at events such as the Yankee Dental Congress, Greater New York Dental Meeting, the Academy of Laser Dentistry, American Sleep and Breathing Academy, and local dental societies. He has published articles on clinical laser use in Dentistry, in Dental Compare, Dental Tribune and LVI Visions. Dr. Shiffman recently became an adjunct professor at Nova Southeastern University College of Dental Medicine.

NightLase snoring treatment results in improved nasal breathing which has numerous health benefits. NightLase reduces snoring by means of a gentle, laser-induced tightening effect caused by the contraction of collagen in the oral mucosa tissue. NightLase uses the photothermal capabilities of the LightWalker laser to convert and initiate the formation of new and more elastic collagen. The target mucosal tissues are the oropharynx, soft palate and uvula, back of the tongue, and the floor of the mouth. The proprietary “Smooth Mode” pulse characteristics create a non-ablative heat generation or “Heat Shock” that initiates the conversion of existing collagen to more elastic and organized forms and also initiates neocollagenesis, which is the creation of new collagen in the fibroblast cells. The effect of the laser energy as it penetrates (by transmission) deeper into the tissues, is a low-level photobiomodulation that directly affects the fibroblast cells and has been found to stimulate protein production from quiescent cells. This process results in a visible elevation of the soft palate and uvula and the tightening of the oropharyngeal tissues, resulting in an improvement in the upper airway volume. Given all of this, NightLase treatment helps patients breathe better through their noses and as a result, they sleep better, too. NightLase has a significant success rate in producing a positive change in sleep patterns. In 2013, a pilot study was completed that addressed snoring with 12 patients. A 12-month follow-up showed a 30% to 90% reduction in snoring tone and volume. Dental health professionals consider NightLase to be another tool in the treatment toolbox providing more options and the possibility of better results when used in combination with MADs and CPAP devices for patients that may not get adequate improvements from only one therapy. Using the modern, innovative, and minimally invasive NightLase therapy, the dental community can now offer patients health improvements that reach beyond restorative and rehabilitative dentistry. DentalSleepPractice.com

CLINICALfocus

Dental Mental Network by Dr. Brett E. Gilbert and Sue Jeffries

“W

hen we are looking for compassion, we need someone who is deeply rooted, able to bend, and, most of all, we need someone who embraces us for our strengths and struggles. We need to honor our struggle by sharing it with someone who has earned the right to hear it. When we’re looking for compassion, it’s about connecting with the right person at the right time about the right issue.” – Brené Brown, The Gifts of Imperfection The pervasive climate of perfectionism and individual blame in dentistry plays a significant role in the high levels of depression, career dissatisfaction, and suicide. Many practice owners lack any personal and administrative support, further cause for diminished mental well-being. All around the world, organizations and individuals are raising awareness about the scope of our mental health crisis. And it is definitely a crisis. More than 300 million people worldwide deal with depression, making it the leading cause of disability.1 Every 40 seconds, a life is lost to suicide.2 As The Guardian put it in a headline last year: “World in mental health crisis of ‘monumental suffering,’ say experts.”3 Dental Mental Network is predicated on the belief that dentistry’s discussion of mental health and wellness must transform from awareness to action. We are creating a firstof-its-kind platform, a safe space unique to dentistry. In this place, the profession will openly and eagerly denounce the existing

52 DSP | Summer 2021

culture of distress and develop methodologies that provide timely and appropriate mental wellness support and resources. The goal is to break through all stigmas surrounding mental health awareness, illness, and suicide. Dental Mental Network is a community of dental professions committed to supporting one another, being supported, and providing a safe space filled with kind, wholehearted, and empathetic colleagues. The mental health of dentists remains an important and largely unspoken issue. Job-related stressors, bullying, treatment error, traumatic patient experiences, and perfectionism lead to dentist depression and burnout. Shame – a universal emotion that contributes to low self-esteem, depression, eating disorders, violence, and addiction – underscores these factors. Dentistry can feel isolating, and perfectionism leads to self-flagellation, self-judgment, and a feeling of being trapped in the office. Dentists routinely feel high levels of stress related to clinical struggles, financial concerns, and the requirement of being at the dental chair working to generate income. Most dentists are idealists who always knew that their calling was to become a doctor who can help others to heal. The decision to enter the profession of dentistry is often chosen early in adulthood before a true understanding of interests and other life events have started. Most enter dental school with an incomplete understanding of what the reality of the lifestyle will be like. No one warns them about the hidden pitfalls and mind-altering stressors of practicing – the costs that leave practice owners and

CLINICALfocus clinicians emotionally wasted and professionally destitute. Sadly, too many students graduate from dental school with PTSD – forever changed and profoundly affected. Humans are fallible. Because dentists are human, accidental errors, practice management mishaps, and financial disasters occur. Although unintended, these errors and accidents can negatively impact patients, families, and staff, leading to adverse mental and emotional effects experienced by the clinician. These effects include burnout, loss of focus, poor work performance, post-traumatic stress disorder, depression, guilt, embarrassment, anxiety, fear, and even suicide. Dentists often feel trapped due to the amount of time and finances already sacrificed. They frequently feel chained to their dental chair, unable to generate income when not performing procedures. They also believe there is nothing they or anyone else can do about it. Support is not substantive in dentistry’s current system, a system that merely wants you to get through. The pervasive climate of perfectionism and individual blame in dentistry plays a significant role in these adverse effects. Many practice owners lack any personal and administrative support, further cause for diminished mental well-being. Dentists have human problems outside of the office. We, too, experience

relationship issues, money troubles, custody battles, and deaths in their own families. Still, many dentists are working long, stress-filled hours focused on strangers’ well-being, leaving little to no time to sort through their own issues. Shame fills this vacuum, as well as thoughts such as “What is wrong with me?” “Why am I the one this happens to?” “Why am I broken?” Shame thrives on secrecy, is insidious, and intensifies by the day. It is imperative that dentists let it out and share their shame stories. But the question is, with whom? It’s distressing for us as clinicians and caregivers to feel paralyzed and powerless when a problem is so immense and overwhelming; after all, we are in the business of healing and making things better. That’s why moving from a general big-picture understanding to actionable measures that encourage mental well-being is the best use of this moment in time. People want and need support to take action: 91% of Americans say their emotional well-being has been hurt by ignoring or not recognizing their warning signs of overstressing.4 Our goal is to assist our fellow professionals in recognizing the warning signs of mental health issues. This will help our colleagues to obtain the support they need and facilitate the improvements they need to make. Even in difficult times, everyone should have the opportunity to elevate to living the lives they deserve, not merely the lives they settle for.

Brett E. Gilbert, DDS, graduated from the University of Maryland Dental School in 2001 and completed his postgraduate training in Endodontics from the University of Maryland Dental School in 2003. He is currently a Clinical Assistant Professor in the Department of Endodontics at the University of Illinois at Chicago College of Dentistry and on staff at Amita Health Resurrection Medical Center in Chicago. He is a past-president of the Illinois Association of Endodontists. Dr. Gilbert is Board-certified, a Diplomate of the American Board of Endodontics. He was named a top ten young dental educator in America by the Seattle Study Club in 2017. In 2019, he was named to Academic Keys Who’s Who in Dentistry Higher Education. In 2019, he founded an endodontic specialty program at the Chicago Dental Society Foundation Clinic to provide free endodontic services to those in need. He is the founder of Access Endo, a global online education platform devoted to Endodontics and personal development. In 2020, he won the People’s Choice Award as the Top Instructor of 2020 for Endodontics by Course Karma. Dr. Gilbert lectures nationally and internationally on clinical endodontics. Dr. Gilbert is a partner in U.S. Endo Partners and has a full-time private practice limited to endodontics in Niles, Illinois. He is the Director of Intellectual Wellness for the Dental Mental Network. Sue Jeffries, BSDH, RDH, began her dental career in 1983 when she joined the U.S. Navy as a Dental Technician. During her 20year Navy career, she assisted in all dentistry phases, managed several Naval Dental Centers, and completed her dental hygiene degree. Upon retiring, Jeffries began practicing dental hygiene full-time and continues to practice as a guest hygienist. In 2018, she completed a Bachelor of Science degree in Oral Health Promotion at O’Hehir University. Her true passion is advocating for mental health awareness and eradicating its stigma. As cofounder of Dental Mental Network, a 501c3 charitable organization serving dentistry, Jeffries works tirelessly toward that end.

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CLINICALfocus Changing the “Disease Model” of Mental Health Care

A critical examination of the prevailing “disease-model” of mental health care would reveal the necessity for a novel alternative to the notion that psychological distress is a symptom of an illness and should be treated as such. How we care for people with health problems is mainly inefDentists are notorious mental fective – a new approach is needed. for pouring from an Our mental health and well-being depend primarily on the society empty cup, always in which we live, what happens to us, concerned with the and how we learn to make sense of and to our life events. To proceed, wellbeing of others respond we must recognize that distress is usuwhile grossly lacking ally an understandable human reaction life’s challenges, especially episodes in their own self-care. to of abuse, neglect, and inequity. In response to these, practical support rather than prescription medication should become the new norm. Renouncing labels, considering our life circumstances, and documenting our emotional response in a

simple and easily understood format, should become our latest recording. The time for revolutionizing mental healthcare is now. It starts with an unmitigated shift from viewing mental health solely as a biological disease to viewing it through a social and psychological lens. We need to replace unfounded diagnoses with practical, scientific, and understandable alternatives. Instead of treating so-called disorders, we should help people solve the issues leading to distress in their lives. Addressing the cause versus just treating symptoms is critical to a progressive change in how society views and responds to mental illness. A terrific start to a new approach would be asking people for straightforward descriptions of their problems, using their own words. Our social conditions generally shape our psychological health and well-being, so we need to work collectively in creating a vastly more humane society. A priority for all humans should be safeguarding our fellow men, women, and especially children from abuse, neglect, and inequality while developing healthier communities.

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CLINICALfocus Overcome Through Acknowledgment, Vulnerability, and Compassion

Dentistry can integrate positive strategies by promoting kindness, supportive environments, and constructive rather than negative feedback. Constructive feedback, mentorship, and a collectively supportive resource group are desperately needed to support dentists in a safe space. This allows for sharing and being free to show vulnerability without worry of recourse, reprimand, or concerns about a negative effect on reputation. Forging meaningful and tangible connections with others is how we overpower our shame. Shame cannot survive interpersonal relations predicated on understanding and trust. Author Brene Brown aptly summarized the burden of sharing our issues with others. She said, “If we share our shame story with the wrong person, they can easily become one more piece of flying debris in an already dangerous storm. We want a solid connection in a situation like this – something akin to a sturdy tree firmly planted in the ground.” Allowing

others to view you as imperfect will strengthen your bond and result in relationships that will likely last longer than the other relationships you have. By joining Dental Mental Network, you can take action by joining this community and showing up to help support yourself, your family, and all dental professionals around the world. We welcome you and are here to support you. If you would like to join the network or make a donation to allow us to continue to provide support to those we serve, please email: sue@dentalmentalnetwork.com. 1.

GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990– 2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. 2018. https://www.thelancet. com/journals/lancet/article/PIIS0140-6736(18)32279-7/fulltext. Accessed January 20, 2021. World Health Organization. World Mental Health Day 2019 — Focus on Suicide Prevention. www.who.int/newsroom/events/detail/2019/10/10/default-calendar/world-mental-health-day-2019-focus-on-suicide-prevention. Published October 20, 2019. Accessed January 20, 2021. “World in Mental Health Crisis of ‘Monumental Suffering’, Say Experts.” The Guardian. www.theguardian.com/ society/2018/oct/09/world-mental-health-crisis-monumental-suffering-say-experts. Published October 20, 2019. Accessed January 20, 2021. Khidekel M. The COVID-19 pandemic has made spotting our mental health warning signs more critical than ever. Thrive Global. https://thriveglobal.com/stories/mental-health-learn-to-spot-recognize-stress-warning-signs-microsteps/?utm_source=Recirc. Published May 1, 2020. January 20, 2021.

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