Dental Sleep Practice Winter 2021 by MedMark, LLC

Making Medicare Appliances Affordable for All by Randy Clare

Nexus Dental Systems:

THE FUTURE of Sleep Medicine

WINTER 2021 | dentalsleeppractice.com PLUS

Continuing Education

Technology:

Dental Sleep's Gatekeeper to Boost Case Acceptance and Increase Efficiency Supporting Dentists Through PRACTICAL Sleep Apnea Education

by Jason Doucette, DMD, D.ABDSM, and Jeff Rodgers, DMD, D.ABDSM

Great Lakes

NYLON SLEEP HERBST®* SUPERIOR FIT EXCEPTIONAL COMFORT RETENTIVE, LOW-PROFILE DESIGN

    

Precise Engagement of the Undercuts Uniquely Strong, Flexible, Durable Digitally Designed for Accuracy PDAC Approved 2 Year Warranty

SMLP769Rev072021

Visit our website or call for more information: GreatLakesDentalTech.com | 800.828.7626 GREAT PEOPLE. GREAT PRODUCTS. GREAT LAKES.

*Herbst is a registered trademark of Dentaurum, Inc.

PUBLISHER’Sperspective

With a Gladiator’s Determination

“I

am a gladiator! Winter is my season. This is my time. I will not be denied. … I will add more value than anyone else. … Give me your fears, give me your limitations, and I’ll give you results. I am a gladiator!” – Tony Robbins Welcome to our winter issue! The above inspirational message by Tony Robbins sums up how our MedMark team approaches your practices, your patients, and your future. Our goal is to add more value than anyone else. Through our publications, we inform you about trends in dentistry and provide articles that can help you grow clinically and professionally. Our CE articles educate you, and our webinars and podcasts bring amazing opportunities for growth. Our marketing expertise spreads the word to audiences that are searching for insights from leaders like you. This is your time, and we want to give you results! Throughout 2021, you have pushed past fears and muscled through limitations. We were courageous, creative, tenacious, and bold. Our focus was on not only getting back to normal, but also setting and surpassing new goals. We have heard of many triumphs since the beginning of 2021 – not just reopenings, but how you grew this year – with new technologies and techniques that improved patient care and expanded your capabilities. We are honored and thrilled to be a part of your continuing process. In this issue’s Cover Story, Deepit Anand, Brett Brocki, and Patrick Kircher discuss “The Future of Sleep Medicine.” As founders of Nexus Dental Systems, they unite several key solutions for medically necessary dental treatments into one fully integrated system. These include credentialing, whole team training, patient outreach and education, and an innovative medical billing solution integrated into the whole pro-

cess through proprietary software. For our Clinical Focus, Randy Clare focuses on “Making Medicare Appliances Affordable for All.” The article considers strategies that will improve access to oral appliance therapy for underserved patients while improving profit margins for practices that provide this much needed care. Our CE, “Technology: Dental Sleep’s Gatekeeper to Boost Case Acceptance and Increase Efficiency” by Drs. Jason Doucette and Jeff Rodgers, explores solutions that can improve profitability, reduce chair time, and shorten the period between initial screening and successful treatment. Receive 2 hours of CE credit after correctly answering the quiz questions. I am so very excited to announce that Steve Carstensen, DDS, will be returning to our DSP team as Chief Dental Editor, along with the addition of Lee A. Surkin, MD, as our Chief Medial Editor! Together, these two brilliant sleep doctors will be covering the entire gamut of sleep related breathing disorders. I look forward enthusiastically to our DSP future and the importance it will continue to hold within our industry, continuing to educate doctors on the critical treatment of OSA. This coming year is going to be exciting. We are renewed, rejuvenated, revitalized, and ready to take the dental arena by storm. Winter is OUR season, and we are picking up the momentum for 2022 – ready to face the new year with a gladiator’s determination to empower our dental community! To Your Best Success!

Lisa Moler Founder/CEO, MedMark Media

DentalSleepPractice.com

CONTENTS

Cover Story

Nexus Dental Systems: The Future of Sleep Medicine by Deepit Anand, Brett Brocki, & Patrick Kircher Nexus Dental Systems detail how they link up education, team training, patient outreach, and medical billing to alter the DSM landscape.

Clinical Focus

Making Medicare Appliances Affordable for All by Randy Clare Your practice profitability can hinge on which devices you use, especially for the growing, underserved Medicare and Medicaid populations.

Continuing Education

Technology: Dental Sleep’s Gatekeeper to Boost Case Acceptance and Increase Efficiency

Pediatrics

Pediatric Sleep Issues Last a Lifetime; Join the Movement ASAP

by Jason Doucette, DMD, D.ABDSM and Jeff Rodgers, DMD, D.ABDSM How can practices leverage technology to increase predictability, improve profitability, and drive case acceptance? Learn and earn CE in this compelling overview.

by Michelle Sabater Weddle, DDS, FAGD, D.ABDSM Kids are impacted by sleep disorders throughout adulthood. What steps can you take to help them while expanding your practice?

42 2 DSP | Winter 2021

Practice Management

The Debate Rages: Fee For Service vs. Medical Billing by Mona Patel, DMD If medical insurance is such an obstacle in dental sleep practices, what happens when they pivot to fee for service?

2 CE CREDITS

PROSOMNUS EVO

™

Patient Preferred OSA Therapy

Recent 35 Case Series for EVO reported: “We’ve done close to 300 EVO’s and not one return, not one breakage. I can’t say that about any other device.” – B. Kent Smith, DDS, D-ABDSM, D-ASBA

“ProSomnus EVO is an excellent oral appliance. The material increases patient comfort and decreases the need for chairside modifications and adjustments. Device advancement for further protrusion could not be easier for patients. It is definitely my go-to appliance for improved patient comfort and decreased chair time.”

Preference(2)

Recommend(2)

Although 100% preferred EVO over their previous device (that they liked) 96% STRONGLY PREFERRED

100% of the Providers would recommend EVO to a colleague

97%

+15

Efficacy(1)

Delivery(1)

Time Saved(1)

Approximately equal mix of Mild, Moderate and Severe OSA patients

First time fit without adjustments

Average delivery appointments were consequently reduced by 15+ minutes

76%

– Katherine S. Phillips, DDS, MS, D-ABDSM, D-ABOP

“EVO has been a game changer for our practice. My patients love the comfort. My team loves the ease of insertion and virtual elimination of follow up visits and/or remakes. This is the go-to device for our practice.” – Brandon Hedgecock, DDS, D-ABDSM, D-ASBA

96%

100%

min

(1)

ProSomnus Institutional Review Board Study data on file.

(2)

PRO3-331-A

Join the growing number of clinicians who trust ProSomnus devices for excellent patient experiences and outcomes.

844 537 5337 PATENTED ProSomnus.com Patient Preferred OSA Therapy™

CALL 844 537 5337 FOR A FREE STARTER KIT. 3 YEAR WARRANTY

CONTENTS

29 Practice Management

Publisher’s Perspective

With a Gladiator’s Determination

Losing Your Mind from Medical Policy Updates? PLAY BY THE RULES!

by Lisa Moler, Founder/CEO, MedMark Media

by Kyle Curran & Randy Curran To play the game, you have to know the rules. Medical insurance rules keep changing. This poignant piece has the updated playbook.

44 Bigger Picture The Perfect Day Begins with a Good Evening

12 Expert View

by Ryan Holiday Best-selling author, Ryan Holiday shares what Stoicism has taught him about conquering the day by preparing the evening before.

In Your Own Words Want to know what physicians are looking for in a dental sleep practice? Here it is In Their Own Words.

48 Product Spotlight

22 Education Spotlight

There is an Interrelationship Between Pain and Sleep 1 in 4 people with chronic pain also have a sleep disorder. Don’t sleep on pain. Take the next step to help these patients.

Want to Provide Better Patient Care? Consider AireO2 by Vivos Billing Intelligence Service Vivos introduces new intelligent software and billing services to dental sleep practices everywhere.

50 Product Spotlight

24 Billing Blocks

Slow Wave, Inc.

Avoid Medical Denials by Knowing these Trends by Rose Nierman and Courtney Snow What changes are happening in the OAT insurance world? How will it affect you and what do you need to do? Rose and Courtney have the 411 on the E0486.

There’s a new FDA-cleared appliance available. Its unique fabrication process delivers accuracy within 1/100th of a mm. Learn more.

56 Seek and Sleep DSP Staircase

Alternative Views

Can Dementia Begin in Childhood?

by Lisa Feiner, MBA, MEd, CHHC What are the contributing causes of dementia? Beginning in childhood, how might parents and practitioners alter cognitive decline?

4 DSP | Winter 2021

Winter 2021 Publisher | Lisa Moler lmoler@medmarkmedia.com Editor in Chief | Jason Tierney jason@medmarkmedia.com Managing Editor | Lou Shuman, DMD, CAGS lou@medmarkmedia.com Editorial Advisors Jagdeep Bijwadia, MD Randy Clare Scott Craig Randy Curran Barry Glassman, DMD Elias Kalantzis Steve Lamberg, DDS, D.ABDSM Mayoor Patel, DDS, MS, RPSGT, D.ABDSM Mark Murphy, DDS John Viviano, DDS

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

LEARN HOW TO EFFECTIVELY TREAT PAIN & SLEEP

Sleep-Related Breathing Disorders & Craniofacial Pain For Adults & Children A System for Dx and Tx Mini-Residency 2022 SPRING MINI-RESIDENCY Chicago, IL Session 1 April 29-30, 2022 Session 2 May 20-21, 2022 Session 3 June 24-25, 2022 Motor Nerve Reflex Testing A Hands-On Program For Finding Structural Injury 2022 SPRING MOTOR NERVE REFELX TESTING Chicago, IL JUNE 36-37, 2022

Directed by International Educator Steven Olmos, DDS Founder, TMJ & Sleep Therapy Centres International Diplomate, American Board of Craniofacial Dental Sleep Medicine Diplomate, American Board of Dental Sleep Medicine Diplomate, American Board of Craniofacial Pain Diplomate, Academy of Integrative Pain Management FAAOP, FAACP, FICCMO, FADI, FIAO

www.tmjtherapycentre.com | 877.865.4325

CLINICALfocus

Making Medicare Appliances Affordable for All by Randy Clare

edicare provides coverage for more than 100 million people. That’s nearly 1 in 3 Americans. When combined with Medicaid, coverage is extended to 125 million people. The number of people at risk of sleep disordered breathing is skewed much higher in these populations due to comorbid conditions and known risk factors. This patient population is grossly under-treated with oral appliances for sleep apnea despite the undeniable need. Low reimbursement for oral appliance therapy is commonly cited as a contributing factor. This glaring gap is exacerbated by CMS’s requirement of pricey PDAC approved Herbst style custom appliances. It’s important to note that an increasing number of private insurers are adopting Medicare’s appliance design requirements, too. It’s unfortunate but true. Cost is a factor. It is important that we negotiate with these programs in terms of economics and the size of the patient population. Only then can we transition from empty pronouncements to actionable quality-centric and cost-based solutions.

6 DSP | Winter 2021

While both are administered by CMS, Medicare and Medicaid are very different programs. Medicare is a national health insurance program that provides health insurance for Americans 65 years or older. Medicare also provides coverage for individuals with recognized disabilities such as renal disease and ALS. Medicaid is a federal and state program that provides benefits for people with limited income and resources. Medicaid is an extensive program available in every state. It covers nearly 20% of non-elderly Americans, providing coverage for low-income families, pregnant women, children, and people with disabilities. CMS reports that Medicaid consumes over 28% of state budgets running a very close second to education which registered 29% based on a report of expenditures FY2017. That year total Medicaid expenditures amounted to ~$600 billion. More than 1 million doctors, health care providers, and suppliers participate in CMS programs. While dentistry is a covered Medicaid service, coverage varies by state and is

STOP SNORING. START LIVING! FDA-CLEARED

for mild to moderate sleep apnea

SAVE

157*

217*

for 1 appliance

Glidewell Clinical Twinpak™

when you buy 2

Stops snoring or your money back† Improve patients’ sleep quality.

DSM EDU SLEEP EDUCATION FOR DENTISTS Get the free app Bradley Eli, DMD, M.S. Orofacial Pain Specialist | Encinitas, California Graduate of Temple University School of Dentistry Dr. Eli is an expert in treatment of sleep-disordered breathing, including both snoring and sleep apnea.

Get started today! Price does not include shipping or applicable taxes. Glidewell Clinical Twinpak is valid for two appliances for the same case. †Silent Nite stops the snoring or return it within 90 days for a full credit.

Learn More

Sleep appliances from the lab that never sleeps™ 877-210-3338 | glidewell.com/silent-nite-dsp MK T- 01279 0 _ 4 GL-1628 5 5 4 -101921

CLINICALfocus primarily focused on emergency care and improving children’s access to dental care. There are state oral action plans filed by over 25 states that are available for review.

Sleep Apnea Appliances for Medicare and Medicaid

CMS uses a standardized procedure coding system called Healthcare Common Procedure Coding System (HCPCS). Oral appliance therapy has been assigned the HCPCS code E0486. For an MAD like Silent Nite to qualify for E0486, it must have premarket clearance by the FDA. HCPCS code E0486 states, “...oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment.” I am unaware of any lab-fabricated oral appliances on the market today that do not meet this definition.

Diagram of Glidewell Hinge

Randy Clare, Glidewell’s subject matter expert for Snoring and Sleep Apnea brings more than 25 years of experience in the sleep therapy and pulmonary fields to his position. He has held numerous management positions throughout his career and has demonstrated a unique perspective of alternate care diagnostic and therapy models over the years. Clare is considered by many to be an expert in the delivery of sleep apnea therapy in a general dental office. For more from Randy Clare, follow https://glidewelldental.com/company/blog/.

8 DSP | Winter 2021

However, for the device to be suitable for Medicare patients, it must also be approved by Pricing, Data Analysis & Coding (PDAC). PDAC requirements are more stringent, detailed, and demanding. The related policy article clearly outlines the following: “Code E0486 may only be used for custom fabricated mandibular advancement devices. To be coded as E0486, custom fabricated mandibular advancement devices must meet all of the criteria below: • Have a fixed mechanical hinge (see below) at the sides, front or palate; and, • Be able to protrude the individual beneficiary’s mandible beyond the front teeth when adjusted to maximum protrusion; and, • Incorporate a mechanism that allows the mandible to be easily advanced by the beneficiary in increments of one millimeter or less; and, • Retain the adjustment setting when removed from the mouth; and, • Maintain the adjusted mouth position during sleep; and, • Remain fixed in place during sleep so as to prevent dislodging the device; and, • Require no return dental visits beyond the initial 90-day fitting and adjustment period to perform ongoing modification and adjustments in order to maintain effectiveness (see below) A fixed hinge is defined as a mechanical joint, containing an inseparable pivot point. Interlocking flanges, tongue and groove mechanisms, hook and loop or hook and eye clasps.’ Most dental labs have responded to this requirement by making a Herbst style appliance with an expensive hinge accessory to satisfy the CMS standard. Many dentists rightfully complain that the lab fee for the appliance consumes most of the reimbursement.

The Glidewell Hinge is Revolutionary These issues created the demand and opportunity for the new Glidewell Hinge. Glidewell’s Research and Development team started with the basic principles that the final appliance needed to cost less than $250, had to satisfy the CMS criteria for PDAC ap-

WHICH DEVICE BEST FITS YOUR PATIENT’S NEEDS?

OASYS Hinge Appliance ™

Silent Nite®

$157*

Price

$217*

1 appliance

Glidewell Clinical Twinpak

$357*

1 appliance

$689* Glidewell Clinical Twinpak

EMA®

$217*

$409*

1 appliance

Glidewell Clinical Twinpak

dreamTAP ™

$437*

1 appliance

$849* Glidewell Clinical Twinpak

FDA cleared Medicare approved Snoring Mild to moderate sleep apnea Hinge design Metal free Freedom of movement AM Aligner included Stops snoring or your money back†

6 mm

Advancement

10 mm

9 mm

15 mm

One of the best ways to maximize treatment success is to select the proper sleep appliance for your patient. To make your selection, consider the clinical situation of each patient, as well as the key features of each appliance. Each appliance is available as an optional “One for Relief, One for Reserve” Glidewell Clinical Twinpak™ to help ensure patients never go untreated.

Price does not include shipping or applicable taxes. Glidewell Clinical Twinpak is valid for two appliances for the same case. †Silent Nite stops the snoring or return it within 90 days for a full credit.

All third-party trademarks are property of their respective owners.

Learn More

Sleep appliances from the lab that never sleeps™

877-210-3338 | glidewell.com/dsp MK T- 012812 _ 3

GL-18 5 8 5 8 8 -110121

CLINICALfocus

Glidewell Hinge is a stainless steel PDAC approved accessory for Silent NIte

proval, and it needed to build on the Silent Nite framework so that it is easy for dentists to deliver with materials found in a standard dental office. The Glidewell Hinge is the most recent PDAC approved accessory for an MAD to qualify for E0486. Dentists can now order a Silent Nite with a Glidewell Hinge which is a Herbst style bilateral compression MAD for the treatment of OSA. The Glidewell Hinge is a stainless-steel hinge mechanism that can be adjusted while in the patients mouth if necessary. Calibrated score marks on the Glidewell Hinge “arms” help dentists easily balance appliance titration. There are also additional features like the elastic hooks. The Glidewell Hinge makes the Silent Nite a bilateral compression device which pushes the jaw into a therapeutic protrusive position. To prevent undesirable mouth opening during sleep which can result in dry mouth or suboptimal treatment, lugs on the upper tray allow the addition of elastic bands to support the jaw in a closed position encouraging lip seal and quiet nasal breathing.

Conclusion

The need for an effective treatment modality for Medicare and Medicaid demographics is clear. These patients deserve sleep apnea treatment. For many, this would be oral appliance therapy under the care of a licensed dentist. The decision to provide OAT in a dental practice involves consideration of multiple factors. The scope of this article does not al-

10 DSP | Winter 2021

The Silent Nite with the Glidewell Hinge is a labprocessed, custom-fabricated PDAC approved device.

low for an exhaustive review of these factors, but patient demographics, profitability, and practice protocols should all be considered when making the decision to provide oral appliances. Medicare allowed amounts for oral appliance therapy range from ~$1,000 to about $1,900. Mandibular advancement devices, especially those for Medicare patients, must incorporate a few non-negotiable attributes for successful treatment and desirable profitability. The appliance must be affordable, PDAC approved, and fabricated without any special tools. Success in the business of dental sleep medicine requires low appliance cost, standardized clinical workflow protocols, and building case volume. The Silent Nite with the Glidewell Hinge costs less than $250. This is a lab-processed, custom-fabricated PDAC approved device that requires 4 days in lab and includes all the standard warranties for which Glidewell is known. This is clearly a strategy that will improve access to oral appliance therapy for patient populations that are severely underserved while improving the profit margins for practices that provide this much needed care.

Transform Your Practice with TruDenta Our diagnostic technologies and FDA-cleared therapeutic procedures provide pain relief and rehabilitate force imbalances for new and existing patients with sleep apnea, chronic migraines and headaches, tinnitus, and other neck/jaw pain.

Each drug-free treatment plan is tailored to address the individual patient’s symptoms, and includes the use of several tested technologies, including ultrasound, photobiomodulation, microcurrent, and muscle manipulation.

Reap ROI With Your Investment Dental practices that provide TruDenta see nearly 389 percent in return on investment and $1,500 per hour for doctor chair time.

As Seen On

Request a Consultation Today! 855-770-4002 | Trudenta.com/doctors/

EXPERT view

In Your Own Words

he pages of Dental Sleep Practice have been filled with dentists’ experiences and opinions about collaborating with physicians. These views usually follow the narrative that a multi-disciplinary approach to treating sleep patients is the only way – in an ideal world. This is often followed by pages of animus about unrequited referral relationships and languishing lunch and learns. But what do physicians have to say about this same subject? In each issue of Dental Sleep Practice, we ask experienced subject matter experts the same 3 questions. Here are their insights about physician and dentist collaboration… In Your Own Words. 1. What qualifications, traits, or history are you seeking when considering a referral to a dental practice? 2. What is a non-starter for a medico-dental referral relationship in your opinion? 3. Why do you collaborate with dentists & what impact has this had on your patients?

Lee A. Surkin, MD, FACC, FCCP, FASNC, FAASM

1. The qualifications I look for in a sleep dentist are, first and foremost, their training and experience. I send my patients to qualified sleep dentists, who, in my professional opinion, have dedicated the time and effort to obtain the educational foundation on sleep medicine through an accredited academy (preferably a not-for-profit one – either the AADSM or ACSDD). Next is their dedication to patient care. Just as a practicing and board-certified sleep physician individualizes the best possible treatment for their patient, so too should a dentist determine whether the patient to whom they have been referred is an appropriate candidate for oral appliance therapy. There must be a collaborative relationship between the sleep physician and sleep dentist. The next significant factor for me as a cardiologist is willingness to provide care to CMS patients and not up-charge beyond what CMS reimburses. I know this is a tall order but when an elderly patient is simply unable to afford the out-of-pocket cost of oral appliance therapy, it is

12 DSP | Winter 2021

very important to me that a referred patient does not come back for follow up in my clinic without an appliance because the dentist required an upfront fee that dramatically exceeded what their plan reimbursed. And, finally, I want to make sure that adequate communication protocols are in place and the patient will be returned to my care for both efficacy testing and long term follow up. I also ensure that communication is bidirectional. 2. A non-starter is lack of proper training and experience in a dental provider who has clearly taken shortcuts on their path to the field. 3. I have been a major proponent of dental sleep medicine for many years and have always embraced a collaborative and multidisciplinary approach to the treatment of OSA patients. Sleep medicine is undergoing a paradigm shift toward a focus on the individual patient in an effort to provide the best possible care from a phenotype perspective. This has been fairly routine in the cardiology world and continues to evolve as the science dictates. It is exciting to see this begin to unfold in sleep medicine, and I am honored to be a part of it. It is very clear to me that sleep dentists are, and should be, a major healthcare provider. The ADA understands the critical importance of screening for OSA, and it is well known that most people see their dentists more frequently than their primary care provider. Dentists “live” where OSA exists and need to be part of the multidisciplinary healthcare team. Collaboration with the sleep physician is critical to achieving success and oral appliance therapy needs to take center stage along with PAP therapy as first line treatment options. Too many primary care providers and other specialists have little or no knowledge about this critical treatment option, so we have a lot of educating to do. As I have developed relationships with my local sleep dentists, I have seen significant improvement in the health of my patients being treated with

EXPERT view oral appliance therapy. That is the most powerful point to make. Patients feel better and become healthier!

Ryan J. Soose, MD

1. My ideal dental sleep colleague exudes the 3 A’s: available, affable, and able. The availability to see high volume referrals and promptly initiate treatment as well as the availability to personally discuss and collaborate on complex cases. The affability that drives good bedside manner, healthy patient communication, and compassionate longitudinal care. And the ability, training, and expertise to deliver oral appliance therapy in a way that optimizes outcomes and minimizes risk. 2. One is the inability to take medical insurance. OSA is a chronic long-term medical condition with substantial implications on brain health, heart health, driving safety, and quality of life…not a cosmetic problem. The vast majority of patients need to manage this condition within the confines of their medical insurance and under the bigger umbrella of their overall health. 3. I simply couldn’t imagine sleep apnea treatment without oral appliance therapy. It’s such a core component of my patients’ care. Fortunately, the Pittsburgh region has been blessed with some of the best Sleep Dentists in the country. The many endotypes of OSA, the heterogenous nature of OSA anatomy and pathophysiology, necessitate a personalized multidisciplinary team approach for best outcomes – and Sleep Dentistry is a vital part of that team.

Madan Kandula, MD

1. Bottom line: I don’t care about your credentials. I care about your care of our patient. I refer patients to dentists who have simple, efficient, and effective techniques that deliver reliable and consistent results. Good clinicians are optimists. They believe in their skillset and techniques, and their good results reflect this attitude. Bad clinicians are pessimists. They believe every patient is complicated and convoluted. Poor results are sure to follow. I refer patients to clinicians who deliver exceptional customer service and reliable results.

14 DSP | Winter 2021

2. I have a few non-starters: Any dentist who doesn’t understand that they’re in the service industry first. Someone who doesn’t treat their patients with humility and respect. Someone who is constantly confusing patients, especially with an elitist attitude, unwilling to help them understand their care through layman’s terms. Someone who is protecting their own ignorant facade by using medical jargon to hide the fact they don’t actually know what they’re doing or how to help. And of course, poor quality work as evidenced by poor quality outcomes. If any of these are true, we aren’t meant to be. 3. You could say dentists own the teeth and jaws, and ENTs own the throat and sinuses. But, in actuality, we co-own the space where sleep apnea happens. Therefore, we must figure out a collaborative relationship to successfully treat this issue. OSA is an issue that requires collaboration between ENTs and dentists to provide successful outcomes for patients whose lives are quite literally on the line. I care more about my patients’ well-being and longevity than I care about crossing imaginary professional boundaries. All day, dentists are staring into airways – an ENT’s domain – so the more OSA awareness there is in the dental community, the better off patients will be

Joe Ojile, MD, D.ABSM, FCCP

1. It’s important to me that dental sleep colleagues are committed to the patient experience and continual, ongoing sleep education or board accreditation. Patient experience best practices that reduce the friction for the patient include a free or low-cost initial consultation, in-network insurance options for patients, dedicated staff for oral appliances, written communication protocol to the sleep doctor, and planned follow-up sleep testing for efficacy. Another helpful programmatic consideration is notification to our practice of patients who have elected not to schedule or not to proceed so that we may follow up with the patient. 2. This is an interesting and insightful thought question. Acknowledging that the medical model and dental models are

EXPERT view different in structure, flow, and communication. The dental model has traditionally been a more robust individual culture with some specialty referral. The economics more resemble the free market. The medical model has a more regulated underlay due to the ubiquitous involvement of government and insurance agencies. Medicine tends to experience more inter-specialty communication and integration. Given these two general observations the communications between our two specialties are a key aspect in the process. The non-starter situations are the model where dentists seek referrals without sensitivity to the collaborative process or the overall marketplace (for instance, we work with multiple excellent sleep dentists and a suggestion for a sudden abandonment of those relationships by one dentist can be off-putting) and the need to recognize that obstructive sleep

apnea maybe only part of a much bigger medical intervention that is occurring. 3. The collaboration with sleep dentists has been an enrichment to our practice and our patients. To observe the effort and passion that the dentists we have been privileged to regularly collaborate with, their earnest efforts and caring for patients, staying in communication with us throughout the process and stratifying appropriate patients has only helped us to provide comprehensive approaches to management of OSA patients. We discuss oral appliances with a large percentage of our patients as part of their post-test review. It is important that every patient receives a thorough explanation of all treatment options that apply to them and their disease state. It’s essential that we have a confident solution for each modality. The relationship we have developed over the last decade with our dental colleagues has provided this.

DentalSleepPractice.com

COVERstory

THE FUTURE of Sleep Medicine

by Deepit Anand, Brett Brocki, & Patrick Kircher

or too long, Dental Sleep Medicine (DSM) has been a fragmented patchwork of solutions; difficult to navigate and stitch together. And, because obstructive sleep apnea (OSA) is a medical condition that can be treated by a dentist, a group of interdisciplinary providers must work in conjunction with one another. Unfortunately, lack of training, disjointed electronic medical record systems, and fractured insurance payer systems have made it confusing and difficult for patients to access affordable, life-saving treatment. The story of Nexus Dental Systems is about a group of innovative companies joining forces to save more lives. Partnerships were formed with a vision of a comprehensive solution that simplified the delivery of life-saving treatment to millions of patients with OSA. Together we are reshaping the future of dental sleep medicine.

These solutions include credentialing, whole team training, patient Our Vision Over the years we have seen every passoutreach and ing fad, every miracle solution, and heard education, and an every excuse in Dental Sleep Medicine. We innovative medical have seen many dentists give up on sleep medicine because they could not overcome billing solution several common hurdles, the most frequent that is integrated complaint being problems with medical insurance billing. While medical billing is into the whole a huge obstacle, it does not exist in a vacprocess. uum. The truth is that many of these issues are interconnected. To build a sustainable solution for the future of sleep medicine, we need to construct a true ecosystem that is adaptive and resilient to the constant evolution of the industry.

16 DSP | Winter 2021

Nexus Dental Systems was created to unite several key solutions for medically necessary dental treatments into one fully integrated system. These solutions include credentialing (ACSDD), whole team training (N3Sleep), patient outreach and education (DreamSleep, DentalPlay, Dentool App), and an innovative medical billing solution that is integrated into the whole process. We united these capabilities to address the main challenges dentists face when treating sleep.

Recognized Education

There are many options out there for education in Dental Sleep Medicine. From weekend events, online courses, seminars, and webinars to multi-week programs and mini-residencies, there are a lot of options for DSM education. For most of these programs, passing is determined by the completion of a required number of hours and a score on an exam. With one exception that we are aware of, none require that a board review dentist’s cases. Dentists are becoming “Diplomates’’ without ever having treated a case and this is harming the entire field of dental sleep medicine. Physicians go through intensive training, and even after they have graduated, they must complete a residency, where all their cases are reviewed by a senior physician with years of experience, because results in the real world are different from results on an exam. Physicians want to refer to someone they trust with the life and care of their patient. A practitioner who will provide medically appropriate treatment, verified with efficacy testing, who has a proven record of success-

COVERstory

DentalSleepPractice.com

18 DSP | Winter 2021

WARE

EDUCA

fully treating OSA with oral appliance therapy. Therefore, board certification without case review is harming the reputation of DSM. In fact, we believe this so much that we found the only group that requires case review in DSM: The Academy of Clinical Sleep Disorder Disciplines. The ACSDD is a not-for-profit organization that offers a rigorous 13 CE online course program, which qualifies a dentist to submit cases for board review. A multidisciplinary board reviews twenty cases, including five in detailed narratives to evaluate the appropriateness, quality, and efficacy of treatment. There is no other program like it. No other program that INING puts patient care first. No other program RA T proves a dentist knows what they are doing and didn’t just get a certificate for sitting through a weekend course. FT

COVERstory

Team Training

Teams need help for many reasons, but the common issues we have seen are poor understanding of the importance of dental sleep medicine, resistance to change, and lack of T a clearly defined protocol supported Y EC HNOLOG by the dentist. The truth is that most dentists are extremely busy. No matter how many weekend courses, seminars, and online courses you have taken, it is unrealistic to think you can translate that into an actionable protocol for your office, and then train and mentor your whole team on it while maintaining a full dental patient load. There are too many processes, systems and details that need to be ironed out, and the team is already busy with their existing workload. There is no quick fix. So, what can be done? The solution is whole team training that includes custom protocol development and ongoing coaching. Someone who knows the systems and can create step-by-step guides for each team member based on the reality in your practice. This is exactly what N3Sleep was founded to do: fix these problems so dentists can help people and save lives. The N3Sleep team has experience with all the software, systems, and tools you may have already bought. They can identify who on your team should be doing each step and build a fool-proof system to

make sure nothing falls through the cracks. Our system is not a separate process added onto your existing workload, it is integrated directly into current protocols. When we are onsite, we want live patients in for their scheduled appointments so we can directly integrate our process into your protocol. This reduces resistance from the team and fosters a sustainable process moving forward.

Patient Outreach and Education

To succeed in DSM, dentists need to reach the patients who need help. Your first sleep patients will come from your existing dental patients. They are already in your office; they just need screening and a referral for testing. Since 2016, DreamSleep has been creating informative and effective patient outreach materials for the dental office, social media channels and innovative screening events. DentalPlay (Dentoolapp.com) is the perfect complement: a vast library of informative and medically accurate 3D animations of sleep, oral surgery, cosmetic, implant, orthodontic and periodontic procedures. These are available for streaming to a tablet chairside or added to your office video system and customizable with your logo. On-demand access to these videos make your team be more effective when explaining procedures to patients.

Medical Billing

It’s the elephant in the room. It is the number one reason dentists give up. Even in the best-case scenario, it takes forever to get paid and is wildly inconsistent. Insurance companies are not in the business of paying out money. Solving this problem has been the biggest challenge we have faced. Through several acquisitions we’ve made, Nexus Dental Systems can offer a full suite of medical billing capabilities that will bring consistency to reimbursement. Whether In-Network or Out-Of-Network, this billing solution provides every one of our clients with a customized protocol and a clear pathway to optimal, consistent reimbursement. Our system includes comprehensive training for your team, proprietary and integrated billing software, and access to our billing network.

Why We Do This

These four tenets are the foundation of

y Holdings

We offer what no one in the den

Sapphire is uniquely positioned to impact the dental strate Sapphire is uniquely positioned “Expand North American sales and leverage the marketing or “Expand North American sales an

strategic pillars. ng organization to drive adoption of a national turnkey brand”

ial most

ep and es

ain of

OSA public awareness activities: website, social public media, brochures, posters, videos,OSA events andaware most importantly the B to C products media, brochures, importantly the B

Complete turn-key, hands-on approach to Sleep 501C3 Non-Profit Fully accredited, online, onComplete turn-key implementation, ongoing coaching & support and demand Dental Sleep Medicine credentialing. The new sales of equipment, softwareimplementation, and services o only one of its kind in the world. new sales of equip

Medmark LLC is proud to be theUnique leadingtherapeutic interactiveframework for Chronic Unique therapeuti Headache, Migraine, TMD, Tinnitus, Vertigo, Pain of marketing and multi-platform advertising company Headache, Migrain Neck, and focused on the niche specialtiesHead, of dentistry. WeFace are Head, Neck, and F creating a healthier America through knowledge, due diligence, and experience, by empowering dental professionals with high quality clinical information in clear and concise language and showcasing innovative technologies.

Sapphire Sleep Key Hol We offer what no one in the dental space offers

Sapphire is uniquely positioned to impact the dental strategic pillars “Expand North American sales and leverage the marketing organization

Fully accredited, online, on-deman and Adult cases. Seminars, coach

The OrthoCatapult system compr OrthoGallery®, OrthoAnalytics®, an esignatures, practice performance market. Cross platform for other d general

The mission of the Mel Blount Yo programs where they will have a develop principles of respect, res character development and guida adult populous coupled with Mar

The Future of Sleep Medicine Starts Here www.nexusdentalsystems.com

COVERstory Deepit Anand, Brett Brocki, and Patrick Kircher are the founders of Nexus Dental Systems.

our fully integrated Sleep Medicine ecosystem. Over the years we have built this program to address the biggest challenges dentists face. Our goal has always been to create a sustainable and resilient system able to adapt to the constant drumbeat of change in this industry. An estimated 67 million Americans, about 1 in 5, have AHI >5, and they need our help. Their health is suffering, and their condition will get worse without treat-

ment. In 2017 the ADA tasked every dentist with screening for Obstructive Sleep Apnea and providing treatment when prescribed by a physician. We are here to help you deliver on that mission. Deepit Anand, Brett Brocki, and Patrick Kircher are the founders of Nexus Dental Systems. To learn more about what we are building and each of our brands, visit our website nexusdentalsystems.com.

Deepit Anand

Founder, Investor, and Fund Manager of Sapphire Group of Funds, over $100M+ AUM, Deepit brings wealth of experience running a successful Dental Support Organization (DSO) covering the full spectrum of proficiencies including insurance claims, dental supplies, labs, payroll, bookkeeping, 401k setups, digital marketing, website, SEO, PPC etc. This DSO model is built on a consolidation philosophy within the healthcare space. By strategic selection of dental offices at the right EBITDA, and creating a hub spoke model of 4-5 offices within a 20 miles radius and repeating this in several states, the core of the model is constructed. After that, focus is turned to improving operational efficiencies, thereby increasing revenue and net profitability at each location making the DSO attractive to PE firms within his existing network and space.

Brett Brocki

Founder, and has served as Chief Executive Officer of DreamSleep and N3Sleep. Brett has been in the dental industry since birth. His mother was the former head dental assistant at Fort Bragg and Brett has seen the inside of thousands of dental practices, including civilian, military, and hospital practices. His expertise in business, finance, and dental have given him exposure and unrivaled capabilities to truly bring the right picture together for overall health and wellness. Working closely with many practices will achieve the optimum sleep practice with the most thorough care. Brett has truly developed a multidisciplinary team with the tools to connect the Medical and Dental professionals into one cohesive business unit.

Patrick Kircher

Patrick founded National Dental Systems in 2015 comprising a comprehensive medically necessary dental model including the diagnosis and treatment of Obstructive Sleep Apnea, DMSD, and Associated Symptoms. Having spent more than a decade working in Sales, Marketing, Business Development, and Management, as well as developing his own Dental Service Organization, Kircher truly knows what drives the dental business. This experience has given him a truly unique perspective in almost every aspect of the dental business that is quite uncommon.

20 DSP | Winter 2021

Success in Sleep Through the Power of Teamwork Join DreamSleep – a nationwide network of dentists & physicians fighting sleep apnea. Our Whole Patient Program is a comprehensive plan that empowers dental practices with the knowledge, resources, and tools in order to provide patients with the highest standard of care for dental sleep medicine. The Whole Patient Program consists of four principles: Raise public awareness of Obstructive Sleep Apnea, DMSD, TMD, migraine and associated symptoms; train dentists to work with physicians and implement medical treatments; create screening and therapy programs for the industry; and connect patients with providers. Through state of the art, individualized training and implementation processes, we help you seamlessly integrate these medical treatments into your dental practice to increase your patients’ quality of life and add a valuable revenue stream. Call 844.363.7533 today for details.

Limited T

For a limited time only: in Baltimore for a FREE network with the most obstacles to treatment help you integrate dent providing the education

Education

Comprehensive educatio you and your whole team

ucat

ion

Comprehensive education for you and your whole team.

To o l s

• Online, on-demand academic certificati • Individualized traini programs • In-office clinical train • Team Coaching P a • tScreening s t ie•n Practice Manageme Systems Join our nationwide network and get • Medical Billing referrals from our exclusive contracts. • Physician Communi

Exclusive tools and technology to help you stand out and succeed in sleep.

*Device pictured for illustration pur Contract required, additional condi

Your Success is Our Goal 844.363.7533 | n3sleep.com | dreamsleep.rest

Call

EDUCATIONspotlight

There is an Interrelationship Between Pain and Sleep

eeking continuing education can help enhance your dental practice and improve the lives and well-being of your pain and sleep patients.

Sleep complaints are present in up to

88% of chronic pain disorders.

22 DSP | Winter 2021

We require both pain and sleep for survival, but the chronic impairments in the systems of our bodies that regulate pain and sleep can negatively impact the health and well-being of our patients. What we know is that sleep complaints are present in up to 88% of chronic pain disorders. In fact, at least half of people who suffer from insomnia also experience chronic pain. Making matters worse, both chronic pain and sleep disturbances share physical and mental health comorbidities including obesity, type 2 diabetes, and depression. And in the time of the pandemic, those comorbidities can increase a person’s risk of developing severe COVID-19. But as we continue to navigate the ongoing pandemic, we have gained a better understanding that obtaining quality, restorative sleep is vital for coping with the world around us. In 2015, the National Sleep Foundation’s Sleep in America poll found that one in five Americans suffer from chronic

pain and report substandard sleep quality. To add to that, one in four people with chronic pain also have a sleep disorder. This bidirectional relationship is why it is clinically important for us as dentists to assess sleep quality for all patients living with chronic pain and vice versa. At Ben-Pat Institute, we have a particular continuing education course that will provide you with information on how to properly treat your patients and help them prioritize sleep while minimizing pain. This four-part series on pain and sleep will help dentists to better understand oral appliance therapy for dental sleep medicine and pain from temporomandibular disorders (TMD). In this series, dentists can learn the anatomy and neuroanatomy as it applies to pain and sleep while also obtaining skills to perform a comprehensive examination for those patients. Dentists will also learn how to diagnose the various TMD and orofacial pain conditions and how to manage them. Additionally, dentists will learn how to get paid for their services, and how to build a pain and sleep practice. It takes a team to establish proper care for our pain and sleep patients. Take the next step in caring for your patients by completing continuing education in the area of pain and sleep to ensure their health and well-being, especially as we attempt to find an end to the ongoing COVID-19 pandemic.

BILLINGblocks

Avoid Medical Denials by Knowing these Trends by Rose Nierman and Courtney Snow

edical policies change. That is the only thing that can always be counted on in the fickle world of medical billing for Oral Appliance Therapy (OAT) for Obstructive Sleep Apnea (OSA). To remain efficient and successful in medical billing for OAT for OSA, it’s critical to be aware of new trends.

Medical insurers maintain coverage policies that provide criteria a patient must meet to be eligible for coverage. However, coverage criteria don’t remain static. Coverage policies are regularly reviewed and updated. Fortunately, coverage policies are typically publicly accessible on the medical insurer’s website. Some criteria that are universal amongst medical insurers for patients to be eligible for coverage for OAT for OSA: • Must be diagnosed with OSA with a sleep study • Must have a prescription/written order from a physician And a few common criteria: • If severe OSA, must be deemed intolerant/non-compliant or contraindicated for Positive Airway Pressure (PAP) therapy. • If mild OSA, must exhibit at least one of the following comorbidities: history of stroke, hypertension, ischemic heart disease, impaired cognition, mood disorders/insomnia, excessive daytime sleepiness, or significant oxygen desaturation. So, what’s new? It’s not TikTok, but here are some trends you should be aware of: • Proof of delivery is no longer only for Medicare. Increasingly, private/

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. As Vice President and CE faculty member 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.

24 DSP | Winter 2021

commercial insurers are requiring a proof of delivery form signed by the patient. • Notes from a visit with a physician before the sleep study or beginning OAT. Also, not just for Medicare anymore! • Use of an oral appliance that is PDAC approved for HCPCS code E0486. This is yet another rule that is not just for Medicare anymore. Increasing numbers of private/commercial insurers require the use of specific appliances found on the PDAC list for E0486. • Sleep study within one year prior to delivery of oral sleep appliance. While some medical insurers continue to accept sleep studies 2-3 years old, the 1-year trend is undoubtedly rising. • Documentation of absence of TMJ disorder and significant/active periodontal disease. Include this information in the objective section of your SOAP notes from the oral exam. • PAP therapy intolerance/non-compliance or refusal documented by a physician. In the past, an affidavit indicating why the patient cannot tolerate PAP therapy signed by the patient would suffice. Many insurers are now requiring this to be in the physician’s notes instead. Not all medical insurers will require all the items discussed in this article. However, it’s crucial to be familiar with the trends and regularly review local coverage policies for medical insurers in your region. At Nierman Practice Management, we regularly review these coverage policies, alert our clients and continuing education seminar attendees of significant changes & trends, and update the DentalWriter software based on new trends. This ensures your software is compliant and you’re hip to all the current trends in dental sleep medicine.

INTRODUCING THE NEW DENTALWRITER™ PLUS+ SOFTWARE We know how important efficiency & medical reimbursement is for your dental sleep practice and patients. DentalWriter™ Plus+ Software and Nierman Medical Billing Service make it easy.

INTUITIVE WORKFLOW

INTELLIGENTLY DESIGNED

SEAMLESS MEDICAL BILLING

Web-based & customizable EMR designed exclusively for dental sleep medicine, TMD, and oral surgery workflow.

DentalWriter Plus+ builds your case of medical necessity with automated SOAP reports and medical cross-coding.

Enjoy a luxury experience as your DentalWriter+ integrated concierge takes the medical billing load off your shoulders.

WHY DENTAL PRACTICES PARTNER WITH Dentalwriter™ is pure GENIUS and easy to navigate. Nierman is a well-oiled precision team with customer service, great communication, and superior professionalism. One of the best decisions I've ever made! -Dr. Alan Walker Not 100% satisfied with your current solution? There IS a better way - schedule a demo today!

Use code DW+DSP for $500 off

800-879-6468 opt. 1 | NiermanPM.com

PEDIATRICS

Pediatric Sleep Issues Last a Lifetime; Join the Movement ASAP by Michelle Sabater Weddle, DDS, FAGD, D.ABDSM

“M

ichelle, you dentists don’t know what you can do for these kids. Medicine can diagnose this condition. They can manage and give the child allergy medications and CPAP. But you dentists can help TREAT it.” Those memorable words were spoken to me by the late Dr. Christian Guilleminault in a private conversation. TREAT is an ambitious word, but it’s also a goal we’re very comfortable with. Whether OSA or any of the conditions in the SRBD spectrum, we know the etiology is multifactorial. Because of that, treatment requires a multi-prong approach. It is idealistic at best and egotistic at worst to think that dentists can treat, to full resolution, every SRBD patient. But we know that in many cases we can make it better. Anecdotal feedback from other providers, patients, and their families can bring you to tears with the way some of the lives of these children have changed. Equally as important, this supposition is supported by a litany of medical and dental literature. No one should deny a child airway therapy. And no one can deny dentistry’s vital role in the provision of pediatric airway therapies. From overt obstructive sleep apnea (OSA) to the milder conditions in the spectrum of sleep-related breathing disorders (SRBD), the literature is replete with evidence supporting the positive impact dentists can fulfill as part of a multi-disciplinary team delivering positive patient treatment outcomes that benefit their lifelong health trajectory. In the adult sleep medicine field, we grasp the impact of oral appliance therapy in the life of a person. It affects every facet of

26 DSP | Winter 2021

their being – from their performance at work and familial relationships to their diets and medication profile. With pediatric patients, the impact can be even more profound because of their ongoing development. Treated SRBD can have a pronounced positive impact while untreated SRBD can have a disproportionately deleterious impact on the following: • IQ, brain development, and cognition • Focus and school performance • Breathing patterns & sports performance • Behavior which can have implicit (attitudinal issues which affect peers, siblings, and parents) and explicit (juvenile crime, drug use) societal costs • Accidents (auto, sports, etc.) The effects are not only limited to the affected child. They ripple outward and may affect others in their sphere: parents, fellow students, siblings, and other caregivers. Additionally, the advent of Covid-19 underscored the importance of underlying health issues in a population. Hopefully, I’ve convincingly established the fact that dentists can make a real difference. But who’s going to do it? Since we’re dealing with pediatrics, the most obvious choice is the pediatric dentist. But what about general dentists? What role does the orthodontist have? How about periodontists and oral surgeons? All these dentists have a role to play in the management of pediatric airway. Our study club, sees all these specialties represented, and they each play unique, vital positions: • General and Pediatric dentists: Screen, educate, triage, early treatment/management, referrals to specialists

PEDIATRICS • Orthodontists: Screen, Educate, Full management of growth guidance from childhood into adulthood • Periodontists and Oral surgeons: Screen, performance of surgical assists in the orthodontic and growth guidance therapies, SFOT, TMJ support/ therapies. As a reader of Dental Sleep Practice, you likely already manage adult airway and sleep issues. This means you are uniquely positioned to offer pediatric airway and sleep therapies. Consider the following: • Many risk factors in airway and sleep conditions are genetic. • Risk factors that are not genetic are functional, usually affected by the environment and diet, which these adults share with their children. • Adult patients in this type of practice already understand the condition and are there to seek treatment. • Trust and rapport have already been established between the patient (parent), dentist, and team. Allow me to connect the dots here. All the points mentioned above mean that you and your practice can play a pivotal role in these kids’ lives. You are in the best position to add pediatric airway and sleep services to your practice. Managing pediatric airway is firmly in our wheelhouse. This is very similar to the work dentists do daily. In dentistry, care is usually coordinated by the general or restorative dentist with referrals to many different specialists occurring depending on the needs of the patients. We are masters of interdisciplinary treatment. In contrast, many outside the dental healthcare industry practice a multidisciplinary working model, which usually means that one specialty or branch does everything they can do for the patient, and then if there are still conditions that need to be addressed, the patient is referred to the next specialty for care of most (if not all) of the residual symptoms and issues. What’s the difference? Managing pediatric airway and sleep requires the interdisciplinary approach that dentists are very well-versed in. For growing kids, management is not a series of linear visits to one provider, then the next. It usually entails visits to multiple providers at the same time. Who will direct the care? Which providers will the child see and when? This IS in the

dentist’s wheelhouse, and we are best suited to direct this care. You can have an incredible impact on these people’s lives. Will you heed the call? Maybe you’re sold on the concept now. After sharing this information with my colleagues, they inevitably ask the subsequent three questions:

1. How Do I Learn to Do This?

Compared to a decade ago, there are more places to get educated in pediatric airway. We’ve come a long way, but it is still deficient when compared to other continuing education topics like implants or even

Dr. Michelle Weddle is a general dentist in private practice in NJ. She’s a graduate of the NYU College of Dentistry with a General Practice Residency certificate from Newark Beth Israel. She completed the mini-residency in dental sleep medicine at Tufts University and is a Diplomate of the American Board of Dental Sleep Medicine. Dr. Weddle studied at the Pankey Institute, The Dawson Center, and The Kois Center in her pursuit of acquiring higher education. Her general, sleep & TMJ practices focus on the integration of oral health into whole body health. Her practice has a special focus on the management of airway issues in adults and children. Coming full circle, she served as a visiting faculty mentor for the Airway Prosthodontics Workshop at Spear Education. Dr. Weddle is a Fellow of the AGD and the ACD. She is a member of the American Academy of Oral Systemic Health, the AAPMD, the AADSM, and the IAO. She is a member of the AGD, the ADA, and the NJDA, where she served as trustee for her component society. Recently, she co-founded ASAP Pathway, a community of dentists learning to implement a collaborative, interdisciplinary model of pediatric airway management in private practice.

DentalSleepPractice.com

PEDIATRICS adult sleep medicine. Many of the education providers in pediatric dentistry are centered on a commercial product or singular technique. When looking for an education provider, it is important to get perspective from the clinical standpoint, e.g dentists who have been using the product or practicing the technique. Ideally, these dentists are independent practitioners. It’s also crucial to consider how we learn. While something may be resonant the first time, we only retain a miniscule amount information upon first exposure. This No one should deny a of is especially true of new concepts. Seek child airway therapy. educational platforms that provide ongoaccess to the educational materials. And no one can ing The information will be reinforced and deny dentistry’s vital take on different meaning as you get realworld experience.

role in the provision of pediatric airway therapies.

2. Is It Worth the Investment?

Implementation is where the rubber of education meets the road of treatment on the path to the always desirable ROI. Attaining a significant ROI requires work from you and your dental team. This is definitely a team sport. You must have buy-in from the entire team – hygienists, assistants, administrative support, office manager, etc. Without them, you cannot productively do this. It can burn a lot of time and drive down production for the day if you don’t have efficient systems in place. When considering implementing pediatric airway and sleep therapies in your practice, it is of paramount importance that you consider all the following: • Who are the team members who will help spearhead this in the practice? Do you have sufficient staff to do this without negatively affecting your general practice? • How will the team be trained? Like every new product or procedure, successful implementation of pediatric airway and sleep depends on your team being engaged and knowledgeable about how these services fit in to the other services that you offer in your practice. Have you allocated the budget and dedicated the time for this? What happens if there is staff turnover. How will new staff members be trained? How will offering this

28 DSP | Winter 2021

service fit into the existing flow of the practice? • Do you have the support of an external team of healthcare providers to promote the team approach to managing these conditions?

3. Is It Sustainable in My Practice?

Incorporating any new procedure in the practice has challenges. To ensure the smoothest pathway to incorporate pediatric airway and sleep, you’ll need: • Protocols tailored to how your practice operates. • Cohesive dental team that understands the role of each person in the practice in the rationale for integrating this service into your existing services • Realistic financial arrangements that factor the cost to the practice regarding time, materials, and resources so that the practice stays financially viable while trying to incorporate these services. • Support group of like-minded colleagues that have overcome the challenges you’ll face and exchange ideas, best practices, and share camaraderie.

Now What?

The field of pediatric airway and sleep is a rapidly growing field that has not yet reached its potential. There is an immense need for providers to help children and their families. It behooves the profession to increase awareness about how dentists can play a role in helping children with these issues through public awareness but also advocacy at the legislative level. As with many procedures, the limitation for some patients to initiating treatment are financial constraints. Influencing third-party reimbursements for these conditions and services could go a long way in improving the health of the children affected. We are the frontline, the proverbial spearhead. There is a lot of work to be done. Fortunately, there are many dentists. Kids need you. Their families need you. Society needs you. If you are interested in providing pediatric airway and sleep services (screening, early management, treatment, or advocacy), seek a comprehensive education platform focused on the subject ASAP. Join the movement.

PRACTICEmanagement

Losing Your Mind from Medical Policy Updates? PLAY BY THE RULES! by Kyle Curran & Randy Curran

top me if you’ve heard this one before. You know the medical insurance carrier covers the oral appliance, but they keep denying your authorizations and claims. When you call, you’re informed it’s been denied for a lack of proven medical necessity. Your team provided the sleep study and an order from a physician. What else could they need? If you’ve been through this song and dance, rest easy, as this article will navigate you through the twists and turns of obtaining insurance coverage, and ultimately a payment. The springboard for obtaining the proper documentation starts with a recent sleep study and an MD’s order (letter of medical necessity/ Rx), but it doesn’t end there. Generally, documentation must be provided to satisfy the following requirements: 1. The Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or, the AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of: a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or hypertension, ischemic heart disease, or history of stroke; or, 2. If the AHI >30 or the RDI >30 and meets either of the following (a or b): a. The beneficiary is not able to tolerate a positive airway pressure (PAP) device b. The treating practitioner determines that the use of a PAP device is contraindicated.

3. There is absence of temporomandibular dysfunction or periodontal disease Now, this is where things can get wacky. The pathways bifurcate, trifurcate, and veer from the core path with the mind-boggling addition of extra requirements. Here are a few sidewinders that could be delaying your cases: • Aetna requires the sleep study to be scored using a 4% desaturation for hypopneas, and that needs to be documented on the report. • BCBS FEP plans, as well as some standard BCBS plans in certain states, may require all patients to try PAP therapy first, no matter the severity of their OSA. • UHC requires the patient to see a physician trained in sleep prior to granting approval. They also require that the name and price of the appliance be on the physician’s order. form. They also add onto the dental requirements by stating that their patients must have: º Sufficient dentition to allow for retention of appliance º No active periodontal disease or dental decay º No active temporomandibular joint disorder º No restriction in mandibular opening or protrusion • Several carriers require documentation from the patient stating that they would like to use the appliance over PAP therapy, regardless of the disease severity. • Medicare requires the patient to meet with a treating practitioner prior to the sleep test. If Noridian is the administrator in your state, you will also want to be mindful of their Same and Similar DentalSleepPractice.com

PRACTICEmanagement rule. Else, they will deny the claim if the patient has been billed for a PAP device or another appliance in the past five years. To overturn that denial, you will need some additional documentation. • UHC Medicare Advantage/AARP will deny claims for being experimental or non-covered before conducting a medical review. To appeal the decision, they require the provider to sign a Waiver of Liability (WOL) and send it with Contrary to popular the appeal and records. This WOL belief, billing companies states that if the decision is upheld, the provider forfeits the right to bill aren’t the bad guys. the patient. These are some of the most common exceptions to the norm, but there are still other ones out there. That is why it’s pivotal to research the insurance policy first. This will ensure you prepare the proper documentation and you’re equipped if they incorrectly deny the case and you must submit an appeal. Always know the rules to the game you’re playing. To properly position yourself moving forward, we recommend establishing a protocol that meets the requirements of the most stringent policies. If you have the following documents on file for every patient, your likelihood of receiving denials is greatly reduced:

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

30 DSP | Winter 2021

• Face to face notes with a sleep physician. Currently, this can be a telemedicine visit. • Sleep study scored with a 4% desaturation parameters • Full comprehensive dental evaluation meeting UHC’s rigid requirements • Statement of Therapy showing the patient chooses oral appliance therapy or is intolerant to PAP therapy • Health history form with all relevant comorbid conditions, mood disorders, insomnia, impaired cognition, and an Epworth score. Having these documents on file and being knowledgeable about the particular policy will create a much smoother authorization and claims process. You’re still likely to encounter denials and exceptions, but this will occur far less frequently. When it does happen, you will be well positioned to obtain additional documentation or confidently file an effective appeal. Fortunately, as a dental practice, you have options. If this sounds challenging to you and seems to be a good use of your scarce resources, you can certainly begin learning each insurance carrier’s guidelines and designing the internal protocols with the strictest carrier in mind to ensure that all the patients will qualify for coverage. There’s another option if this has your head spinning. You can hire a third-party service for billing and perhaps a third-party service for sleep testing, too. The billing service will ensure all documents are in order before submitting the prior authorization request or submitting a claim. Billing services only succeed when their practices succeed, so they stay on top of these policies and ensure practice compliance to meet the coverage criteria. Contrary to popular belief, billing companies aren’t the bad guys. They are just protecting you as a practice to ensure coverage and payment. A sleep testing service may also be helpful as they will have sleep physicians readily available to help meet the strict coverage requirements that we are currently seeing from some carriers. The onus is on each of us to know the rule book and meet the insurance companies’ seemingly superfluous requirements. Then patients get the treatment they need and you get the reimbursement you’ve earned.

CONTINUING education

Technology:

Dental Sleep’s Gatekeeper to Boost Case Acceptance and Increase Efficiency by Jason Doucette, DMD, D.ABDSM, and Jeff Rodgers, DMD, D.ABDSM

echnology continues to revolutionize the practice of dental sleep medicine (DSM). Various instruments, software, and service solutions have enhanced the field and helped provide practices with increasingly predictable and prompt clinical results. This level of predictability can lead to better clinical results faster which creates healthier patients and more productive multi-disciplinary relationships. We will explore various solutions available that help achieve three key elements: 1. Improve patient acceptance and clinical outcomes 2. Increase practice efficiency 3. Grow practice profitability

Educational Aims This self-instructional course for dentists aims to show that technology has revolutionized the dental sleep medicine field. From the introduction of new appliance designs and the evolution of manufacturing methods to the growing adoption of intraoral scanners and electronical medical records, innovation is a key driver of the field’s growth. Numerous solutions have enhanced the space and provided practices with increasingly predictable and desirable clinical outcomes. These solutions can also improve profitability through reduction in chair time and dramatically abbreviating the period between initial screening and successful treatment.

Expected Outcomes Dental Sleep Practice subscribers can answer the CE questions online at dentalsleeppractice.com/ce-articles to earn 2 hours of CE from reading the article. Correctly answering the questions will exhibit the reader will: 1. Understand how technology can benefit a dental sleep practice 2. Realize the implications of electronic medical records and intraoral scanners 3. Discern the differences between various bite registration tools 4. Grasp how some protocols may predictably accelerate treatment outcomes

32 DSP | Winter 2021

In the field’s early days, clinicians would use the George Gauge® (Great Lakes Dental Technologies, Tonawanda, NY) and cumbersome Gothic arch tracers to lock down a bite position before pouring stone models and mounting each bite on an articulator prior to sending off for one of the few oral appliances that were available. Appliance delivery involved a lengthy process of adjusting fit followed by titrations based purely on subjective feedback and guesswork. Home sleep testing (HST) was not widely available, so many patients had to undergo multiple follow-up polysomnograms (PSG). On the administrative side, insurance coverage was spotty, and Medicare coverage did not exist. The HCFA 1500 form was manually filled out in pen and mailed in via snail mail. It seemed to be lost or denied more than 50% of the time. Today dental sleep practices utilize dedicated electronic medical records (EMR). They can become Medicare providers, select to optimize in- and out-of-network billing solutions, and realize the enormous benefits of a fully digital health history. Many patients

CONTINUING education can be diagnosed via HST, and physician referrals or appliance prescriptions are often transmitted electronically. To improve the accuracy of airway assessments and bite records, clinicians can leverage CBCT scans or pharyngometry and rhinometry. The increasing adoption of intraoral scanners means impressions are scanned and delivered to the lab before the patient hits the parking lot. High quality appliances are precision milled and simply drop in after being custom fabricated to our precise measurements. This generates a greater likelihood the patient will realize better outcomes sooner. Some readers are innovators and early adopters fully leveraging technology. Others are late adopters that have yet to incorporate these time- and energy-saving tools into their practices. Yet other readers have some of these tools and not others. Unfortunately, there is another category of clinicians that cite a litany of reasons to forego sleep altogether. Their chorus of disapproval contains lyrics like “Sleep is too difficult”, “This doesn’t work, patients don’t accept treatment” and of course the hit single “It’s impossible to get paid.”

Systems-based Solutions

A comprehensive end-to-end system is critical. Owning a single HST device or two and thinking you are going to become the sleep medicine guru in your city is like having the best tires for your car but no engine or steering wheel. You probably aren’t going to go very far. On the front end, a dedicated practice management system for your sleep business is a must if you intend to scale your sleep practice up beyond that of a one-case-permonth hobbyist. Systems such as DentalWriter™ (Nierman Practice Management, Tequesta, FL), DS3 (Dental Sleep Solutions, Bradenton, FL), and Imagn (DevDent, Orem, UT) provide products to meet this need. An increasing number of “sleep only” practices have been adopting EHR platforms like AdvancedMD™ (AdvancedMD, South Jordan, UT) and athenahealth™ (athenahealth, Watertown, MA) because of the high level of customization, connectivity, and robust feature set. The most popular of these solutions provide scheduling, integrated medical charting with screening and exam forms, customizable communication letters, templates, SOAP notes and claim submissions

to be managed independently or as part of a 3rd-party medical billing service. Consider the last 5 sleep patients you treated. Pre-treatment, did you correspond with the complete list of the patients’ healthcare providers: Primary care physicians, pulmonologists, ENTs, neurologists, cardiologists, endocrinologists, rheumatologists? Did each of those providers receive a letter from you at the initiation of treatment for your mutual patient? This letter should have outlined how the patient came to your office, the comprehensive list of records and measurements you’ve taken to ensure optimal results such as Epworth or other screener results, pharyngometry and rhinometry reports, CBCT evaluation, and all other relevant clinical data. This level of documentation and communication differentiate your practice and combat any preconceived notions they may have about collaboration with you. Post-treatment, those same physicians get another letter from you with a status update, follow-up subjective evaluation, and sleep study results. Did the letter outline any ongoing concerns or issues they may need to monitor such as hypertension medication dosage? Did it summarize treatment, and conclude

The ability to see airway collapse and minimum-crosssectional area in real time presents a compelling measurement for sleep dentists.

Dr. Jason Doucette is a Nevada native; he attended the University of Nevada, Reno and received his bachelor’s degree of science in 1995. He then attended Oregon Health Sciences University in Portland, Oregon where he received his Doctor of Dental Medicine in 1999. Dr. Doucette returned to Reno to begin his career in dentistry. As a result of Dr. Doucette’s extensive training and background in comprehensive dentistry over the last eighteen years, coupled with his concern for every individual’s overall health, Dr. Doucette has become acutely aware of the vital role that efficient sleep plays in the optimal health and healing of his patients. Dr. Doucette is very passionate about heavily screening and treating all of his patients for sleep breathing disorders such as snoring and obstructive sleep apnea. Dr. Jeff Rodgers specializes in dental sleep medicine and has been in private practice for over 20 years. A Diplomate of both the American Board of Dental Sleep Medicine (ABDSM) and the American Sleep and Breathing Academy (ASBA), Rodgers is a board-certified expert in sleep, treating patients who suffer from sleep breathing disorders at his practice Sleep Better Georgia in Dunwoody, Ga. He is committed to raising awareness of sleep issues and oral appliance therapy as a treatment option for the common, but often undiagnosed, condition of sleep apnea. Dr. Rodgers earned a BS in biology from Lee University in Cleveland, Tenn, and is a 1995 graduate of the University of Alabama School of Dentistry.

DentalSleepPractice.com

CONTINUING education with an offer for complimentary consultations with any other patients struggling with obstructive sleep apnea (OSA) or CPAP intolerance? Did your letter emphasize that you accept all major medical insurance? Did it highlight your status as a Medicare Provider? Your responses to those last two questions are critical. Every letter should remind referral sources of that. In an informal survey, the number one reason the physician respondents cited for not referring to dentists was not concern about appliance efficacy. The primary reason was concern about medical insurance coverage. One respondent shared that a patient reported seeing a dentist who said, “We don’t take insurance, our cash fee is $5,000 and we accept Visa, Mastercard, and Care Credit.” Reassuring your current and prospective medical referral sources that you will work with the patient’s medical insurance is critical to future referrals. Harnessing the power of technology through use of sleep software will keep referral sources informed and increase their confidence in you as a partner which will drive more referrals.

Scanning the Horizon

The advent of intraoral scanning (IOS) has streamlined the DSM records process by reducing chair time for impressions and bite registrations while providing instantaneous transfer of data to the preferred dental lab. Early generations of scanners struggled

with “sleep bites” that had large open spaces between arches. Significant advancements have been made with the recent generation of scanners and IOS software such as the CS 3700 (Carestream Dental, Atlanta, GA), Heron IOS (3Disc, Herndon, VA), and the i700 (Medit, Seoul, South Korea). Two of the most prolific dental sleep medical device manufacturers estimate that digital records outnumber analog impressions nearly 4 to 1. Mark Murphy, DDS, D.ABDSM serves as Lead Faculty for Clinical Education at ProSomnus Sleep Technologies. He approximates that 75% of the cases fabricated by ProSomnus are from digital scans. Walid Raad, Chief Executive Officer of American Medical Appliance Company said, “We track this closely and today that number is just shy of 80%. With the way it’s trending, we expect to see this increase to 90% by the end of next year.” Digital scans fit the medical model many sleep dentists are striving for. A growing number of practices have instituted a single consult/records appointment where prospective sleep apnea patients are tested with the pharyngometer/rhinometer and IOS & CBCT scans are captured. When the prescription for the sleep appliance is received, all the necessary records have already been taken to submit to the lab and insurance. This streamlined process from initial engagement to delivery ensures an optimal patient experience while reducing the number of appointments and chair time for the practice.

On the Record – Pharyngometry and Rhinometry

Figure 1: Heron IOS (3Disc, Herndon, VA)

34 DSP | Winter 2021

Technology has developed to help clinicians accurately capture records. Acoustic geometric imaging is one proven way to do this. While not new, it has continually evolved since E. Benson Hood Labs developed a commercially viable acoustic rhinometer in the mid-1980s. This was followed soon after by the commercialization of acoustic pharyngometry. The technology was acquired by Sleep Group Solutions (Hollywood, FL) in 2006 and has undergone two significant technology iterations to further improve its utility in the DSM field. The Eccovision Acoustic Pharyngometer/ Rhinometer uses two distinct handpieces known as wave tubes to measure the oral and nasal airways, respectively. The system generates an acoustic pulse that travels into the airway and transmits out to microphone

CONTINUING education

Figure 2: Eccovision Model 32000 Acoustic Pharyngometer/ Rhinometer

receptors in the wave tube. Proprietary Eccovision software analyzes the reflected sound and creates a pharyngometer/rhinometer graphical representation of the cross-sectional area of the airway as a function of distance. The rhinometer measures 8cm into the nasal airway, and the pharyngometer measures 25cm into the oral airway. The genesis of the technology was to assist otolaryngologists and anesthesiologists by providing an efficient, radiation-free way to identify upper airway obstructions. This was especially useful in the ENT field to justify medical necessity and quantify outcomes related to upper airway nasal surgery. In the early 90s Hoffstein et al. concluded that, “…this technique is the only one which allows non-invasive, accurate, reproducible and inexpensive measurements of the upper airway…it is capable of providing dynamic characteristics of the upper airway.” Being able to measure static airway size as well as real-time dynamic change is a critical aspect of the utility of acoustic imaging in dental sleep medicine. Obstructive Sleep Apnea is a disease of airway collapsibility, not necessarily airway size. Simply stated, large airways that are highly collapsible can have OSA while small airways that are otherwise very stable may not. It was not long before numerous studies cited measurement by acoustic pharyngometry to be indicative

of both the presence and potential severity of OSA. Rivlin et al and DeYoung et al concluded respectively, “The acoustic technique is performed in the awake state and needs a minimal degree of patient cooperation. The good correlation between pharyngeal cross-sectional area and the severity of the disorder may give us a simple way to detect patients with OSA.” The study went on to state, “The current study demonstrates that Minimum CrossSectional Area, determined by acoustic pharyngometry, can significantly differentiate between those with mild/no-OSA versus moderate-to-severe OSA…In conclusion, we have demonstrated that acoustic pharyngometry provides an objective and simple test with strong independent predictive value for the presence or absence of moderate-to-severe OSA.” The technology has been widely embraced in DSM because of the strong correlations between acoustic measurements and the presence and severity of OSA. The ability to see airway collapse and minimum-cross-sectional area (MCA) in real time presents a compelling measurement for sleep dentists. What is the goal of oral appliance therapy? We are not growing airways. We are taking airways that have excess tissue, poor compliant muscle tone, and outside pressure from the tongue and lateral pharyngeal fat pads and adding vertical and horizontal dimension to the bite position to create adequate stability. Providing an instantaneous radiation-free measurement accurately depicting airway collapse that strongly correlates with presence and severity of OSA enables clinicians to show how the airway behaves in response to multiple mandibular positions. It was noted in DeYoung’s paper and in subsequent publications, a measurement of < 1.86cm2 for the MCA of the airway between the oral pharyngeal junction (OPJ) and the glottis was identified as a key indicator of risk for OSA. In The Sleep Magazine, 2012, Atul Malhotra, MD declared, “These data suggest that acoustic pharyngometry can be used to anticipate response to Mandibular Advancement Splint (MAS) therapy” In 2020, Jerry Hu, DDS and John Comisi, DDS, MAGD published “Vertical Dimension in Oral Appliance Therapy” in the Journal of the Academy of General Dentistry. Several key findings included that the occlusal po-

…the position determined with the 70% George Gauge bite was, on average, 5.0mm more protrusive than the pharyngometerestablished bite position.

DentalSleepPractice.com

CONTINUING education sition established via pharyngometry was effective in lowering the AHI without the need for appliance titration procedures. Additionally, the position determined with the 70% George Gauge bite was, on average, 5.0mm more protrusive than the pharyngometer-established bite position. As a reader of Dental Sleep Practice, you are likely familiar with the concept of Maximum Medical Improvement (MMI). We propound that appliance therapy’s goal is MMI with the least amount of mandibular positional change possible. It has been well documented that complications from appliance therapy increase exponentially as we reach patients’ range-of-motion and anatomical limitations with excess titration. Aarab, et al demonstrated that the number of side effects increase as protrusion exceeds 50%.12 Use of acoustic pharyngometry to identify MCA, along with subsequent titration tests with bite repositioning jigs to determine airway collapsibility, and ultimately, identification of an ideal airway “sweet spot” (as a starting point for appliance therapy) have gained significant traction among dental sleep practitioners. In 2020, Opsahl et. al concluded in the Journal of Oral Rehabilitation that, “The (AP) Acoustic Pharyngometer protocol applied seems to contribute to the excellent effect of OA treatment in this study” In the following, acoustic airway readings are displayed on a graph showing a 2D line representing cross-sectional area as a function of distance throughout the airway. Anatomical landmarks can be identified and isolated so that the entire airway from OPJ through oropharynx, epiglottis, hypopharynx, and glottis can be analyzed. Eccovision software analyzes the baseline airway size and compares this to airway col-

lapsibility measurements resulting in a stability percentage based on the dynamic collapsibility of the tissue. The higher the stability percentage, the less collapsible the airway. Additionally, the minimum cross-sectional area measurement (MCA) is identified – in the case of the patient graphically presented in the foregoing, has a 1.1cm2 MCA (at collapse).

But the Patient is Upright and Awake…

A common misconception about acoustic pharyngometry is that it is attempting to replicate a “sleeping airway.” To the contrary, it is measuring the propensity of an awake airway to collapse and the degree to which the airway is susceptible to collapse. Airway behavior changes during supine sleep. This is not in question. According to Malhotra, the upper airway collapsibility measured during wakefulness provides useful physiologic information about pharyngeal mechanics during sleep.7 Positional effects on pharyngeal size have been studied extensively. Martin et. al8 showed that when measured in a seated upright position, patients with OSA had smaller cross-sectional area readings at the OPJ than those that snored as well as non-apneic patients. When measured supine there was no statistical difference in airway measurement amongst the three groups. The authors concluded that the findings support the supposition that OSA patients will unconsciously defend and protect their airway when put in an airway compromised supine position. Other studies9 have also concluded that there is increased muscle activity and genioglossus activation in patients with OSA when tested in a supine position. Anyone in dentistry has experienced this in the form of “wrestling” with a patient’s tongue while trying to do dental work. The same propensity to protect the airway does not exist in patients when they are upright readily enabling the clinician using the acoustic pharyngometer to obtain accurate, reproducible, results without the patient compensating for airway collapse. In summary, people are tested upright and awake. Those measurements, while not exact replications of what happens in supine sleep, correlate very strongly with OSA and our ability to put the patient in a position where airway collapse is greatly reduced.

Will This Work?

Figure 3: Pharyngometer baseline & collapse tests overlayed to show airway stability

36 DSP | Winter 2021

Many dental practices struggle to successfully present oral appliance therapy to

CONTINUING education patients. The Fall 2021 issue of Dental Sleep Practice features multiple industry opinion leaders who shared their thoughts and insights on case presentations techniques. We hypothesize that treatment presentation can be distilled to three key elements: 1. Listen to their problems – identify the afflictions Listen, ask questions, and listen some more. Stop presenting the treatment so early in the process. By presenting the appliance (solution) to a patient who has yet to fully understand their problem, treatment can be misperceived as a commodity; something that can be shopped or postponed for a “better deal.”. This will thrust you into a discussion about money, insurance, and cost. That conversation can lead to “mutually assured disenchantment”, another type of MAD but one that no one benefits from. Instead, actively listen to the patient’s chief complaints and make sure you dig deep into those. If their complaint is “my partner hates my snoring” the patient’s problem is not the snoring. Their problem (affliction) is that they may be in separate bedrooms from their partner and their relationship is being harmed by the snoring. If their complaint is fatigue, then dig deeper for the affliction. Maybe it’s that they don’t have enough energy to play with their grandchildren or that they are so tired they have fallen asleep while driving. Document those afflictions so you can reference them again because those are going to become the patients “why”, their true motivator for treatment. In his book Influence the Psychology of Persuasion, author Robert Cialdini writes, “The idea of potential loss plays a large role in human decision making. In fact, people seem to be more motivated by the thought of losing something than by the thought of gaining something of equal value.”13 2. Speak to positive outcomes Take those afflictions and fears of loss (spouse, time with kids, etc.) and translate them to positive outcomes. Oral appliance therapy will likely reduce the AHI, increase SpO2, lower blood pressure, and help them sleep better. However, for most patients, the chief complaints, afflictions, and fears you gleaned earlier in the process have nothing to do with those. When was the last time a patient came

in and said, “My AHI is out of control, I really want to find a way to get it down to a more manageable number?” Focus on positive outcomes, ask in the form of a “yes” question. Redirect the fear they had into positive outcomes with therapy. It is rarely about sleep test metrics or why your appliance is so great and how comfortable it will be. It’s always about turning the affliction and fear into positive outcomes. “Aren’t you looking forward to being able to sleep in the same bed as your partner again?” “I bet you’re excited to be able to drive home from work without fear of falling asleep and hurting someone.” “Isn’t it going to be great to have energy again to play with your kids?” 3. Be confident & share it This is where using objective tools like acoustic pharyngometry, subjective snore sounds, and even CBCT scans can all assist in creating confidence with your patient. Thus far, in the process with them it has been largely subjective so having objective measurements to lean on at this point will go a long way in generating a commitment from the patient. If you can demonstrate how their airway improves several hundred percent in a new position, it can instill the confidence they need to proceed with treatment. Often during the process with the clinical sleep assistant working through the various bite jigs, the patient will share in the results and have that satori moment. They will see and feel their airway no longer collapsing. As you identify that proverbial sweet spot with ideal vertical and protrusion the doctor, staff, and patient all feel greater confidence that appliance therapy will work.

How Can I Eliminate or Reduce Titration?

What is titration? Where does it come from and why do we talk about it with oral appliance therapy? Much of what we do in dentistry is measured in microns – calculated and precisely performed. This leaves the authors bewildered by how some providers are okay with just guessing when it comes to oral appliance therapy.

Figure 4: Endoscopy depicting airway caliper change in response to increased PAP pressure

DentalSleepPractice.com

CONTINUING education Pearson’s Law states, “When performance is measured, performance improves. When performance is measured and reported back, the rate of improvement accelerates.” Measurement is key. Titration is the continual adjustment of dose based on patient response. We adopted titration from the Positive Airway Pressure lexicon. PAP pressure can be adjusted just as appliance position can be advanced. So, are both appliances and CPAP dose-dependent? The answer is “sort of.” This means they both yield response to change, but it’s not indefinite and there is a point of diminishing return. The image in Figure 4 shows an endoscope looking down an airway as various amounts of pressure with PAP therapy is applied as measured in cmH2O. You will notice the percentage increase in airway caliper (increase in minimum cross-sectional opening) is significant through the lower numbers and even to 8 or possibly 10cmH2O at which point the return on increasing pressure is essentially non-existent. One reason patients are intolerant to PAP therapy is difficulty tolerating higher pressures – so going from 10 in this example up to 20 does not yield meaningful increases in airway cross-sectional area. Instead, would most certainly result in decreased compliance and increased complication from therapy. Bottom line; there is a therapeutic ‘sweet spot’ that provides maximum benefit. Increasing beyond that point does more harm than good. The same can be applied to appliance therapy. With appliances, we are dealing with change in two dimensions. Vertical, as evidenced by Hu and Comisi5, impact airway collapsibility as does horizontal advancement. Rehab et. al10 also documented the effect of changes in the intermaxillary distance in mandibular advancement splints noting that, “The use of MAS with increased vertical dimension improved the velopharyngeal caliper and improvement in PSG variables especially AHI was observed”

Figure 5: Pharyngometer bite reposition reading with Airway Metrics jig in place

38 DSP | Winter 2021

The George Gauge has been commonly used as a method for identifying oral appliance starting position. The gauge is available with 2mm and 5mm vertical bite forks, and it’s often cited that starting patients at 60-70% of their total protrusive range is average. The shortcomings associated with this method are glaring. What if either of those fixed vertical dimensions are not ideal for your patient? How would you even know? And if 60-70% protrusion is “average”, how do you know if you are starting too far or not far enough? Or how far you need to go after delivery? Or if you nailed it perfect on day one? Allow us to illustrate this point with a simple analogy. The average size shoe for US men is a 10.5, and the average for women is 8.5. When we buy shoes, do we start everyone at 10.5 and slowly titrate up or down in .5 increments until we get to a proper size? Why not measure in real time? The analogy illustrates that we all have a different airway just like we all have different feet. By utilizing technology, we can more accurately and rapidly arrive at a ‘sweet spot’ treatment position often on day one with zero appliance position change. It is this level of predictive accuracy our patients deserve and referring physicians expect.

From Theory to Practice

Using pharyngometry in conjunction with bite repositioning tools such as Lucia Jig Kits (Great Lakes Dental Technologies) or the Airway Metrics component system, the sleep assistant can view the airway’s ability to collapse in various positions. This image shows a 6mm vertical jig in an edge-to-edge bite position. The patient performs a collapse test on the pharyngometer, and then a new jig is attempted at a different vertical. Once the optimal vertical position is identified then the patient is stepped forward in 1mm increments. The goal is to find the position that yields the maximum medical improvement in airway measurements with the least extreme vertical and horizontal positions. In figure 6, the same patient is shown in red with a 1.1cm2 minimum cross-sectional area measurement improved to a 2.08cm2 reading with a bite jig in place. A robust response to three-dimensional mandibular repositioning like this is highly indicative of a positive treatment result with appliance therapy set in that position. One of the costliest aspects of appliance therapy is the ‘long haul’ case where you ad-

CONTINUING education just, re-test, adjust again, re-test again, and then adjust some more. Then, as the appliance is maxed out, we do not know where to go. Consequently, most clinicians make a new appliance or adjust the current one with a different vertical and try again – endlessly searching for a position that may or may not exist and at which they may never arrive. Oftentimes, the patient loses confidence in the therapy and discontinues use, or possibly worse, they continue using an appliance that is not positioned in an ideal spot and they live with sub-optimal results. This dose-sampling, position-seeking approach is irresponsible, unprofessional, and costly. Thankfully, technology and innovation open new doors to predictability and efficiency. By utilizing an evidence-based approach to appliance therapy with pre-measurement and pre-titration of your patient you can arrive at the treatment position quickly and predictably while greatly eliminating appliance adjustments.

Figure 6: (Red) Patient's initial collapsed airway (Yellow) Collapse with a bite jig in place showing a robust airway response

Table 1: 67-year-old male, BMI 24, 16” neck, ESS 10, 2 years in dorsal appliance

AHI

Diagnostic Sleep Study

Dorsal Appliance

RDI

SpO2 Nadir

82%

86%

% Time < 90% SpO2

8.1%

1.6%

It’s Not Working! Now What?

Everyone has patients come in with appliances made from other dentists or perhaps even a case you have struggled with treating successfully in the past. Here, we will look at how technology can be used to help revive and turn around a case that had a sub-optimal result with appliance therapy. The patient in Table 1 was instructed to advance the appliance post-delivery 4mm protrusively beyond the initial set point. Subjective reports of snoring improved however no significant improvement in other subjective metrics. What do we do? Do we say, “You’re severe, this is the best we can do” and then encourage him to resume using CPAP? Before doing so, we opted to use acoustic pharyngometer to measure his baseline airway collapse (RED) and identify the minimum cross-sectional area and then see how his reading looks with his appliance in place (YELLOW). This patient has a 1.1cm2 collapse and with his appliance in place it increases to 1.28cm2. This would not qualify as a statistically significant improvement and treatment in this position would not be recommended. This is validated by the fact that we know the appliance is not working well for the patient in this position despite having advanced it significantly on his own. While not the most glamourous

Figure 7: Pharyngometer graph showing a "non-responder" with no improvement in collapse readings with and without appliance in place

feature, negative predictive value is important as well. Loube et. al11 used acoustic pharyngometry to evaluate changes in the pharynx produced by mandibular advancement and found that “no statistically significant change” was 95% predictive of appliance failure. As has been discussed at length in the literature, there exists a subset of patients who do not respond well to appliance therapy. Identifying a difficult case or potential non-responder up front would be very beneficial in saving time and effort as well as directing the patient to a more optimal therapy. In this case a new bite was taken using bite jigs to identify a position where there was shown to be a 156% improvement in airway minimum cross-sectional area. This DentalSleepPractice.com

CONTINUING education robust improvement is highly indicative of a positive outcome therefore, a bite was scanned and submitted in this position. Figure 9 shows the patient’s previous dorsal device and new Panthera D-SAD (Panthera, Quebec, Canada) appliance. Note how much less protrusion is built into the new appliance yet it yields a significantly improved airway reading. Follow-up sleep testing supported the findings from the pharyngometer with the correct position greatly improving clinical outcomes:

Conclusion

Technology has been the underpinning of dental sleep medicine’s explosive growth. Cutting edge materials, device designs, and manufacturing capabilities have delivered more effective appliances. Software innovations have led to new efficiency gains,

increased reimbursement, better patient experiences, and improved interdisciplinary communication. Seismic shifts in the areas of intraoral scanning and predictive instrumentation have led to shorter records-to-delivery times with increasingly accurate records and less chair time. This leads to increased practice revenues, improved profit margins, and fewer costly appointments – a win/win for patients and practices. Airway ‘sweet spots’ do exist and utilizing technology like acoustic pharyngometry can identify how the airway responds to mandibular positional change. This provides insight into which patients will respond favorably to oral appliance therapy, who will not, and where clinicians should take bite registrations for maximal efficacy and minimal titration. The information gleaned from these tests is clinically useful to help reduce future adjustments and to better educate patients which builds confidence in your proposed treatment plan. 1.

Figure 8: Pharyngometer collapse readings show a substantial improvement with the newly tested position

4. 5.

7. 8.

Figure 9: Original dorsal appliance and newly fabricated Panthera D-SAD in the correct position

Table 2: 67-year-old male, BMI 24, 16” neck, ESS 10

11.

Diagnostic Sleep Study

Dorsal Appliance

New Appliance

AHI

RDI

SpO2 Nadir

82%

86%

88%

% Time < 90% SpO2

8.1%

1.6%

.1%

40 DSP | Winter 2021

10.

12.

13.

The Acoustic Reflection Technique for Non-invasive Assessment of Upper Airway Area. European Respiratory Journal, 1991. Authors: V. Hoffstein, J. J. Fredberg Upper Airway Morphology in Patients with Idiopathic Obstructive Sleep Apnea. American Review of Respiratory Disease, 1984. Authors: J. Rivlin, V. Hoffstein, J. Kalbfleisch, W. MnNicholas, N. Zamel, and A. C. Bryan Acoustic pharyngometry measurement of minimal cross-sectional airway area is a significant independent predictor of moderate-to-severe OSA. Journal of Clinical Sleep Medicine Vol 9, No. 11, 2013. Pamela N DeYoung, B.S., Jessie p Bakker, PhD, Scott A Sands, PhD, Salma Batool-Anwar, M.D, James Connolly, James Butler PhD, Atul Malhotra, MD Using Anatomical Assessment to Guide Oral Appliance Therapy. Atul Malhotra, MD. The Sleep Magazine, 2012 Vertical dimension in dental sleep medicine oral appliance therapy. Journal of the Academy of General Dentistry – July/Aug 2020. Jerry C. Hu, DDS, John C. Comisi, DDS, MAGD Acoustic pharyngometry - A new method to facilitate oral appliance therapy. Journal of Oral Rehabilitation, July 2020. Ulrik Leidland Opsahl1,2,3 | Morten Berge1,2 | Sverre Lehmann2,4 | Bjørn Bjorvatn2 | Per Opsahl3 | Anders Johansson1,2 Malhotra A, Pillar G, Fogel R, et al. Upper-airway collapsibility: measurements and sleep effects. Chest 2001;120:156–161 Martin S, Marshal I, Douglas N. The effect of posture on airway caliber with the sleep apnea/hypopnea syndrome. Am J Crit Care Med 1995;152:721–724 Douglas NJ, Jan MA, Yildirim N, Warren PM, Drummond GB. Effect of posture and breathing route on genioglossal electromyogram activity in normal subjects and in patients with sleep apnea/ hypopnea syndrome. Am Rev Respir Dis 1993;148:1341–1345 The effect of changes in the intermaxillary distance in mandibular advancement splints as a treatment of Obstructive Sleep Apnea. Tanta Dental Journal 12: 193-198 Rehab Abdallah, Hoda Rashad, Hahed Kashef, Mohamed ElSheikh Loube D. Predictive value of pharyngometry-derived measurements for oral appliance treatment of OSAS. Seattle, WA: Sleep Disorders Center, Virginia Mason Medical Center; 2000 Aarab G, Lobbezoo F, Hamburger HL, Naeije M. Effects of an oral appliance with different mandibular protrusion positions at a constant vertical dimension on obstructive sleep apnea. Clin Oral Investig. 2010;14(3):339–345. Cialdini, R. B. (2007). Influence: the psychology of persuasion. Rev. ed. ; 1st Collins business essentials ed. New York: Collins.

CONTINUING education

Continuing Education Test

CE CREDITS

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 8 CE credits for only $149 by visiting https://dentalsleeppractice.com/subscribe/.

n To receive credit: Go online to dentalsleeppractice.com/continuing-education/,

AGD Code: 730 Date Published: November 15, 2021 Course Expires: November 15, 2024

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

click on the article, then click on the take quiz button, and enter your test answers To provide feedback on this article and CE, email us at education@medmarkmedia.com.

Technology: Dental Sleep’s Gatekeeper to Boost Case Acceptance and Increase Efficiency by Jason Doucette, DMD, D.ABDSM, and Jeff Rodgers, DMD, D.ABDSM 1. Tools that can be used to obtain sleep bite registrations include ____________. a. George Gauge b. Gothic arch tracing c. Pharyngometry d. Airway Metrics e. All of the above 2. In 2020, the Journal of the Academy of General Dentistry published an article by Hu and Comisi which stated that occlusal position established via pharyngometry was effective in lowering AHI without the need for __________________________. a. A bite registration b. Appliance titration procedures c. Post-treatment testing d. None of the above 3. The first commercially viable rhinometer was brought to market in the mid-1980s by _________. a. Apple b. Microsoft c. E. Benson Hood Labs d. Netscape e. Casio 4. MCA is an acronym representing ______________. a. Molar-Cuspid-Aspiration b. Minimum-Cross-Sectional-Area c. Most-Coveted-Asset d. None of the above 5. Acoustic pharyngometry is intended to replicate a “sleeping airway.” a. True

b. False 6. Pearson’s Law states _________________________. a. When RDI > AHI, OAT is precluded as a treatment option b. When performance is measured, performance improves. When performance is measured and reported back, the rate of improvement accelerates c. The number of transistors in a dense integrated circuit doubles about every two years d. None of the above 7. The literature states that a subset of patients exists who do not respond favorably to oral appliance therapy. a. True b. False 8. __________________ is the continual adjustment of dose based on patient response. a. Minimization b. Titration c. Secularization d. Remediation 9. The rhinometer measures _____cm into the nasal airway. a. 4 b. 6 c. 8 d. 10 10. The rhinometer’s handpieces are known as __________. a. Knuckle pucks b. Wave tubes c. Hande-knobs d. Sound emitters

DentalSleepPractice.com

PRACTICEmanagement

The Debate Rages: Fee For Service vs. Medical Billing by Mona Patel, DMD

ccept medical insurance. Contract with a medical billing company. This is the dictum proclaimed from most dental sleep medicine courses. Lecturers claim significant money can be made if you buy their software or use their medical billing services. It sounds very appealing, but if you’re like most dentists, including myself, then your experience with medical insurance is quite the opposite.

making it very easy for our patients. This has resulted in a very favorable case acceptance rate. I am not boasting, but some of my insurance-accepting colleagues have shared that our acceptance rates are significantly higher than theirs. Without the hassles and headaches.

Getting started in sleep was challenging enough! We had to learn which home sleep test to use, what to charge, which appliances to use for which patients, how to treatment plan sleep appliances, and how to build systems for our team. The last thing I wanted to do was add medical billing to the seemingly overwhelming and ever-growing to-do list. So, I didn’t. Instead, I started my sleep program with a fee-for-service (FFS) model. Now, several years later, I can confidently say that I wouldn’t have done it any other way. Other colleagues of mine do successfully use medical insurance reimbursement in dental sleep, but for our team – simplicity was key to optimal results. In my experience, here are some of the benefits of using the FFS model: • Simplifies collections • Reduces confusion for patients • Creates value-focused treatment plan • Allows for 3rd-party financing options In our practice, patients can feel confident in exactly what they are getting, what they are paying, and the options for payment. We focus on building tremendous value and

Here are some pros: • Potentially reduced cost for the patient • Potentially increased case acceptance • Potentially appealing to referring physicians • Adds value to your office offering alternative financial options

42 DSP | Winter 2021

Medical Insurance Isn’t All Negative Though.

What About the Negatives of the FFS Model?

Long ago, our general dentistry office adopted the FFS model, so there were no implicit switching costs. Having said that, if you accept dental insurance, patients may ask why you don’t bill medical insurance. When this happens, we explain that we are not contracted with insurances and offer to provide any documentation they need to pursue reimbursement independently. This could potentially be perceived as a negative, but we view it as an opportunity to build more value.

What About Negative Aspects of Medical Insurance?

When we initially attempted to bill medical insurance, we had some undesirable ex-

PRACTICEmanagement periences and uncovered these negatives: • High patient expectations • High deductibles that patients couldn’t afford • Low coverage limitations • Complicated workflow • Confusing timeline For our practice, medical billing added cost, complexity, and confusion. Patients would get upset when we had to send them a bill for the remainder of their treatment plan 30 days after we provided the appliance. This was because they wrongly thought medical insurance would cover 100% of their treatment plan and because medical insurance doesn’t have to respond to a claim until the

30th day of submission (after you deliver an appliance). As anyone that has had to endure lengthy hospital stays can attest, medical insurance isn’t bad. It can be beneficial for practices and can contribute to building physician relationships, building value, and contributing to long term referral potential, but it isn’t required to succeed in DSM. For our practice, it made sense to use a fee-for-service model; to keep it simple, increase production, and build value. Medical billing isn’t the only way to do sleep in your practice. Consider the options and decide what is suitable for your patients and your practice.

“…some of my insurance-accepting colleagues have shared that our acceptance rates are significantly higher than theirs.”

Mona Patel, DMD, began her education with the University of Birmingham Queen Elizabeth Dental School in England and moved to the USA in 1992. She later attended the University of Pennsylvania Dental School. In 1995 she started in private practice and completed over 700 hours in CE to provide comprehensive and holistic care to her patients. Dr. Patel is a member of the American Academy of Dental Sleep Medicine, co-founder of Dynamic Dental Divas, and many other associations. She recently sold her restorative practice and will soon be opening a boutique dental sleep practice while educating dentists on dental sleep medicine implementation.

STOP GUESSING APPLIANCE POSITION REDUCE TITRATIONS AND IMPROVE OUTCOMES WITH PRECISION AIRWAY MEASUREMENT TECHNOLOGY

Measure airway size and collapsibility Identify “sweet spot” for appliance bite Reduce titrations and follow up appointments Improve case acceptance and profitability Want to see how Eccovision can help your sleep practice? Schedule a consultation here: bit.ly/3pMp94U

Or Call 1-866-964-9143

DentalSleepPractice.com

BIGGERpicture

The Perfect Day Begins with a Good Evening by Ryan Holiday

ll the talk about morning routines makes it easy to overlook that a good morning is impossible without a good evening. I am reminded just how essential a good evening routine is as I write this from an RV in Balmorhea, TX – as I drive across the country to do some media for my new book, Courage is Calling: Fortune Favors The Brave. It was one of Seneca’s observations – that nearly everything in life is circular: there’s an opening and a close, a start and a finish. Life, he says, is a collection of large circles enclosing smaller ones. Birth to death. Childhood. A year. A month. “And the smallest circle of all,” he writes, “is the day; even a day has its beginning and its ending, its sunrise and its sunset.” To the Stoics, every day was to be lived as if it closed the story, every night ended as if it was the last night we had. They’re right. How we close out the day matters. The decisions we make. The reflection we encourage. The time we drift off to sleep. All of it is about finishing well…because then and only then can we start tomorrow better too. What does a good evening routine look like? Whether I’m home or on the road, these are the 9 things I try to do every evening. Each is rooted in the wisdom of the ancient Stoics and when applied, as Seneca said, “let us go to our sleep with joy and gladness.”

44 DSP | Winter 2021

Make Time for Leisure

The opposite of work is not laziness or lounging around, it’s leisure. In the ancient world, leisure meant scholé. School. But not the get good grades and “get ahead” kind of school. No, in the ancient world, it meant learning and studying and pursuing higher things to enrich one’s soul and spirit. Seneca wrote thoughtful letters to friends. Zeno gathered at the Stoa Poikile to discuss ideas. Marcus Aurelius attended philosophical lectures. My family reads together. Marcus said it was a requirement to “Give yourself time to learn something new and good, and cease to be whirled around.” And as Seneca wrote in his essay On the Tranquility of the Mind, “We must be indulgent to the mind, and regularly grant it the leisure that serves as its food and strength.” After indulging the mind, you’ll have worked up the appetite to…

Enjoy a Philosophical Dinner

Some people watch TV at dinner. Some people eat at their desk and answer emails between bites. Some people eat as fast as they can so they can get back to work.

BIGGERpicture In The Learned Banqueters, written just after the time of Marcus Aurelius, we learn that the sixth Stoic scholarch Antipater routinely invited friends over for dinner and long discussions about philosophy. A few decades after Antipater, Cato would become famous for his philosophical dinners. Even his last meal – before his famous suicide – he was debating the very implications of life and death, good and bad, at such a dinner. More recently, the philosopher Agnes Callard told me on the Daily Stoic podcast that she, her husband, and her children have philosophical debates over dinner. The topics range from serious to silly, but it’s the activity itself that really matters. It’s that for an hour or two every night, she is not doing anything but connecting with the people she loves. My kids are younger, so our dinner discussions range from silly to sillier. But again, it’s the time together that really matters. After filling up our stomachs, it’s time to…

Go for a Walk

After a meal, but before it’s dark, it is a wonderful time to get active. Seneca wrote about taking a walk outdoors as a kind of medicine. In a notoriously loud city like Rome, peace and quiet would have been hard to come by. The noises of wagons, the shouting of vendors, the hammering of blacksmiths – all filled the streets with piercing violence. So Seneca said, “We should take wandering outdoor walks, so that the mind might be nourished and refreshed by the open air and deep breathing.” Marcus Aurelius too talked about the cleansing effects of a walk in nature. On his evening walks, he liked to take a moment to look up at the stars to “wash off the mud of life below.” Freud was known for his walks around Vienna’s Ringstrasse after his evening meal. David Sedaris likes to take nighttime strolls on the back roads of his neighborhood in the English countryside and pick up garbage. Dan Rather talked about how “One of my favorite things long has been taking a leisurely stroll with wife Jean at twilight time.” When we’re home, we get the kids in the stroller and do as much as three miles on the dirt road around our house, or in the backwoods and pastures on our farm. We see rabbits and deer and cows and armadillos. We stop and pet the donkeys. Like Sedaris, we pick up garbage. These are some of the very best moments in life. When it’s quiet. When

we’re fully present and there. When we’re around people we love. As Rather said, “I gently recommend it. Just walk slowly in the time after the sun sets and before night descends.” Once back from a walk, we…

Tuck the Kids In

Not everyone has kids, but everyone can learn from this exercise. Marcus Aurelius, borrowing from Epictetus, tells us that… As you kiss your son good night, whisper to yourself, “He may be dead in the morning.” Don’t tempt fate, you say. By talking about a natural event? Is fate tempted when we speak of grain being reaped? What is the point of this morbid exer- ...Seneca said, cise? It’s not about trying to reduce the af“let us go to our fection you feel for the people you love. It’s not about preparing for the pain of losing sleep with joy and a child (nothing can prepare you for that). gladness.” It’s about not wasting a single second of the time you do get with the people you love. A person who faces the fact that they can lose someone they love at any moment is a person who is present. Who loves. Who isn’t rushing through moments. Who doesn’t hold onto stupid things. Marcus lost 5 children. 5! It should never happen, but it does. There’s nothing we can do about that. We can, however, drink in the present before we…

Review the Day

Winston Churchill was famously afraid of going to bed at the end of the day having not created, written or done anything that moved his life forward. “Every night,” he wrote, “I try myself by Court Martial to see if I have done anything effective during the day. I don’t mean just pawing the ground, anyone can go through the motions, but something really effective.” In a letter to his older brother Novatus, Seneca describes the exercise he borrowed from another prominent philosopher.

Ryan Holiday is one of the world’s foremost thinkers and writers on ancient philosophy and its place in everyday life. He is a sought-after speaker, strategist, and the author of many bestselling books including The Obstacle Is the Way; Ego Is the Enemy; The Daily Stoic; and the #1 New York Times bestseller Stillness Is the Key. His books have been translated into over 30 languages and read by over two million people worldwide. He lives outside Austin, Texas, with his family.

DentalSleepPractice.com

BIGGERpicture “When the light has been removed and my wife has fallen silent,” Seneca wrote, “I examine my entire day and go back over what I’ve done and said, hiding nothing from myself, passing nothing by.” Every night, Seneca sat down and forced himself to questions like these: What bad habits did I cure? What temptations did I resist? In what specific way am I now better than I was yesterday? Success and happiness require self-awareness. Self-reflection. Be unflinching in your assessments. Notice what contributed to your happiness and what detracted from it. Write down what you’d like to work on or quotes that you like. Writing, analyzing, reflecting, interrogating, taking inventory of how you spent The greats – they the day – this is how you continue improvprotect their sleep ing. Asking yourself questions. Questioning every experience, every day. because their best Did I follow my plans for the day? Was I work depends on it. prepared enough? What could I do better? What have I learned that will help me tomorrow? These simple questions make an enormous impact. So I spend some time every night answering them. After this reflection, my evening routine is drawing to a close. It’s time to…

Count Your Blessings

This is another exercise from Seneca. He said we should wrap up each day as if it were our last. The person who does this, who meditates on their mortality in the evening, Seneca believed, has a super power when they wake up. “When a man has said, ‘I have lived!’” Seneca wrote, then “every morning he arises is a bonus.” Think back: to that one time you were playing with house money, if not literally then metaphorically. Or when your vacation got extended. Or that appointment you were dreading canceled at the last moment. Do you remember how you felt? Probably, in a word – better. You feel lighter. Nicer. You appreciate everything. You are present. All the trivial concerns and short-term anxieties go away – because for a second, you realize how little they matter. Well, that’s how one ought to live. Go to bed, having lived a full day, appreciating that you may not get the privilege of waking up tomorrow. And if you do wake up, it will be impossible not to see every second of the next

46 DSP | Winter 2021

twenty-four hours as a bonus. As a vacation extended. An appointment with death put off one more day. As playing with house money. And now, as the day comes to a close, it is time for the most important part, to…

Go to Bed at a Set Time

All the other habits and practices listed here become irrelevant if you don’t have the energy and clarity to do them. What time you wake up tomorrow is irrelevant…if you didn’t get enough sleep tonight. One thing every parent knows is that kids are a mess when they don’t sleep. But for some reason, we think we’re different. We think we can get away with pulling an all-nighter here and there. We think we can substitute stimulants for sleep. Nonsense. We only have so much energy for our work, for our relationships, for ourselves. A smart person understands this and guards their sleep carefully. The greats – they protect their sleep because their best work depends on it. The clearer they can think and the better their mental and physical state – the better they perform. In other words, the more sleep, the better. The philosopher and writer Arthur Schopenhauer used to say that “sleep is the source of all health and energy.” He said it better still on a separate occasion: “Sleep is the interest we have to pay on the capital which is called in at death. The higher the interest rate and the more regularly it is paid, the further the date of redemption is postponed.” Me? I get my 7-8 hours every night. Sleep is one of the most important parts of my work routine, period. All-nighters are for people who don’t know how to plan, who put things off to the last minute. If you want to be great at what you do, start going to bed earlier. Give yourself a bedtime that you honor and respect and enforce. Value sleep. Take care of yourself. Put yourself in a good spot to…

Start Again

As I say in the title of this piece, the perfect day begins with a good evening. A good evening routine is just priming us to have a great day – there is still work to be done when we wake up. It’s for a reason that one of our fifty rules for life from the Stoics is “own the morning.” Well-begun is half done, as they say. Fortunately, the Stoics – in their writing and in their example – left us even more wisdom on what a good start to the day looks like.

www.dentalsleeppractice.com

Supporting Dentists Through Practical Sleep Apnea Education READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter

CONNECT with us on social media

Other specialties in the MedMark Media family www.orthopracticeus.com

www.implantpracticeus.com

Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

www.endopracticeus.com

PRODUCTspotlight

Want to Provide Better Patient Care? Consider AireO2 by Vivos Billing Intelligence Service

here’s a lot that comes with running a successful dental practice. From providing top-of-the-line care and a great workplace to managing schedules and billing, it can be overwhelming to sort through it all – especially if we try to do so manually. The good news is that you don’t have to do it alone. With digital solutions like electronic medical records (EMR), Billing Intelligence Service, and comprehensive management software, dentists can streamline their processes and ultimately improve the sleep and well-being of their patients. This can be done with reduced costs and expanded sleep apnea treatment options without adding another employee to the payroll. The right software and medical billing services will provide the support you need to address any areas of the patient experience that may need some extra attention, whether it’s billing, scheduling, or verifying patient benefits. It will also help you manage the complexity associated with driving these services – because the truth is, as much as we all want to consistently focus on our patients and provide the best sleep apnea treatment we can, we also need to learn to take a break. AireO2 – the billing platform powered by Vivos Billing Intelligence Service – empowers dentists to provide a seamless patient experience while allowing you to slow down

48 DSP | Winter 2021

and breathe. With this comprehensive software, not only can you protect and store patient records, but you can also reduce the complexity of medical billing. Sit back, take a breath, and let the software and experts do it for you. Built by dentists for dentists, this fullservice platform includes features such as the following: • A dedicated account manager • Verification of benefits and preauthorizations • ICD 10 medical billers • Electronic claim submission • Supportive documentation templates • Customized analytics and weekly reporting • Cloud-based EHR • Billing software packages available for small, medium, and large practices • And more! Prioritizing great patient care doesn’t have to mean giving up your free time, stressing out your staff, or sacrificing any aspect of your services. AireO2 ensures that all the complex work you have to complete flows smoothly from start to finish. Reach out to Vivos BIS at www.vivosbis. com today to implement the software so you can spend less time on administrative tasks and more time doing what you do best: helping your patients get the best sleep possible.

Take a Breath Leave Medical Billing to AireO2, Powered by VivosBI Cloud-Based Software Built by Dentists for Dentists

vivosbis.com

PRODUCTspotlight

Slow Wave, Inc.

low Wave, Inc. manufactures the newly FDA-cleared and multi-patented Slow Wave DS8, a next generation oral appliance for the treatment of sleep apnea and snoring. The unique design of Slow Wave DS8 features a focus on incorporating a vertical opening of 6 mm to 8 mm that allows the mandible to move forward in a natural position rather than pulling the jaw forward. The result is both patient comfort and high efficacy. There is no need for a morning repositioner for patients using the Slow Wave DS8. This is also the first FDAcleared oral appliance to be 3D printed on a Formlabs printer from a digital scan that provides accuracy to within 100th of a millimeter. This provides custom patient fit without the need for appliance adjustment. The Slow Wave DS8 has even been granted a unique billing code by Medicare/Medicaid due to its unique design features.

50 DSP | Winter 2021

The Slow Wave market approach is to enable dentists to leverage what they already do — identify patients, perform scans, and provide patient follow-up. Slow Wave eliminates the need for dentists to take on tasks they don’t want, like referrals with sleep specialists, neurologists, or other medical professionals to get a medical diagnosis or perform medical billing services for an oral appliance. The Slow Wave network handles the sleep study, diagnosis, and medical billing. Because the Slow Wave DS8 is custom printed on a Formlabs printer, it can happen at the Slow Wave lab or right in the dentist’s office. It is possible for patients to be scanned in the morning and take home a custom-fitted appliance that solves their sleep apnea or snoring issues later that day! Slow Wave handles all of the product design and can print directly to the printer in the dental office. We even help with printer setup, supplies, and training for your dental office team.

www.SlowWave.net K1027*

New HCPCS Code for

Obstructive Sleep Apnea Slow Wave DS8 •

The first appliance approved under code K1027

•

Multi-patented design that includes making more room for the tongue

•

All Digital - From 3D Scan to 3D Print (in our office or yours)

*K1027 is a valid 2021 HCPCS code Level II Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated.

Introducing the new era of Oral Appliance Technology!

Slow Wave DS8

1st FDA-cleared oral appliance for obstructive sleep apnea & snoring to be 3D Printed on a Formlabs printer! Medical billing handled by Slow Wave (or you if you already have it set up)

Slow Wave, Inc. 1002 Marble Heights Dr. Marble Falls, TX 78654 Phone: (830) 220-5700

www.SlowWave.net

ALTERNATIVEview

Can Dementia Begin in Childhood? by Lisa Feiner, MBA, M.Ed., NBC-HWC

ementia is considered an “old person’s” disease: half of all people age 85 and older develop some form of dementia. However, in 2020 Blue Cross Blue Shield reported a 373% spike in early-onset and Alzheimer’s cases among 30-44 year-olds.1 We are learning how the seeds of this disease may be sown much earlier in life, and dental professionals are in a unique position to help identify some of the major risk factors. In the last four years, research has shown links between dementia and such things as air pollution; diets laden with sugar, simple carbs and fast food; hormonal imbalances; lack of exercise; social isolation; stress; gum disease and poor sleep. As we know, most of these causes can be addressed. And since 50% of all 85 year olds will develop some form of dementia, it’s time to pay attention. Individuals with memory loss often suffer from more than one cause, and the approach

52 DSP | Winter 2021

that seems to work best is not a single drug or intervention but instead, a multi-modal approach, posited and researched by Dr. Dale Bredesen of UCLA and the Buck Institute for Research on Aging. In a 2014 study, 9 out of 10 people diagnosed with mild to moderate cognitive impairment regained their cognition, and six of those who had left their jobs were able to return to work. Bredesen has identified several subtypes of Alzheimer’s disease, and in subsequent papers, his 2017 book The End of Alzheimer’s and an upcoming book, chronicles how these patients have regained cognitive function. What’s clear is that the earlier the intervention to address memory loss, the better the outcome. The first phase of the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) was conducted between 2009 and 2011, and assigned 1,260 subjects to one of two groups: The first group was counseled on diet, performed

ALTERNATIVEview aerobic and strength training exercises, was cognitively stimulated, and received vascular risk monitoring. The control group had two general medical visits. Those in the treatment group saw an increase in complex memory, executive functioning, and processing speed. Most exciting, improvements were seen even in people who had the APoE4 gene, which predisposes them to dementia. Children and even young adults may not feel the effects of poor eating and lifestyle habits. It’s like a new car: even if you don’t use the right gas or change the oil regularly, it functions pretty well. At some point, though, the car starts to make noises, lights go on, and it may be hard to get it back in shape. Like this car, dementia develops in people over time, often decades. A nonprofit called Sharp Again Naturally (SAN) is educating the public and medical community about causes of memory loss and dementia that can be prevented and treated. SAN and its Medical & Dental Advisory Board have identified 10 causes of memory loss (Table 1). Because it’s much easier to prevent memory loss than reverse it, being aware of the causes and treating them can help preserve cognition. Here is a brief description of the causes that can and should be addressed early and throughout life. For more information on each, go to sharpagain.org. Nutrition (including supplements) is comprised of everything from what we put in our mouths to digestion and the health of the gut microbiome – which we are learning more about every day. What we eat as children becomes habitual and is associated

with emotions and comfort, so good nutrition is important to give kids the best start in life. A diet of sugar and simple carbs like white rice, pasta, and potatoes often leads to insulin resistance as we age, which is why Alzheimer’s is sometimes known as “diabetes of the brain.” Dentists know these same foods affect the health of the gums and teeth, and the development of facial structure. Toxins are part of our world and are everywhere. We ingest pesticides and food colorings in our food, inhale pollutants in the air, and absorb chemicals when applying creams and lotions. Add up the multiple exposures every day over decades – what we call “a toxic body burden” – and the body simply reaches a point where it can no longer stay healthy and starts to exhibit symptoms that include memory loss. Another toxin we can’t see or often feel, but are bombarded by every day is Electromagnetic Frequency (EMF) from computers, cellphones, Apple watches, Fitbits and “smart” appliances and electronics. EMFs impact the functioning of our cells. Research is ongoing, with studies showing some connections to problems like insomnia, headaches, and dehydration, and possible links to a myriad of diseases and medical issues. Heavy metals, like mercury and lead, are neurotoxic. Some individuals are more sensitive to these metals and may not be able to easily detoxify or rid the body of them. Sources of methyl mercury may include drinking water, air pollutants, and large “steak” fish such as tuna, swordfish and shark. Exposure to elemental mercury can come from breathing in mercury vapor, including small amounts from silver amalgam fillings. We

Table 1: 10 Causes of Memory Loss† *Nutritional imbalances *Toxins Effects of prescription medication *Mercury and other heavy metals Hormonal imbalances *Low level infections *Inadequate exercise, social interaction and mental stimulation *Prolonged stress *Sleep and breathing problems *Physical and emotional trauma † We add to this list as research becomes available. *Causes relating to lifestyle and environmental exposure.

Lisa Feiner, MBA, M.Ed., NBC-HWC, is Co-Founder and Board Chair of Sharp Again Naturally (SAN). As a health and wellness coach for almost 20 years, she uses an integrative approach with clients who have a variety of health issues. Lisa’s involvement with elders, including those with dementia, goes back almost 25 years as a volunteer and board member for The New Jewish Home in NY. Sharp Again Naturally (SAN), founded in 2012, educates the public and medical community about causes of memory loss and dementia, and how these conditions can be prevented, treated and often reversed. Their programs empower everyone to take charge of their cognitive health. Lisa has a private practice in New Rochelle, NY.

DentalSleepPractice.com

ALTERNATIVEview

You and your staff can be critical partners in making sure patients and their parents understand the risks that begin in childhood.

54 DSP | Winter 2021

need to take precautions so that children are not being exposed to these metals beyond safe levels. Inflammation is our body’s response to foreign invaders or injury. Our immune system gets activated and the injury usually resolves quickly, especially in kids. However, when inflammation is caused by Lyme Disease, mold, an underlying infection, or hard to treat viruses, it can linger and become systemic. Oral infections, too, can be hard to detect, and if not addressed, create inflammation. When the body is inflamed, the brain can become inflamed too. Lifestyle factors like exercise, social interaction and mental stimulation, are critical for brain health. Exercise keeps bodies of all ages toned, limber and agile. It also improves balance; helps us manage stress; and keeps our dispositions more positive. When children have fewer physical education classes, and spend too much time on electronics, they get used to a sedentary lifestyle and develop the associated health risks. Stress can be motivating and productive in short bursts. However, unremitting, prolonged stress which produces high levels of cortisol and adrenaline in the body, adversely affects the brain and our sense of well-being. Kids are experiencing greater anxiety and stress than ever before. Sleep plays a vital role in consolidating memory, fostering creativity and insight, and regulating emotion. It is during deep sleep that the brain detoxifies, getting rid of cellular debris and amyloid plaque. Kids need a lot of sleep as their brains continue to develop, and adults of all ages continue to need 7-8 hours a night for optimal cognition. Sleep can be disrupted by stress, too much screen time, poor diets, and airway issues. No matter what the cause, poor sleep can lead to memory problems and ultimately, to dementia. Teachers are seeing the effects of sleep and breathing problems in students’ learning and behavior. The causes are varied and include asthma, allergies, anxiety, and a narrowed airway. Sleep disordered breathing (SDB) in childhood is associated with neurocognitive issues and “acute brain changes.” Children with SDB often develop sleep apnea, both of which prevent the body from getting adequate deep sleep. Physical and emotional trauma, encompassing everything from abuse to brain inju-

ry and post-traumatic stress disorder (PTSD), often results in cognitive problems. Adverse Childhood Experiences (ACE’s) are a predictor of memory issues in midlife and dementia later on. Contact sports also put young brains at risk. Soccer and football, and falls from skiing, bike riding, skateboarding, etc. – are ways kids suffer head trauma. There is a genetic component to dementia, and research is showing that the kinds of interventions discussed above can significantly delay, if not prevent, memory loss in those with the APoE4 gene. Higher education, healthy habits and an active lifestyle are extremely powerful in keeping memory loss at bay.

Your Role in Helping Prevent Memory Loss

As parents, practitioners and role models, we can help children maintain optimum brain health by establishing and reinforcing good habits. This includes educating both children and parents, setting a good example, and referring kids to the appropriate professionals when necessary. 1. Know what contributes to memory loss, and communicate that causes can be prevented and addressed. 2. As practitioners whose patients span the age continuum, you are in a perfect position to educate patients and their parents about habits and behavior that adversely affect their health – and specifically their cognition. 3. Make sure your office environment is as safe and healthy as possible. Do not have candy in the waiting room, and be aware of overmedicating and using toxic substances. 4. If you see a child with breathing or airway issues, refer them. 5. If a patient isn’t sleeping well, explain the connection to brain function, and make sure they have their sleep quality evaluated. We know that changes in the brain occur all throughout our lives. You and your staff can be critical partners in making sure patients and their parents understand the risks for dementia that begin in childhood, so they reach old age with their cognition intact. 1.

https://www.bcbs.com/the-health-of-america/reports/early-onset-dementia-alzheimers-disease-affecting-younger-american-adults?utm_source=prnw&utm_medium=&utm_content=&utm_campaign=&utm_term=

Is your patient at risk for a sleep disorder?

HELP THEM NOW! A compromised airway can substantially aﬀect quality of sleep. In turn, sleep disturbances can be an indication of a compromised airway or other sleep disorders.

Have your patient complete this short survey to learn if they are at risk; help them get on their way to solving sleep problems that could be seriously impairing their health, cognitive functioning, learning, behaviors, and/or jeopardizing safety.

http://bit.ly/FAH-SleepInventory

www.airwayhealth.org

SEEKandSLEEP

Staircase Place the eight dental sleep related words in the horizontal rows so that the letters in the diagonal staircase spell out another dental sleep related word.

OSA AIRWAY BILLING MEDICALLY REFERRAL CHILD TRENDS ORAL

For the solution, visit www.dentalsleeppractice.com.

56 DSP | Winter 2021

Dental Sleep Education That Fits Your Schedule Dental Sleep Education that fits your schedule The Academy of Clinical Sleep Disorders Disciplines is the only organization offering a fully online and on-demand certificate in Dental Sleep Medicine. Study theonly lectures and course materials at your own The Academy of Clinical Sleep Disorder Disciplines is the organization offering a fully online pace, then when you are ready, take theSleep exam.Medicine. The C.DSM certificate from ACSDD provides the necessary and on-demand certificate in Dental Study the lectures and course materials at your own pace, then when you are ready, takeapproach the exam. 12 modules present both the medical and medical and dental knowledge to confidently physicians and seek insurance reimbursement. dental science of sleep a solidfor foundation for understanding The medicine certificate providing is a prerequisite ACSDD Fellow and Diplomate.clinical applications. Most dentists are able to complete the 13 CE program in 4-6 months.

The certificate is a prerequisite for ACSDD Fellow and Diplomate.

Enroll ACSDD.ORG Enroll Today Today at at ACSDD.ORG

The Academy of Clinical Sleep Disorders Disciplines (ACSDD) is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. The Academy of Clinical Sleep Disorders Disciplines (ACSDD) is an ADA CERP Recognized Provider. This program has been submitted for approval by the ACSDD for a maximum of 13 credits as meeting general dental requirements.

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider at info@acsdd.org or to ADA CERP at www.ada.org/goto/cerp.

How Can DynaFlex® Be Your Partner In Telemedicine? DynaFlex® wants to be your partner in telemedicine, we are proud to offer our new “At Home Impression Kit”. Now more than ever, doctors are turning to telemedicine in order to treat patients, including the treatment of Obstructive Sleep Apnea (OSA). Learn how your office can seamlessly incorporate the At Home Impression Kit into your office work flow.

At Home Impression Kit • Rx Ordered • Easy To Follow Instructions • Device Can Be Delivered To Home Or Doctor’s Office • Exclusively at DynaFlex®

“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-in-one impression box mailed to patients; where patients still felt safe and we could help them with their sleep apnea needs.”

Dr. Chad Denman CEO & Owner Sleep Cycle Center

Scan QR Code To Learn More