Chairside Magazine Volume 15: Special COVID-19 Edition by Glidewell

SPECIAL COVID-19 EDITION

Implant, Restorative and Esthetic Dentistry

FINDING STRENGTH IN COMMUNITY AND EDUCATION Dentists support each other and learn valuable info as members of the free Glidewell Online Study Club p. 20

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PUBLISHER’S LETTER

Relentless Improvement: The Key to Overcoming Crisis Life can be … unpredictable. We welcomed 2020 at Glidewell with a celebration of our 50th anniversary. Reflecting on a half-century of continuous growth and development in the service of dentists like you. Working together to make it easier for patients to receive quality dentistry, and for practices to thrive.

We believe the tools available to dentists tomorrow should be better than those available today. So that clinicians are working not just harder, but also smarter.

With our forward momentum and the many exciting innovations poised to kick-start our next half-century of service, it felt like dentistry had never been stronger. Then the coronavirus struck. Suddenly, dentistry ground to a halt. But dentists are a resilient lot. Accustomed to challenges. To nervous patients and stringent infection control procedures. With extra precautions, some improvisation, and that do-ityourself spirit, many of you are already blazing your own trail to the new “normal,” working harder than ever to make sure your patients’ critical needs are met. At Glidewell, we’re committed to the same. Over 50 years, I’ve seen good times and bad. I’ve found the trick to weathering both is to focus on your guiding purpose, or “true north.” Ours is to enhance the quality and reduce the cost of the materials and techniques

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available to clinicians. To constantly make dentistry faster, better and less expensive — at all times. During this last decade of relentless growth, we’ve been diligently preparing the next wave of clinical and laboratory advancements. In doing so, we find ourselves uniquely suited to serving your current and future needs with: • Free online access to business and practice management advice, as well as a broad array of clinical CE programs • Hard-to-find personal protective equipment • Powerful, flexible digital dentistry options unmatched in the industry •A growing family of industry-leading BruxZir® Zirconia restorations • Comprehensive implant education, digital treatment planning and restorative solutions • Easy-to-adopt dental sleep therapy and appliances Our solutions go well beyond those of the traditional laboratory. Because we believe the tools available to dentists tomorrow should be better than those available today. So that clinicians are working not just harder, but also smarter. To be better prepared for the unexpected, as we are now. Life can be unpredictable, but dentistry doesn’t have to be. May your road to recovery be swift and certain.

Yours in health,

Jim Glidewell, CDT President and CEO, Glidewell

My Personal Battle with COVID-19 To most, COVID-19 remains an invisible menace. For all the headlines and historic disruption, it’s a statistical minority who have any firsthand experience with the illness itself. Regrettably, I’m one of them. When I walked into the hospital on March 23, I weighed 230 pounds. Twelve days later, leaving in a wheelchair, I weighed 203 pounds. I couldn’t walk, and could scarcely talk. The intubation left me depressed, and the drugs administered left me confused.

alone between nurse visits, staring at the ceiling. … If I’d had a switch that would have ended it all, I would have turned it off, certain I wasn’t going to make it. But I also worried about my wife and kids. I couldn’t even tell them goodbye. I couldn’t speak, and my cell phone battery was dead. Would they be all right? Had I done enough to ensure their health and happiness? I had similar thoughts about my company — the extended family of Glidewell employees and customers, and all the great work that they do. After 50 years, could it all unravel so quickly? I was fortunate to be included in a clinical trial for Remdesivir, a drug that I believe helped me recover. After waiting several days for the drug to arrive, we saw improvement after two days of IV delivery. My temperature dropped from 100 degrees to 98.6, and stayed there.

But I’d survived, whereas so many others haven’t. The doctors and nurses couldn’t have been nicer. During the second night, I was given a drug that would “help me sleep.” I woke up around 2 a.m. so confused that I climbed out of bed to use the bathroom — not realizing I was connected to an assortment of tubes and a catheter. I’d pulled the tubes out, leaving blood all over the floor. The poor nurse hollered at me and helped me back to bed. I still couldn’t figure out where I was. The worst of it was the intubation. My personal doctor debated its necessity, but the hospital staff won out. I suppose we’ll never really know what role the procedure played in my recovery, but two days in, I was suicidal. Lying there

I feel the combination of virus and treatment has left me with a permanent decrease in vital lung capacity — probably 10% or more. But I can live with that. It’s a fair price to still be here, watching over my family and company.

I’m also proud to see how well they fared in my absence. It renews my hope that at least some of what we do may extend beyond our own fragile lifetimes. That the sacrifices we make, the experiences we share, the lessons we impart, can be used to improve and sustain those we must eventually leave behind. We all get only so much time. Our legacies are determined by how we spend it. I’m grateful to the dedicated health care providers who were there to aid me, and I’m continually inspired by those of you who’ve similarly committed your professional lives to serving the health and well-being of others. It’s why I joke that my “exit strategy” is “a pine box.” Dentistry has provided me with so much, I can’t simply walk away into some golden notion of retirement. All I can do is try to give back. For everything we’ve accomplished, there are so many exciting developments on the horizon. And I feel I owe it to dentists and patients everywhere to see them through. Spending whatever time I have left helping to ensure you’re successful with yours. – Jim Glidewell

Jim and his wife, Parvina, with their four children.

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TABLE OF CONTENTS BUSINESS ADVICE

DIGITAL DENTISTRY

EDUCATION

20 Strategies for Successful Practice Recovery

COVID-19 and a New Standard in Digital Dentistry

Finding Strength in Community and Education

Dr. Roger Levin — Production and revenue are more important than ever before. Here are actionable ways to not just weather the challenges of COVID-19 but also create success for your business.

Jim Glidewell, CDT — Digital workflows offer manifold benefits: greater accuracy, rapid turnaround, and more. With Glidewell, you can enjoy these benefits, even if you send physical impressions.

Earlier this year, Dr. Neil Park saw dentists begin to grapple with the challenges of COVID-19, and his new mission at Glidewell became clear. He focused on launching the company’s Special COVID-19 Crisis Webinar Series, a daily resource for business and clinical advice. Today, that valuable support continues through the free Glidewell Online Study Club.

16 Fulfilling the Promise of Single-Visit Dentistry with the glidewell.io™ In-Office Solution Dr. Cary LaCouture and his team have used the glidewell.io™ In-Office Solution to mill almost 2,000 BruxZir® NOW crowns. And they’re not slowing down.

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FACTS AND FIGURES

ESTHETIC DENTISTRY

DENTAL SLEEP MEDICINE

15 Things You Didn’t Know About Glidewell

Aligning Patients’ Esthetic and Financial Goals

Screening Patients for SleepRelated Breathing Disorders

Bobbie Norton, RDA — Test your knowledge of your favorite full-service dental laboratory. With this fast-moving feature, you can tour the numerous ways that Glidewell stands ready to serve you and your patients.

Dr. Justin Chi — Some patients’ finances have tightened due to the economic fallout of COVID-19. For dentists, being sensitive to this requires expanding available treatment options. Here are three distinct possibilities for esthetic dental needs.

Drs. Ken Berley and Jennifer Hathaway — Part 2 of this three-part series delineates methods to screen for sleep apnea and other sleep disorders. The screening process requires no additional equipment, and this important service can expand your practice’s revenue streams.

Esthetic Provisionals: Now More Than Ever

Providing Immediate Treatment: Introducing the PMAD Protocol

Dr. Steven Barrett — Providing BioTemps® Provisionals can be one way to help patients feel confident and motivated to continue treatment. Dr. Barrett shares clinical tips based on his experience placing more than 10,000 units of these provisionals.

Dr. Ken Berley and Jennifer Neal, J.D. — The final installment in this three-part series details the urgency of sleep-related breathing disorders, especially in light of COVID-19. Learn how provisional mandibular advancement devices can be crucial in delivering life-saving interim treatment.

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PUBLISHER Jim Glidewell, CDT EDITOR-IN-CHIEF Neil Park, DMD CLINICAL EDITOR Jack Hahn, DDS EXECUTIVE EDITORS Grant Bullis, Greg Minzenmayer, Eldon Thompson MANAGING EDITOR Bobbie Norton, RDA CREATIVE COORDINATOR Jennifer Gutierrez CONTRIBUTING COPYWRITERS/EDITORS Aleesha Chaney, Danny Evans, Ilona French, Chris Newcomb, Kiali Wong Orlowski, Brenda Paro, Keith Peters, Adam Pringle, Michelle Raddatz, Bradley Zint GRAPHIC DESIGN TEAM LEAD Joel Guerra GRAPHIC DESIGNERS/ILLUSTRATORS Diana Goldner, Phil Nguyen, Allison Stewart, Mike Trujillo WEB DEVELOPERS Anna Kim, Caity Schoenfeld PHOTOGRAPHERS/VIDEOGRAPHERS Kyle Frager, James Kwasniewski, Sam Lea, Andrew Lee, David Manahan, Crystal Nguonly, Marc Repaire, Stanford J. Southall, Sterling Wright, Maurice Wyble

STEVEN BARRETT, DDS

JENNIFER HATHAWAY, DDS, FAGD

Dr. Steven Barrett earned his DDS from Case Western Reserve University School of Dental Medicine and shortly after joined the U.S. Navy, where he served for three years. In 1991, he joined Greenberg Dental & Orthodontics, a private group practice now with over 80 locations in Florida. Currently the clinical director and a senior partner with the group, he uses his nearly 30 years of experience practicing restorative dentistry to organize the group’s in-house continuing education program, lecture at dental schools and provide one-on-one mentorships throughout the state.

Dr. Jennifer Hathaway is a graduate of Texas A&M College of Dentistry (formerly Baylor College of Dentistry) in Dallas. She did her General Practice Residency in hospital dentistry at the University of Texas Health Science Center at Houston. She has been in private practice since 1993 in her hometown of Bryan, Texas, and is on staff at her local hospital. Dr. Hathaway recently completed the American Academy of Dental Sleep Medicine (AADSM) Mastery Course I to become an AADSM Qualified Dentist. She is focused on attaining ABDSM Diplomate status.

KEN BERLEY, DDS, J.D.

ROGER LEVIN, DDS

Dr. Ken Berley is a dentist and attorney with a practice focused on the treatment of sleep-disordered breathing and TMD. He is a Diplomate of the American Board of Dental Sleep Medicine (ABDSM), a lecturer, and a consultant in the areas of risk management and the development of a successful dental sleep medicine (DSM) practice. Dr. Berley has written numerous consent forms that are used in general and DSM practices. In addition, he is the president of the Dental Sleep Apnea Team, which provides educational opportunities for doctors and dental staff, and he is the coauthor of “The Clinician’s Handbook for Dental Sleep Medicine.”

Dr. Roger Levin is the CEO of Levin Group, Inc., a leading dental management consulting firm. Founded in 1985, Levin Group has worked with more than 30,000 dental practices. Dr. Levin is one of the most sought-after speakers in dentistry and is a leading authority on dental practice success and sustainable growth. He has authored 65 books and more than 4,000 articles on dental practice management and marketing.

COORDINATORS/AD REPRESENTATIVES Michael R. Martinez, Maria Ramos If you have questions, comments or suggestions, email us at chairside@glidewelldental.com. Your comments may be featured in an upcoming issue or on our website. © 2020 Glidewell Neither Chairside magazine nor any employees involved in its publication (“publisher”) make any warranty, expressed or implied, or assume any liability or responsibility for the accuracy, completeness, or usefulness of any information, apparatus, product, or process disclosed, or represent that its use would not infringe proprietary rights. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer or otherwise does not necessarily constitute or imply its endorsement, recommendation, or favoring by the publisher. The views and opinions of authors expressed herein do not necessarily state or reflect those of the publisher and shall not be used for advertising or product endorsement purposes. CAUTION: When viewing the techniques, procedures, theories and materials that are presented, you must make your own decisions about specific treatment for patients and exercise personal professional judgment regarding the need for further clinical testing or education and your own clinical expertise before trying to implement new procedures. Chairside is a registered trademark of Glidewell.

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CONTRIBUTORS JUSTIN CHI, DDS, CDT

JENNIFER NEAL, RN, J.D. Jennifer Neal is a licensed practicing attorney in Texas. As a consultant who assists practices that provide dental sleep medicine for veterans, she advises in matters related to accreditation, referrals and billing. She has been a registered nurse for over 20 years. As a military spouse, she has supported her husband, Lt. Col. Phillip Neal II, DMD, Chief of Dental Sleep Medicine for the U.S. Army, in providing education to Army dentists. She graduated from St. Mary’s University School of Law in 2017.

Dr. Justin Chi is director of clinical technologies at Glidewell. He joined Glidewell as a clinical research associate in 2015 after graduating from the Herman Ostrow School of Dentistry of USC. Dr. Chi’s previous education included receiving his Bachelor of Science degree in dental laboratory technology from the LSU School of Dentistry, and earning his CDT in crown & bridge in 2007.

JIM GLIDEWELL, CDT Jim Glidewell, CDT, is the founder and CEO of Glidewell, a multifaceted technology company among those at the forefront of the oral health industry. Employing a diverse team of specialists and support personnel, Jim continues his lifelong dream of advancing the materials and techniques available to dentists and laboratories, enhancing knowledge through free education platforms, and increasing patient access to premium dental services.

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BOBBIE NORTON, RDA Bobbie Norton became a registered dental assistant in 1998, launching a dynamic career that featured oral surgery, orthodontic and prosthodontic practices. In 2010, she joined Glidewell as an implant technical advisor and subsequently became supervisor of the implant call center. She transferred to the Marketing department at Glidewell in 2016 and became managing editor of Chairside® magazine the next year. In her additional role as project manager for clinical affairs, Bobbie is a main events producer for the annual Glidewell Symposium.

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20 Strategies for Successful Practice Recovery by Roger Levin, DDS chairside@glidewelldental.com

s the restrictions that closed dental practices across the nation begin to lift, dentists must consider how they will approach their COVID-19 recovery. This article will take you through proven, actionable strategies that will help you emerge successfully from this crisis.

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Let me preface these strategies by saying that I’m not going to attempt to anticipate what regulations might come out of this COVID-19 crisis and how those will impact dentistry. We can only work with what we know as of today. Instead, I’ll focus on strategies that help you achieve production. While production has always been important, in the time of recovery it becomes more important than ever before. I believe that dentists going back to work will need to turn their businesses around. Fortunately, there are proven, key strategies that will help you achieve this. These strategies are taught in business schools and covered in textbooks; if you follow the academic science, you have an excellent chance of turning around your business. In a turnaround you need to be hyper-focused on a few key things — and the one I’m going to focus on in this article is revenue. This is the formula I teach: Production creates revenue, revenue creates cash, and cash creates income. The following strategies are aimed to address that formula.

#1: F OCUS ON THE NEXT STAGE WHILE IN THE CURRENT STAGE In order to understand how to approach the COVID-19 crisis, we’ve built a model with three stages: • Stage 1: The COVID-19 Crisis • Stage 2: Entering Recovery • Stage 3: Recovery Keep in mind that there are three stages of this COVID-19 crisis and that you should be looking to solve the forthcoming challenges in the next stage. As the situation in your state evolves and you move from stage to stage, remember to look ahead. For example, in moving from Stage 1 to

Stage 2, you should think about which patients you might bring back first and which staff you’ll need in order to treat those patients.

#2: K NOW THAT THERE’S A RECOVERY TIMELINE Within the recovery, we believe there’s a timeline: • Phase 1 (Months 1–4): Extreme Busyness Due to Pent-Up Demand • Phase 2 (Months 5–12): Production Decline • Phase 3 (Months 13–24): True Recovery Upon reopening your practice, you’ll likely be extremely busy based on the pent-up demand. Keep in mind that, while this may feel like everything is back to normal, it is unlikely that this period will last. In Months 5–12, expect your production to drop. This reality is based on so many patients losing their jobs and needing to focus their energies elsewhere.

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In Months 13–24, you’ll begin the critical recovery phase. This phase determines if you recover, and how fast and how well you recover. The goal of this third phase is to reach 80% of the average monthly revenue that you had in 2019 by the 24th month of the recovery process. If you can reach that number, that helps secure your practice’s future.

#3: D EVELOP CRISIS LEADERSHIP Crisis leadership is different from everyday practice leadership. There are three factors of leadership in a crisis: resilience, agility and flexibility. In resilience, you must be willing to go with the flow as information arises. This doesn’t mean being a victim or focusing only on reacting. Rather, it means that you shouldn’t be so locked in to the way things should be that you find yourself in serious trouble. The second factor is agility (i.e., the ability to pivot). Be able to change direction.

The last factor is flexibility. No matter how well you plan, things are not going to turn out exactly the way you want them to. Remember this statement: No plan survives a collision with reality. To be a good crisis leader, you cannot be rigid — you’ll have to be resilient, agile and flexible.

#4: U SE THE ONE-PAGE COVID-19 STRATEGIC RECOVERY PLAN Visit the Levin Group’s COVID-19 Recovery Resource Center at levingroup.com and download the free One-Page COVID-19 Strategic Recovery Plan. This critical tool breaks your response management into four quadrants: practice, staff, patients and financials. For each category you have to write a goal. Then, in each category you’ll list three or four key value-based strategies that will directly contribute to the recovery goal of that quadrant. Ensure that you’re only focused on the recovery and not on the next five to 10 years. So, for example, under the “patients” category you might put down how many active patients you want to have. And you’d devise key strategies that would help you reach that goal. Keep in mind that every strategy must be measurable and quantifiable. And every category must have a goal statement to work toward.

• Attorneys • Consultants • Coaches • Landlords • Suppliers • Laboratories • Credit card companies • Leaseholders • Vendors • Friends Be considerate of the people in your top 25 list (as well as everyone else). These people are going to help you in your recovery, and they’ll likely remember how you behaved during the crisis.

#6: A DOPT A NEW RECOVERY SCHEDULE AND EXPAND RESPONSIBILITIES Firstly, you’ll likely have to expand your hours. This recovery period will not be business as usual. You may have to work evenings or weekends, or even cancel vacations. Ensure that you or your staff members are answering your phone lines every single time they ring. You must be reachable.

Secondly, you and your staff will have to take on new responsibilities. You should be writing scripts right now for the calls you’ll be making when your practice is open. Address a variety of topics, including rescheduling overdue patients or talking to new patients. While you may have automated text-messaging software that already does this, patients will be much more receptive to calls. Your scripting must include how you’ll be keeping your patients safe from disease, as well as any expanded financial options you’ll be offering. With these scripts, create a schedule for contacting patients. Call them once a week for three weeks, then text them once a week for three weeks, then email them once a week for three weeks. Ensure that you’re showing them that you’re compassionate and that you acknowledge the hardships they may be in with their families or finances. You should be prioritizing the highest production first. You must block out time in your new schedule for new patients and emergencies because these will help keep your production level high. The faster you get in productive treatment, the easier your

#5: I DENTIFY YOUR TOP 25 RECOVERY RELATIONSHIPS AND BE CONSIDERATE Make a list of everyone who is going to help you in the recovery. It might include any of the following: • Staff • Bankers • Financial advisors • Accountants

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turnaround will be. New patients and emergency patients represent a higher financial value than existing patients do.

#7: L EARN HOW THE GREAT RECESSION IMPACTED DENTAL HYGIENE AND PLAN ACCORDINGLY Considering we do not yet have any data about what will happen in the dental practice due to COVID-19, we might be able to learn from the Great Recession. If we look back at that time period, hygiene appointments dropped 15% and approximately 20% of hygienists lost their jobs. We can anticipate that hygiene may be a bit of a challenge after the first two months of recovery. There will likely be a surge of pent-up demand immediately when practices open, but after that we expect a drop. You’ll need to create a temporary solution to answer that demand. However, there will be a decline in hygiene appointments in Months 3–5. You’ll have to continually reevaluate your staffing needs during this period.

#8: K NOW YOUR BREAK-EVEN POINT Your break-even point is critical and simple. You can find it by measuring the revenue you expect to have per week against the expenses you expect to pay per week. If revenue exceeds expenses, you’re positive. If it doesn’t, you’re negative.

#9: S CHEDULE THE HIGHEST REVENUE PATIENTS FIRST Schedule new patients, large cases and emergencies first. These cases will lead to high production and keep your practice alive. You might be asking whether or not this is fair. Well, this isn’t a moral debate — it’s a survival debate. It is smart to have your highest production as early as possible. You need to have revenue generated so you can continue helping patients over a longer period of time. The first objective of your turnaround is to get to that break-even point. Once you’ve hit that, you’ve survived. After that you can start working toward profit and greatly expand the types of patients you’re seeing.

#10: E XPAND FINANCIAL OPTIONS We recommend that you increase patient financing by 200%–300%. You’ll be able to make this part of your scripting for patients. Additionally, you may want to add payment plans to your practice. Even though this likely will result in your collection rate dropping, you must keep in mind that the break-even point and

You must monitor this number relationship constantly. You must be taking a pulse of this number every day and getting a hard number every week. This recovery period is not business as usual, so you must be constantly aware of your break-even point.

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covering overhead are essential for survival. Collecting a percentage of those payments is better than continuing to turn away patients. There’s a higher percentage of patients who don’t have the disposable income to pay for treatment up front. Also, consider offering discounts to some fee-for-service patients.

#11: P ERFORM A DENTAL INSURANCE ANALYSIS Use this time to perform an insurance analysis. Think about the following as you decide whether or not to enroll: • What is your revenue percentage from dental insurance? • What is your revenue percentage from each specific dental insurance? • What is the number of patients in all insurance plans? • What is the number of patients in each specific plan? Don’t make any knee-jerk decisions. You can enroll at a later time if needed. Once you’ve made your analysis, you should run another analysis every six months to determine whether or not you should be in a specific insurance plan.

#12: CREATE SCRIPTS Scripting will be essential to your recovery. You and your staff should be using scripts for all communications with patients. You must have compassionate scripts for everything: collections, onboarding, insurance explanations, etc.

#13: A NALYZE CASH WEEKLY Cash is king — if you have cash, you survive. And if you have cash, you also have options. You’ll need to know weekly how much cash you will have on hand and whether or not you’ll be cash-positive or -negative. Knowing this allows you to make decisions and start building cash reserves.

#14: ACCUMULATE FOUR MONTHS OF CASH Work toward accumulating four months of cash. This will happen gradually, over 12–18 months. Put this cash in a separate account so you don’t use it. We simply don’t know if COVID-19 will come back and force us to suspend practicing again. We don’t know what the future holds. We need to be prepared for future risks. If you never use that cash, then it becomes income you can take home later. However, having that cash in reserve ensures that your practice can survive.

#15: B RING BACK A FOCUSED TEAM If your team hasn’t been brought back yet, you should be communicating with the team daily. When it is time to bring people back, you’ll need to create a new culture that’s focused on recovery. People coming back should have a much better work ethic simply because there will be fewer jobs

available. Rally your team members around recovery and cross-train them to take care of multiple roles. Over time you may have to reevaluate your staffing allocation and let people go, so you’ll need to ensure your remaining employees are widely capable. Lastly, think about putting in a recovery bonus. You may be wondering how you’re going to be in a position to give a bonus considering you’re out of work. This will be different from any normal bonus. This bonus would be strictly for the recovery. Tell your team members that if their performance is extraordinary over the next six months, they will receive X. But they must understand that if they do not perform extraordinarily, they will receive nothing. It must be black and white. I’m confident that if they perform extraordinarily, you’ll be in a place to give them the bonus.

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#16: C OMMUNICATE, COMMUNICATE, COMMUNICATE Right now, if you’re not open you should be communicating with the team daily, communicating one-onone with each team member weekly, and communicating with three to five patients daily. Your staff and patients will be more eager to return if you do this. And don’t forget about social media, where you can communicate in a positive and upbeat way to ensure your practice stays in people’s minds.

#17: M EASURE KEY PERFORMANCE INDICATORS Right now all your measurements should be focused on the recovery.

You should be measuring all of these at a minimum: • Production • Collections • Revenue • Cash • Doctor income • Number of active patients • Number of overdue patients • Expenses Track these numbers daily and weekly. By doing so you’ll see the trends and be able to make informed decisions.

#18: B EGIN CONSIDERING TELEDENTISTRY I’m becoming very bullish toward teledentistry. While there certainly are technological aspects that still need to be ironed out, I believe that dentists will be able to use teledentistry in a limited sense in the near future. For example, for post-op appointments you’ll be able to simply evaluate your provided care without having to use up valuable chair time.

#19: C ONSIDER ADOPTING IN-HOUSE PATIENT DENTAL MEMBERSHIP PLANS Some of your patients have likely lost their jobs and their dental insurance. During the recovery period, you may want to consider adopting in-house dental membership plans to allow these patients to continue accessing care. With these plans, patients are able to stay with you for a monthly fee. There’s a number of good plans out there. The one I’m most familiar with is DentalHQ.

Right now you cannot afford to make mistakes, so you have to keep your team laser-focused. A good way to do this is to create daily checklists for every position. This will help team members (and you) avoid skipping steps.

CONCLUSION Before the COVID-19 crisis, you could still achieve success by being less efficient or even inefficient. This will not be the case anymore.

#20: B UILD TEAM ACCOUNTABILITY

The likely forthcoming regulation will not make us faster or more efficient — so you’ll need to expect to be a little bit slower and focus on being more productive than ever. I encourage you to follow the experts, be mindful of best practices, and be resilient, agile and flexible.

To keep every single team member accountable (including the doctor), every person should be assigned three priorities. To keep the team focused, these priorities should be hung up in the staff room and repeated in weekly meetings.

You must have absolute faith that you will prevail. You’re going to have to confront the brutal facts: You’ll be expanding hours, working harder, and making tough decisions. If you do those things, you can get through this. CM

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COVID-19 and a New Standard in Digital Dentistry by Jim Glidewell, CDT chairside@glidewelldental.com

or 50 years, Iâ&#x20AC;&#x2122;ve worked to enhance the quality and reduce the cost of tools, materials, and techniques available to dentists. The goal? To make it easier for patients to accept treatment, and for practices to thrive.

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During that half-century, I’ve witnessed good times and bad — public health scares, natural disasters, war, terrorism, economic recession. What have all of these disruptions had in common? They’ve pushed us to change. To adapt and evolve. Because any organism that cannot reach equilibrium with its environment is destined to fail. The coronavirus pandemic has proven to be another such event. Altering the world around us. Causing us to reconsider what we know and how others view us. Challenging us to establish a new “normal” in how we work, if we want to be successful. In the post-COVID–19 world, dentists will require assurances of safety for their staff and patients. To minimize interactions, treatment solutions will need to be straightforward and predictable. More than ever, restorations and preventive appliances will have to be accurate, to minimize chairside adjustment. Practices will want steady cash flow in order to operate with freedom and flexibility, which will require rapid turnaround of lab services. Efficiency in all aspects of treatment and operations will be critical. These are likely among the goals of a dentist’s practice in the best of times. In times like these, with so little margin for error, they become necessary. To assist dentists in these areas, Glidewell is making it easier than ever to realize the benefits of a digital workflow. With Glidewell Intelligent Manufacturing (IM), we can digitize physical impressions through specialized micro-CT scanning technology, and replace the traditional plaster model process with our virtual plaster experience (VPX) in a highly precise software environment. We then design the restoration with the aid of proprietary artificial intelligence, and submit the digital file to a computerized production facility that is less susceptible to the limitations or

variations of human handling. In the end, restorations are produced faster, more consistently, and without the natural error stack-up that plagues conventional laboratory processes. And digital file storage means we no longer need to retain physical impressions or study models, so potentially pathogenic surfaces and crosscontamination are all but eliminated. Since digitization takes place in the lab, no capital equipment purchases or workflow alterations are required of the dentist. Clinicians can simply impress as they normally would, ship to Glidewell, and expect to receive their final restoration in as little as three to five days. With cases completed sooner, payment or reimbursement can be processed faster — of benefit to maintaining a healthy practice. For clinicians seeking more personal control of their digital dentistry workflow, we proudly offer the glidewell.io™ In-Office Solution. This versatile system provides the simplest way to scan, mill and deliver chairside restorations in a single visit — or seamlessly connect to digital production experts at Glidewell for assistance with more complex cases. It’s a “do it yourself” lab in the com-

fort of the office, with built-in flexibility and support at any stage of the CAD/ CAM process, and with significant savings opportunities for the everyday restorative work at the heart of a dentist’s practice. These technologies have been in development for years, and weren’t specifically designed to address concerns raised by the COVID-19 crisis. But, as fate would have it, they’re ideally suited to helping dentists practice safely, efficiently and profitably in these uncertain times — and with clear competitive advantages going forward. Times of strife can also be times of growth, revealing opportunities we might not have seen otherwise. At Glidewell, we’ve always strived to provide the best possible solutions for today while also developing even better solutions for tomorrow. For every innovation, there is a point of adoption in which promise meets reality, and a new standard is set. When it comes to digital dentistry, we believe this is that moment. And when we look back, we’ll wonder how we ever practiced restorative dentistry any other way.

With Glidewell Intelligent Manufacturing (IM), conventional dental impressions are digitized through micro-CT scanning technology.

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2 DIGITAL WORKFLOWS FOR FASTER RESULTS Digitize with Micro-CT

Create 3D Model with Virtual Plaster Experience (VPX)

AI-Enhanced Crown Design

Augmented Production

Design In Office

Mill In Office

Deliver Same-Day Crown

Deliver Restoration

Take Conventional Impression

Take Digital Impression

IN-OFFICE SOLUTION

Digital workflows provide faster, more consistent results. For Glidewell IM, there are no additional steps for dentists. Clinicians can simply impress as they normally would, ship to Glidewell, and expect to receive their final restoration in as little as three to five days. For dentists who use the glidewell.io In-Office Solution, the process of restoring a smile can be condensed to a single visit. Simply scan, mill and deliver chairside restorations, all in one appointment. CM

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At the 2019 Glidewell Symposium in Orlando, Florida, Dr. Cary LaCouture (seventh from right) and his team visited with President and CEO Jim Glidewell, CDT, (far left) and Glidewell clinician Dr. Justin Chi (far right). Dr. LaCouture and his team also took part in hands-on fastdesign.ioâ&#x201E;˘ training when they attended the symposium.

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Fulfilling the Promise of Single-Visit Dentistry with the glidewell.ioâ&#x201E;˘ In-Office Solution

he promise of single-visit dentistry, much like the paperless office, has been much talked about yet infrequently realized. Cost, support and perhaps, most importantly, concerns about how to implement chairside technologies and workflows have hampered adoption. Too often it was left to those with the time and inclination to master complex design software and unforgiving workflows.

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Glidewell provided Dr. LaCouture’s team with advanced training in the use of the glidewell.io™ In-Office Solution. Now, the team members utilize a dedicated lab area to design and mill their single-visit restorations.

But as we move toward a postCOVID–19 world, single-visit dentistry is no longer just for the “other” practice. Because the advantages to be had over traditional laboratory processes are going to be more important than ever for your patients. Cary LaCouture, DDS, founder of Burning Tree Family Dentistry (Franktown, Colorado) and Creekside Dental (Parker, Colorado), first explored single-visit dentistry over 15 years ago. More recently, he incorporated the glidewell.io In-Office Solution into his practice. “Our team has come to deeply appreciate the fastmill.io™ in so many ways,” he said. “Recently, we were open for emergency dental procedures only, and were able to perform a number

of restorative treatments at the initial appointment. Doing so saves us the time and expense of multiple operatory setups, of course. And patients really appreciate the convenience.” He added, “Looking ahead, it’s safe to assume those cost and convenience factors will only become more critical. Because an incredibly high number of patients will have faced employment disruptions that will inhibit them from taking multiple days off from work. Fewer visits also mean a reduced risk of exposure for everyone involved.” Dr. LaCouture’s decision to give single-visit dentistry a second try was influenced by three primary considerations.

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First, the highly intelligent fastdesign.io Software demystified the restoration design process and made it accessible to both him and his team. Second, his developing relationship with the team at Glidewell gave him confidence that they would readily support him throughout the implementation process. Last — and by no means least — was the unique ability of the fastmill.io to produce fully sintered BruxZir® Zirconia restorations. “BruxZir NOW is a real game changer,” Dr. LaCouture said. “I’m now able to mill premium zirconia restorations in-office, with no oven time or glazing required. Because BruxZir NOW is pre-sintered, an entire, time-intensive step in the CAD/CAM workflow is eliminated. We did our research, and no other chairside system can equal that.”

And with the release of BruxZir Esthetic NOW Milling Blocks, chairside zirconia restorations are not just for the posterior anymore. “BruxZir Esthetic NOW offers the same combination of strength and beauty we would receive from the lab,” Dr. LaCouture said. “So we’re able to confidently provide single-visit zirconia restorations in the smile zone, too.” Since bringing the glidewell.io In-Office Solution to both Burning Tree Family Dentistry and Creekside Dental in 2018, Dr. LaCouture and his team have milled almost 2,000 BruxZir NOW crowns. He believes empowering and trusting your team is fundamental to the successful adoption of single-visit dentistry. “You don’t want a system that requires hours and hours of training or specialized skill to use. The glidewell.io system is intuitive enough for my whole staff to work with, and the support is there whenever needed. Like any other aspect of the practice, it’s my team working in unison that makes single-visit dentistry a reality.”

“BruxZir NOW is a real game changer. I’m now able to mill premium zirconia restorations in-office, with no oven time or glazing required. Because BruxZir NOW is pre-sintered, an entire, time-intensive step in the CAD/CAM workflow is eliminated.”

In their use of the glidewell.io In-Office Solution, Dr. LaCouture’s team has quickly become proficient at each step of the process, from the scan and design phases, to the milling of restorations. This allows him to focus on the prep and seating of cases, which makes for a more efficient practice — while also providing team members room for professional growth. “As a dental restorative team, we’ve embraced a same-appointment workflow,” he said. “I don’t know that anything has galvanized our team more, as together we strive to deliver a smooth process for each patient. It’s fun!” Dr. LaCouture’s team has visited Glidewell for advanced training, which is offered to all new customers approximately three months after their system is installed and they’ve completed their in-office training. Additionally, the team traveled together to Orlando, Florida, for the 2019 Glidewell Symposium, which included hands-on fastdesign.io training. And how do patients respond to the new digital processes in the practice? “Patients are so appreciative of the technology serving them,” Dr. LaCouture said. “Each patient typically receives a brief tour of our single-visit ‘fastmill’ process, and they love it!” In the words of Brian Whitlock, a recent patient at Burning Tree Family Dentistry: “Awesome team and surprising talent in Franktown! I don’t normally write reviews, but Jenn, Liz, Lauren and Dr. LaCouture were fantastic, took me in without an appointment and got me out the same afternoon with a custom-made crown! Highly recommended.”

Dr. LaCouture’s staff members are committed to the success of their practices and take an active part in the process of fabricating chairside restorations.

and lab operations, to name just a few. According to Dr. LaCouture, “It’s all about the relationship with and support of the team at the lab, which is fully committed to the practice’s success.” Designed and manufactured in the USA using the expertise of Glidewell’s extensive R&D and engineering resources, glidewell.io brings the capabilities of the lab to the practice while also providing a seamless link for more complex and time-consuming cases. And as a manufacturer-direct solution, the cost of the glidewell.io In-Office Solution is over $70,000 less than the traditional market leader, and over $20,000 less than other industry options. In Dr. LaCouture’s estimation, “Initial expense is no longer a significant barrier to entry. With attractive financing options and immediate lab savings on every case, Glidewell offers a flexible CAD/CAM solution that can pay for itself quickly and well into the digital future — which appears to be a lot closer than it once did.” CM

Looking beyond the practice, the extended team includes all of Glidewell’s support personnel — installation, training, technical support

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EDUCATION SPOTLIGHT

Finding Strength in Community and

Education

n mid-March, dental offices started closing down. Beleaguered by the COVID-19 threat, CDC regulations and state mandates, as well as a lack of coherent information to guide their response, most dentists had shuttered their offices, opening only for emergencies. As proprietors of small businesses, dentists faced unprecedented financial hardships, and were forced to furlough employees and look for ways to rescue their dental practices. As a leader in dental continuing education for over 30 years, Dr. Neil Park thought he could help. The vice president of clinical affairs for Glidewell had overseen hundreds of successful live courses and symposia, as well as Chairside ® magazine. He began having phone conversations with dentists across the U.S. to determine their greatest needs and to design a program that would respond to those requests. The first priority was to assemble a Business Advisory Panel, a group of experts in legal matters, accounting, banking and practice management.

“I can’t express enough gratitude for the service you all provided to the dental community during the last seven weeks. I’ve been in private practice in Maryland for 18 years, and, for the first time, I felt it wasn’t about who had the bigger/fancier/better practice. We all had the same fears and sleepless nights. Your daily webinars were so invaluable and helpful.” – Christine Lee Kim, DDS

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Business Advisory Panel These advisers were responsible for providing the latest information on crisis response. Federal legislation had funded a flurry of loan and stimulus proposals, as well as legal mandates and obligations, and clarification was needed on the frequent changes in these programs. Young dentists, burdened with student loans, needed to understand their repayment options. And all dentists needed to understand how to manage their teams and apply communication strategies to minimize the damage to their practices and maximize their recovery. In order to provide easy access to thousands of participants, a webinar format was selected. And, because of the constant updates to coronavirusrelated regulations, Dr. Park decided a daily schedule was necessary. The result was the Special COVID-19 Crisis Webinar Series, a daily program that provided practitioners with two types of essential content. First, the Business Advisory Panel would share daily updates on the financial and practice challenges that dentists faced. These experts would provide information released only hours earlier, equipping dentists to make well-founded decisions. Secondly, clinical experts would present practical lectures that would enable the delivery of a wide variety of clinical solutions in an efficient, high-quality setting. This component of the webinar series was designed to help dentists make the most of their forced inactivity. Dr. Park saw a need — as well as an opportunity — for dentists to upgrade their clinical skills during this time. Practices would need new revenue streams during the recovery period, and adding clinical instruction to the

DAVID HOCHBERG, DDS Dr. David Hochberg operates a general practice in Atlanta that has provided restorative, implant and cosmetic dentistry services for more than 30 years. He has lectured nationally and is the immediate past president of the American Academy of Implant Dentistry.

ROGER LEVIN, DDS Dr. Roger Levin is the CEO of Levin Group, Inc., a top consulting firm that has advised more than 30,000 dental practices. As a leading authority on dental practice success, he has written more than 4,000 articles on dental practice management and marketing.

NEIL I. PARK, DMD Dr. Neil Park is vice president of clinical affairs at Glidewell, which he joined in 2016. He oversees clinical research & development, as well as training and education programs in implant, restorative and esthetic dentistry. He also is editor-in-chief of Chairside magazine.

GARY PRITCHARD, J.D. Gary Pritchard received his law degree from Loyola University New Orleans College of Law, and went on to serve as general counsel for Clayton Homes, Inc., a Berkshire Hathaway company, and a Fortune 500 company. He is an in-house labor counselor for Glidewell.

BRAD MCKEIVER, CPA, MBA Brad McKeiver is partner-in-charge of Aprio’s National Dental Industry Practice, an accounting solutions group. He arms dentists with real-time financial data and has helped numerous practitioners make informed business decisions to drive increased profitability.

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daily webinar could help secure that new income. His hope was that, by learning from some of the most successful clinicians in the world, dentists would reopen their practices better able to provide productive treatment, from dental sleep medicine, to esthetic dentistry, to the surgical and restorative aspects of implant dentistry. The Special COVID-19 Crisis Webinar Series began on March 25 and was an immediate success. From the first webinar until the final daily episode, more than 8,000 dentists attended these programs, with total enrollment of over 50,000. The Business Advisory Panel, featuring Dr. Roger Levin, Dr. David Hochberg, Dr. Park, Gary Pritchard and Brad McKeiver as core members, answered hundreds of questions from attendees. With friendly banter among the panelists and Dr. Park as moderator, the webinar series became a touchstone for dentists who found themselves with unexpected free time in the midst of the pandemic.

the difficult process of reopening their practices, the special webinar series concluded. But the job is not yet complete.

“Glidewell’s seminars are the highlight of my day! The information presented is terrific, and I have not missed one in four weeks! … Bravo to you and the entire team, and Jim Glidewell for this special gift. Hearing Gary and Brad talk on the law/accounting issues is especially appreciated. Thank you so VERY MUCH!” – Frank A. Berman, DDS

On May 6, as dentists in many parts of the country headed back to begin

To continue to help dentists regain their pre-COVID–19 success, Dr. Park and his team have launched the Glidewell Online Study Club. The study club’s offerings include a weekly webinar that maintains the same familiar format, with opening updates from the Business Advisory Panel, followed by a practical, useful lecture from a clinical expert. The Glidewell Online Study Club, with free membership and free programming, is open to all dentists, and features a number of benefits (see below). Dr. Park and his team at Glidewell are committed to continuing to support dentists through the challenges of the pandemic, and into the future. Their goal is to create an online community where experts provide valuable business and clinical advice, and members can ask questions and contribute their own experiences as the entire profession moves forward. To join the Glidewell Online Study Club, click here. CM

• Weekly webinar every Friday at 9 a.m. (Pacific) • Free online dental CE that includes over 50 free courses, all available here • Discounts on live courses and the Glidewell Symposium • Discounts on Misch International Implant Institute courses

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15 Things You Didn’t Know About Glidewell by Bobbie Norton, RDA chairside@glidewelldental.com

ou already know Glidewell as a full-service dental laboratory. And maybe you’re familiar with other ways that we serve dentists, from education, to implant manufacturing, to some of the product innovations that we have introduced over the past 50 years. Here, we’re excited to share some Glidewell facts and figures you might not know.

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. President and CEO Jim 1 Glidewell, CDT, established his first dental laboratory in January 1970 in Orange County, California. 2

4. Glidewell has a team of more than 150 experts who lead our Research & Development initiatives. The team includes nine Ph.D.-credentialed scientists and five dentists, along with chemists, engineers, Certified Dental Technicians (CDTs) and Master Dental Technicians (MDTs).

. Five different materials are 7 available for the glidewell.io In-Office Solution. These milling blocks are engineered for a range of restorations, from temporary inlays to long-lasting, full-coverage crowns.

8 5 6 2. Our products now include U.S.-made face masks and sanitizing spray, sold directly to dentists through Glidewell Direct (888-303-3975). These products, fabricated in our ISO-certified and FDA-regulated manufacturing facilities in Southern California, are provided as economical solutions to help dentists, staff and patients stay safe and healthy.

months

3. We provide worry-free warranties and a no-fault remake policy.

. As a vertically integrated com5 pany, we have developed our own software for the digital design of restorations. Our innovative software includes fastdesign.io™, which is part of the glidewell.io™ In-Office Solution. This software takes digital design to a new level by relying on Glidewell ARI (Applied Restorative Intelligence), exclusive artificial intelligence technology developed in conjunction with AI experts at UC Berkeley. 6. The fastmill.io™ In-Office Mill is built in the USA. As part of the glidewell.io system, this chairside mill enables dentists to deliver same-visit restorations made from BruxZir® NOW Milling Blocks — the only in-office zirconia milling blocks that are ready to deliver without time-consuming oven sintering.

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. After extensive research and 8 validation, we launched BruxZir Zirconia in 2009. The independent Gordon J. Christensen Clinicians Report® has described BruxZir Zirconia as “the most successful tooth-colored restoration in the history of dentistry.”* * An independent, nonprofit, dental education and product testing foundation, Clinicians Report®, August 2019. For the full report, go to bruxzir.com/most-successful.

Silent Nite®

OASYS Hinge Appliance™

EMA®

dreamTAP™

9. Glidewell is the largest U.S. provider of sleep appliances. These appliances also can be prescribed as provisional mandibular advancement devices for patients who are suffering from sleep-related breathing disorders.

11. The Glidewell customer service team is available during extended hours (5 a.m.–5 p.m. Pacific time). Just call 800-854-7256. Our promise to you is that we will always answer your call within three rings.

14. At our state-of-the-art, ISO-certified facilities in Irvine, California, we manufacture all Inclusive® prosthetic components and Hahn™ Tapered Implants.

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12. The GlideWELLness Center is an on-site clinic that is available for Glidewell employees. The staff includes a physician, physician assistant, acupuncturist, massage therapist, physical therapist and medical assistants.

15. More than 8,000 dentists have tuned in to a special webinar series hosted by Glidewell to help dentists overcome the sweeping challenges of COVID-19. CM

10. Glidewell pioneered the use of CT scanning to digitize your impressions. In fact, we are now manufacturing our own CT scanner design, specifically for this purpose. This technology is essential for the all-digital laboratory workflow of Glidewell Intelligent Manufacturing (IM), which delivers faster, more consistent restorations.

13. The company’s very own fitness center, Gym GlideWELL, opened in 2011. To continue serving employees amid stay-at-home orders, the fitness center launched at-home fitness challenges and other online resources.

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Aligning Patientsâ&#x20AC;&#x2122; Esthetic and Financial Goals by Justin Chi, DDS, CDT chairside@glidewelldental.com

or so many of our patients, recent months have been challenging on both a personal and financial level. Patients still want the dentistry that will make them feel confident about their smiles, but, for many, finances have constricted due to the economic consequences of COVID-19. Despite payment options that may be available, many patients are simply unable to afford ceramic veneers and other first-choice esthetic treatment. Flexibility in determining patient treatment plans is one of the keys to success during this recovery, so how then can we deftly scale our treatment options to suit a range of budgets? When it comes to esthetic dental needs, I would like to propose three options.

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Before

Smile Transitions™

A complex treatment plan is needed to improve this patient’s smile. For a temporary, affordable transformation, her doctor delivered Smile Transitions. – Clinical dentistry by Taylor Manalili, DDS

SMILE TRANSITIONS™ The Smile Transitions cosmetic appliance, which simply fits over existing teeth, is an affordable option that can benefit patients who want near-immediate results for minimal cost and effort. After one appointment for impressions or scans, they can return to the office about a week later to receive their Smile Transitions. No tooth preparation or cementation is required. And, for patients who desire to do so, the appliance can be worn while eating and drinking. ™

In addition to the dramatic esthetic improvement, patients find the results to be motivational. Wearing Smile Transitions provides a glimpse of what’s possible, from filling in missing teeth to rejuvenating a stained, worn smile. Patients can enjoy full, albeit temporary, smile makeovers at a fraction of the top-tier cost, and still look forward to more definitive esthetic treatment when finances improve.

DIRECT BONDING (DIRECT COMPOSITE VENEERS) Direct composite veneers can also provide an interim option that is budget-friendly and provides many of the esthetic benefits of ceramic veneers. The esthetic outcome is highly dependent on clinical execution, as direct bonding is technically demanding. However, this option is still very cost-effective and convenient, requiring just one or two appointments. For cases of 1–2 units, I like to do direct bonding in a single appointment. For cases of more than 2 units, I advise using diagnostic wax-ups, which can be created on-site or ordered from the lab. When a diagnostic waxup is used, the full process for direct composite veneers includes a treatment-planning appointment, an optional second appointment to review the diagnostic wax-up and mock-up, and the final appointment for the direct bonding procedure.

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CASE STUDY

Figures 1a, 1b: This patient had peg laterals and a congenitally missing maxillary left canine. Because her natural teeth were not discolored, malformed or misaligned, but only lacking in size and shape, I determined that the additive technique of direct composite bonding would be an appropriate, minimally invasive treatment.

Figure 2: To treatment plan this case, I poured a second set of casts and created a diagnostic wax-up of the esthetic areas. I reduced the length of tooth #10, which originally was about even with the centrals, to achieve a better esthetic result. I applied wax to the mesial and distal surfaces of teeth #7 & #10, and to prevent the laterals from appearing too wide I added wax to the mesial portions of teeth #6 & #12. The left bicuspid occupies the space of the congenitally missing canine on that side of the arch, so I’m attempting to mimic the left canine by extending the bicuspid, lengthening it a little bit and bringing the mesial surface over.

Figure 3: From the wax-up, I fabricate a putty matrix that enables me to transfer the planned changes from the wax-up model into the mouth. I position the putty matrix intraorally along the incisal edge to allow me to see the planned position of the incisal edges. Also, the scalloping of the matrix helps me determine exactly where to position the interproximal areas on each tooth. The only area where I will remove tooth structure will be on the incisal edge of tooth #10, with the rest of the areas built up with composite resin.

Figure 6: I apply phosphoric acid in a 37% concentration to all of the surfaces to be bonded. Because I am entirely in enamel, I will allow the acid to etch the surfaces for at least 20 seconds. To ensure the desired area is etched, it’s a good idea to apply the acid at least 2 mm beyond the anticipated restorative area. I like Gel Etchant from Kerr Corporation (Brea, Calif.) because of the material’s ideal viscosity and how it rinses off very quickly. When applying the etchant to the mesial surfaces of the laterals, I protect the centrals with a clear matrix.

Figure 4: At the start of the case, I recommend the use of a prophy cup and pumice to clean the tooth surfaces.

Figure 7: Once I confirm the enamel surfaces have a frosted appearance, I apply Scotchbond™ Universal bonding agent (3M Company; St. Paul, Minn.) to all of the bonding surfaces. Like the etchant, I extend the bond slightly beyond where I expect to apply the resin. Once the bond is applied, I air-thin the bond to ensure the solvents evaporate. After drying, I polymerize the material for 10 seconds.

Figure 5: Prior to isolation, I try in the putty matrix to verify that it seats completely with the rubber dam in place. I then place a rubber dam to avoid contamination, because I will be performing bonding procedures on multiple teeth. I use the second-to-smallest hole punch so it will be more constricting at the base of each tooth. For additional stability, I place individual floss ligatures.

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Figure 8: I begin the resin application with a spatula-shaped instrument by applying the material cervically to establish a new, natural emergence profile. The putty matrix aids in determining the new incisal edge position, and the interproximal scalloping along the incisal embrasures indicates exactly where I should extend the resin application on the proximal surfaces. I use the spatula resin applicator for most of the resin placement and shaping. For some of the finer shaping, an explorer or probe can be used. I light-cure for 20 seconds to fully polymerize the material.

Figure 10: I like to use Sof-Lex™ discs (3M Company). The darker colors of the Sof-Lex discs are used primarily for gross reduction, and the lighter ones are used for refining the contours and margins and also removing any large areas of surface roughness. The lightest colors allow the polishing of the restorations to a high shine. My goal is for the margins to be indiscernible. After checking the occlusion, I’ll use a slow-speed round bur to adjust any high spots. It typically will remove the composite material with a minimal effect on the enamel.

Figure 12: I finalize the polishing by using an Occlubrush® by Kerr Corporation. It has special impregnated fibers that polish the composite material to a high shine without the need for an additional paste. After that, I can check the restorations with floss, and confirm smooth contacts and the absence of rough areas along the transition to the natural tooth.

13a

Figure 9: In the esthetic zone, I try to shape the resin close to the final contours as much as possible, but slightly over-bulked. Rather than spend too much time smoothing the restoration during the resin application, I find it faster to dial in the final contours during the polishing phase. Before moving ahead to polishing, I’ll use a #12 blade to remove any roughness along the transition between the natural tooth and the resin application. Any overhangs or roughness can lead to gingival inflammation.

Figure 11: I finish the restoration with a coarse composite polisher and then a fine composite polisher, to remove any surface scratches. It is important to polish well and get the surface as smooth as possible. Ensuring there’s no porosity in the composite will minimize the composite’s susceptibility to staining in the future.

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13c

Figures 13a–13c: The patient was very excited about the final esthetic improvement. The completed composite treatment served as a minimally invasive way to alter the shape of the teeth in an affordable, reversible manner.

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CERAMIC VENEERS Assuming the patient’s teeth do not require full-coverage restorations, ceramic veneers are the premier option that I propose when patients can afford to make a substantial investment in their smiles. Ceramic veneers offer the most ideal esthetics and stability. Plus, ceramic veneers allow the greatest range for improving the shape and color of teeth. When I am choosing veneer materials, I prescribe based on an occlusal analysis. In the absence of parafunctional habits, I order Obsidian® lithium silicate ceramic, which provides fantastic translucency and shade. And for those

veneer cases that demand extra strength, my material of choice is BruxZir® Esthetic Zirconia. In addition to these proven materials, I rely on diagnostic wax-ups for planning the case. This step enables me to successfully communicate my vision for the case to my lab team. And when I’m chairside, the diagnostic wax-up is indispensable for patient communication and motivation. All around, I view diagnostic wax-ups as the best way to eliminate surprises and stay in sync with my patients and lab team for esthetic success.

CASE STUDY

Figure 1: This 19-year-old patient wanted to improve her smile. Her chief complaints were her small teeth, spaces and gummy smile.

Figures 2a, 2b: Clinical evaluation revealed spaces between all anterior teeth, excessive gingival display throughout the esthetic zone and smaller clinical crown dimensions. In discussing treatment options with her, I recommended minimal-prep Obsidian veneers for teeth #4–12 and a crownlengthening procedure.

Figure 3: Using a diagnostic wax-up, I can fabricate a putty matrix to create an acrylic mock-up. This is an optimal method for evaluating the treatment plan, including the esthetics, function and speech.

Figure 4: After the patient has accepted the treatment plan, it’s time to move ahead to the gingivectomy. I use the Waterlase iPlus (BIOLASE, Inc.; Irvine, Calif.) to outline the new contours. For this initial step, I select a laser bandage preset, which allows me to superficially score the gums.

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Figure 5: Next, I advance to a higherwattage gingivectomy setting to steadily cut the tissue. With its easy-to-navigate interface and many presets, the Waterlase iPlus system is intuitive and straightforward to use.

Figure 8: Post-gingivectomy, the gingival margins are more harmonious. Improving the contours and height of the gingival veil was pivotal for the overall esthetic outcome.

Figure 6: After completing the crownlengthening procedure, I use Luxatemp Ultra® (DMG America; Ridgefield Park, N.J.) in shade A1 to temporize the patient. The temporaries guide the soft-tissue healing.

Figure 7: When the patient returns for the final appointment, I use NX3 Nexus™ Third Generation (Kerr Corporation) to cement the Obsidian veneers on teeth #4–12. As this case shows, Obsidian veneers are exceptionally natural-looking in shade and translucency.

Figure 9: The patient was delighted upon seeing her new smile. The Obsidian veneers, in conjunction with the gingivectomy, resulted in a more proportional, vibrant smile.

CONCLUSION As dentists, we always prefer to render the ideal treatment. However, particularly in times such as these, it’s not just about precise clinical techniques. We must stay attuned to patients’ financial priorities and be ready to advise them on a spectrum of restorative options that will provide them with the esthetic benefits they are seeking. CM

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Esthetic Provisionals: Now More Than Ever by Steven Barrett, DDS chairside@glidewelldental.com

or many years now, a quality laboratory-fabricated provisional has been an important part of my protocol for achieving patient acceptance and satisfaction with esthetic cases. After successfully placing over 10,000 units of these provisionals, I am now finding a significant new benefit in their use. As so many of us have discovered during the restarting of our practices after the COVID-19 shutdown, I find that many patients have financial challenges that prevent them from completing their cases as quickly as we would like. In fact, many of my patients require me to leave the provisionals in place much longer than my typical six to eight weeks.

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BioTemps® Provisionals are my solution for predictable, strong temporary restorations for patients. These laboratory-made esthetic shells from Glidewell are relined over the tooth preparations. Using BioTemps, and keeping the provisionals in place a bit longer, is now a key strategy in moving treatment forward for patients.

For cases where I am not changing the length of the centrals (either longer or shorter), I measure the length of one of the central incisors with a digital caliper. I communicate this measurement to the lab, providing the exact desired length for the centrals. Because BioTemps Provisionals are made from a digital process, the lab can easily duplicate the correct length.

When I order BioTemps Provisionals, I take comfort in knowing Glidewell offers a six-month warranty on these provisional restorations. This benefit is another reason my office is relying on BioTemps more than ever to get our patients through tough financial times. Let’s go through some cases that demonstrate how I use BioTemps Provisionals in my treatment protocol. As you’ll see, BioTemps are useful for cases that involve major changes to the anterior teeth and those that do not.

TREATMENT PLANNING I always start my esthetic cases with a series of photos, not only to document the starting point, but also to communicate my needs to Glidewell when I order BioTemps Provisionals.

A good tip is to take a picture of the caliper as you measure the central incisor. For this case I’m documenting the length of the tooth that I want to match. I then can send the pre-op picture to Glidewell for fabrication of the BioTemps Provisionals.

When the case is returned, I measure the BioTemps on the model for confirmation.

For larger esthetic cases, I have the patients return to the office a few days later so I can evaluate their smile without any facial numbness. New full-smile and rest photos are taken, and any changes are made if needed. I communicate these changes to the lab with photographs, study models or new scans of the perfected provisional.

Taking photos of the patient at rest and fully smiling helps guide me to the correct incisal edge position of the central incisors. After seating the BioTemps, it is important to measure the centrals before finishing. This allows for verifying a correct match to the previously determined length. With a numb upper lip, it is hard to evaluate esthetics. Therefore, measuring the BioTemps is a critical step to ensure predictability.

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After

Because BioTemps Provisionals are designed digitally, they are easily replicated for the final restorations. For this case, the approved designs were used to create BruxZirÂŽ Esthetic Zirconia restorations (above).

In situations that call for changing the length of the central incisors, I need to determine the length. Will the centrals be longer or shorter?

PATIENT 1: R EDUCING THE LENGTH OF THE CENTRALS

After

In the case shown on the right, my patient disliked the long appearance of her teeth. To simulate shorter teeth, I use a black marker to draw directly on the incisal edge of one of the centrals. Then, I take additional photos. In the subsequent photos, the black marker is not apparent, and the teeth magically appear shorter.

After

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PATIENT 2: CREATING LONGER CENTRALS For this patient, we wanted to increase the length of the centrals. Using composite, I can quickly add length to the central incisors and achieve a motivational mockup. Whether Iâ&#x20AC;&#x2122;m adding to the length or marking an incisal edge for shortening, I evaluate the new incisal edge position, along with other factors such as esthetics, speech and any occlusal issues.

After: The BioTemps Provisionals the day of seating.

Many DLSR cameras have built-in Wi-Fi, which allows for quickly sending mock-up photos to a phone. You then can choose from a number of available apps that enable you to create simple sideby-side layouts displaying the mock-up photos next to the before photos, for easy comparison. I use this process to show patients the photos I just took and to further discuss the treatment plan.

After the correct length of one or both centrals has been determined, I record the length with the digital caliper. I take a photo of the caliper in place and send this information to the lab.

Before

Using this simple process, I am assured predictable results for the BioTemps Provisionals.

After

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TIPS FOR ORDERING BIOTEMPS®

TIPS FOR RELINING PROVISIONALS

• Coat the inside of the provisionals with monomer from the acrylic. • Mix the acrylic reline material to a honey-like consistency in a dappen dish and load into the provisionals. • It is better to overfill the provisionals with acrylic than to underfill. • Use a microbrush or explorer to push the acrylic down into the provisionals to minimize any voids. • Send the lab a quality model or scan for them to work with. This applies to crown & bridge cases and veneer cases. • Write your lab prescription when you have the stone model in your hand or the photographs in front of you. This will allow you to remember details about the case and include these instructions in your lab prescription. Details such as tooth rotation, buccal corridor issues or tooth proportions are important. • Look at the arch form and note any changes to be made. • Look at the gingival heights and mark the model or photo with any changes that you are planning. The lab will incorporate those changes into your BioTemps.

Use even pressure when seating BioTemps Provisionals, ensuring the centrals are level and not canted. It is good to have excess acrylic flow out at the margins.

• Send a shade photo for the BioTemps when you send your lab prescription. This is very important because you want to deliver BioTemps with the best shade possible. This will be a stepping stone in ensuring the final shade is correct. • Consider asking for 1 mm reduction of the teeth and for multiple units to be splinted together. I always do. From multiple single units to a bridge, you can order BioTemps Provisionals for your crown & bridge cases for anterior or posterior cases. You also can order BioTemps for veneer cases.

After the excess acrylic is wiped away with liquid monomer and the acrylic is dry, your BioTemps will look similar to this. All the margins are captured and can easily be trimmed.

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TOOLS FOR TRIMMING AND POLISHING BIOTEMPS

TIPS FOR CEMENTATION OF BIOTEMPS

BioTemps Provisionals should be highly polished after all the adjustments are made. A clean, wet rag wheel with laboratory pumice (medium grit) is applied first, followed by Fabulustre® (Grobet USA; Carlstadt, N.J.) for a very high shine.

Goldies® Carbide Bur 82-T and 84-T (8002 and 8001; Dedeco International Inc.)

I always use IRM (Dentsply Sirona; Charlotte, N.C.) because it is strong and soothing to the teeth. The free eugenol is no longer present within a week, so there is no issue with bonding the restorations in place. For faster setting, I add a few drops of water to the mixture when I mix the IRM. This greatly accelerates the setting time.

NTI® Double-Sided Diamond Disc (D354-220; Kerr Rotary) I apply petroleum jelly to the outside of the provisionals so the IRM material will not stick.

3M™ Sof-Lex™ Extra-Thin Contouring and Polishing Discs

NTI Silicone Polisher White 10-pack (P0301-220; Kerr Rotary)

• Coarse (2382C; 3M) • Medium (2382M; 3M) • Fine (2382F; 3M)

To make cleanup easy, I use a microbrush to apply the IRM material in a thin layer to the inside of the provisionals.

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When I prescribe BioTemps Provisionals for veneer cases, I spot-etch and spot-bond near the incisal edge (never near the margin), apply flowable composite and seat the provisionals. In some cases, a very small amount of permanent cement may be needed in place of flowable composite.

CONCLUSION I view BioTemps Provisionals as a stepping stone to the final result. Done well, BioTemps can give your patients a valuable preview of the planned treatment and provide the lab a great template to follow. These esthetic temporaries also allow your patients to confidently go to work, and be with family and friends, even if financial limitations require them to be in provisionals longer than usual. Follow these simple protocols, and send your patients out the door happy, smiling and eager to send you more referrals. CM

Before

BioTemps

Final Restorations

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Screening Patients for SleepRelated Breathing Disorders by Ken Berley, DDS, J.D., and Jennifer Hathaway, DDS, FAGD chairside@glidewelldental.com

he world has changed dramatically in the time since this series launched. The first article (ChairsideÂŽ magazine Vol. 15, Issue 1) covered the legal necessity of initiating a program to screen all patients for sleep-related breathing disorders. Now, as we focus on rebuilding our practices after the COVID-19 shutdown, this is a particularly favorable time for clinicians to study the intersection of dentistry and sleep apnea (and other sleep disorders).

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Pause to establish a screening protocol that can identify patients who may have airway or sleepiness issues. These patients can receive potentially life-saving intervention through provisional mandibular advancement devices. Screening for sleep-related breathing disorders requires no additional equipment, and this important service can expand your practice’s revenue streams. Complaints relating to sleep and wakefulness are ubiquitous in our dental patient populations. Both adult and pediatric patients suffer.1 As a result of the high incidence of sleep-related breathing disorders, the American Dental Association (ADA) has resolved that all dentists must institute a program to screen

their patients for airway and sleepiness issues.2 Screening can be accomplished in various ways. The most effective technique may be to add a few questions to your health history.

APPLYING THE ‘SNORE +’ METHOD Generally, it is accepted that 70% of patients who snore loudly have sleep-related breathing disorders. When patients answer “yes” to question 1, apply the “Snore +” method to look for other indicators that confirm the probability of sleep disorders. For example, a patient who reports snoring loudly every night and being

EXAMPLE QUESTIONS FOR SCREENING

If a patient’s answers regarding airway health point to a possible airway or sleepiness risk, further screening and examination are indicated.3 Patients with a sleep disorder frequently present with a complex medical history. It is common for patients with uncontrolled obstructive sleep apnea to have previous diagnoses of certain health conditions and dental signs,3,4 such as those in the following lists.

COMMON PREVIOUS DIAGNOSES

1. Do you snore?

1. Hypertension

2. Have you ever had a sleep study?

2. Stroke

3. Have you ever been diagnosed with sleep apnea or another sleep disorder?

3. Heart disease 4. Type 2 diabetes

4. Have you ever used a CPAP device? 5. Have you ever awakened gasping or choking? 6. Has anyone ever told you that you stopped breathing during sleep?

5. Obesity (body mass index > 30) 6. Depression 7. Gastroesophageal reflux disease (GERD) 8. Sexual dysfunction

7. Do you doze easily or feel sleepy in quiet situations?

9. Dementia/Alzheimer’s disease

8. Do you take naps?

11. Atrial fibrillation

10. Cancer

9. Do you feel rested after a night’s sleep? 10. Do you frequently have to get up at night to use the restroom?

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COMMON DENTAL SIGNS OF SLEEP-RELATED BREATHING DISORDERS 1. Temporomandibular joint dysfunction

7. Large (coated and scalloped) tongue

2. Bruxism

8. Enlarged tonsils

3. Excessive tooth wear (particularly on the anterior teeth)

9. Small nasal valves (difficulty breathing through the nose)

4. Vaulted palate

10. Battered soft palate

5. Malocclusion (anterior crowding and crossbite)

11. Elongated, battered uvula

6. Constricted mandible

12. Class III or Class IV Mallampati classification

KNOWING THE RISK FACTORS Mallampati classification is used to determine the relative length of the soft palate and, secondarily, the size of the tongue. The longer the soft palate, the higher the risk of obstructive sleep apnea or another sleep-related breathing disorder. For assessment, a patient would need to sit upright, open the mouth wide and stick out the tongue. The classifications of 1–4 are determined by how much of the soft palate and uvula are visible when looking into a patient’s mouth from the front. A patient with a Mallampati classification of 3 or 4 has a high probability of having obstructive sleep apnea.5

MALLAMPATI CLASSIFICATIONS • Class I: Uvula, fauces, soft palate and tonsil pillars are visible • Class II: Uvula, soft palate and fauces are visible • Class III: Base of uvula and soft palate are visible • Class IV: Only hard palate is visible

Hard palate

Uvula Pillar

Soft palate

Class I

Class II

Class III

Class IV

Clinicians can use the Mallampati classifications to evaluate the relative length of the soft palate and, secondarily, the size of the tongue. The longer the soft palate, the higher the risk of obstructive sleep apnea or another sleep-related breathing disorder.

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Once a patient is identified as having a high probability of a sleep disorder, it is important to assess how the potential issue might be affecting the patient. The Epworth Sleepiness Scale (ESS) is a screening tool that can assist dentists and physicians in determining patients’ relative sleepiness.6 The ESS features a series of eight questions designed to determine the likelihood of a patient falling asleep in common situations. If a patient has a high probability of falling asleep at an inappropriate time, it is prudent for a dentist to initiate immediate care. However, the ESS is limited in that it evaluates only the level of daytime sleepiness. The maximum score on the ESS is 24, and patients who score 10 or more on the ESS are excessively sleepy. It is not uncommon for these patients to have automobile accidents or other types of serious injuries. When screening procedures uncover patients who have ESS scores ≥ 10, practitioners should use every reasonable means to lessen the probability of these patients causing injury to themselves or others. If a patient has a high probability of having a sleep disorder, it is important to assess the severity of the patient’s symptoms to determine whether any provisional therapy is indicated.

If a patient is excessively sleepy upon screening, a provisional mandibular advancement device is a reasonable therapy to be utilized during the wait for a definitive diagnosis and treatment.

EPWORTH SLEEPINESS SCALE (ESS) Situation

Chance of dozing (0–3)

Sitting and reading

Watching television

Sitting inactive in a public place — for example, a theater or meeting

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon

Sitting and talking to someone

Sitting quietly after lunch (when you’ve had no alcohol)

In a car while stopped in traffic

Total Score 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Reference: Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991 Dec;14(6):540-5.

The Epworth Sleepiness Scale (ESS) can be a helpful screening tool for determining whether a patient is dangerously sleepy and needs immediate therapy.

A positive response to the airway questions in your health history raises a concern that the patient may have one of many possible sleep disorders. In-office screening surveys may not effectively distinguish between patients who have sleep hygiene issues versus those who have a diagnosable sleep disorder. Only an overnight sleep test can provide a definitive diagnosis. Therefore, all patients who screen positively for sleep-related breathing disorders must be referred to a physician for evaluation. Under current protocols, sleep physicians are tasked with the responsibility of determining the most appropriate therapy. However, in light of the limited number of sleep physicians in the U.S., wait times are becoming unacceptably

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long. It is not uncommon for patients to wait months for an appointment with a sleep physician. Given the serious consequences of excessive daytime sleepiness, it is important for clinicians to provide provisional dental treatment options for patients who are facing such burdensome wait times. If a patient is excessively sleepy upon screening, a provisional mandibular advancement device is a reasonable therapy to be utilized during the wait for a definitive diagnosis and treatment. The Silent Nite® Sleep Appliance is a typical recommendation for a provisional mandibular advancement device. The Silent Nite sleep device, which can be fabricated by Glidewell in five in-lab working days, is reason-

ably priced. The price is important as all provisional therapy is provided on a cash basis. Because there is no definitive diagnosis, medical insurance benefits are unavailable.

CONCLUSION It is now a legal requirement for all dentists to screen their patients for sleep-related breathing disorders. If, during screening, you identify a patient who is dangerously sleepy, a provisional mandibular advancement device such as a Silent Nite appliance may be necessary to minimize risk for the patient as well as your dental practice. Make sure to read the next article in this series. In part three, we’re discussing how to safely implement provisional mandibular advancement devices as interim dental treatments for possible sleep apnea and other sleep disorders. CM

Silent Nite® Sleep Appliance

REFERENCES

1. Redline S, Larkin E, Schluchter M, et al. Incidence of sleep disordered breathing (SDB) in a population-based sample. Sleep. 2001;24:A294. 2. American Dental Association [internet]. Chicago: American Dental Association; c2019. The role of dentistry in the treatment of sleep related breathing disorders [cited 2019 Aug 25]. Available from: https://www.ada.org/~/media /ADA/Member%20Center/FIles/The-Role-of-Dentistry-in -Sleep-Related-Breathing-Disorders.pdf. 3. Barkoukis T, Matheson J, Ferber R, Doghramji K. Therapy in sleep medicine. Philadelphia: Elsevier/Saunders; 2011. 4. Berley JK, Carstensen S. The clinician’s handbook for dental sleep medicine. Chicago: Quintessence Publishing; 2019. 5. Yu JL, Rosen I. Utility of the modified Mallampati grade and Friedman tongue position in the assessment of obstructive sleep apnea. J Clin Sleep Med. 2020 Feb 15;16(2):303-8. Epub 2020 Jan 13. 6. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991 Dec;14(6):540-5.

n October 2017, the ADA adopted a resolution titled, “The Role of Dentistry in the Treatment of Sleep Related Breathing Disorders. ” This resolution states, in part, that “dentists are encouraged to screen patients for SRBD as part of a comprehensive medical and dental history … If risk for SRBD is determined, these patients should be referred, as needed, to the appropriate physicians for proper diagnosis.”1 The ADA policy statement additionally recognizes the growing prevalence of sleep disorders found in pediatric dental patients: “In children, screening through history and clinical examination may identify signs and symptoms of deficient growth and development, or other risk factors that may lead to airway issues. If risk for SRBD is determined, intervention through medical/dental referral treatment may be appropriate or … to help treat the SRBD and/or develop an optimal physiologic airway and breathing pattern.”1 The previous statement clearly places all dentists on legal notice that sonable and prudent practitioner a reawould screen all patients for SRBDs. This is particularly true for patients presenting with a high probability of SRBDs.2 SRBD is an umbrella term used to describe several chronic sleep-related conditions in which there is a partial or complete blockage of airflow during sleep. Unfortunately, these events Dental practitioners should can occur many times routinely screen all patients throughout immediate care for patients for SRBDs and provide the night.3 The tongue, with significant SRBD tonsils, uvula symptoms. and soft palate may act in concert to restrict or completely block a patient’s both a prevalent phenomenon5 airway during sleep. These airway and described by bed associated with serious restrictions are a direct partners, and health conresult of disturbed sleep. Obstructive sequences.5,6 When DDS anatomical Teng, Jesse sleep patients have J.D., andcharacteristics, negative apnea (OSA), which is Ken Berley, DDS, an SRBD, their sleep inspiratory pressure by far the most is interrupted and gravity. A common form of sleep-disordered by repetitive events partial airway blockage chairside@glidewelldental.com in which their can present as breathing, is associated breathing stops and snoring. In more serious with many starts. These cases, the other adverse health airway events frequently patient’s airway can consequences, be completely result in including an increased daytime sleepiness or blocked for more than risk of death.8 fatigue, which a minute.4 may interfere with a patient’s ability Untreated sleep apnea and treatment of to function and reduces Numerous on the screening has been difocus will studies the that patient’s all have why demonstratof articles rectly linked to hypertension, quality of life.7 Symptoms article will outline Thissleep-disordered ed that This is the first in a series strokes, may breathing disorders (SRBDs). breathing is heart attacks, Type 2 diabetes, implications. include snoring, pauses patients with sleep-related as well as potential legal cancer, in breathing their patients for SRBDs dementia, industrial screen must dentists and automobile

Screen for Why Every Dentist Must Disorders hing Sleep-Related Breat

PART 1 “Why Every Dentist Must Screen for Sleep-Related Breathing Disorders”

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of oxygen and CO2. This damage leads to severe pneumonia and, in many cases, death. Complicating the situation even further, as a direct result of the pandemic, most sleep labs have shut down and polysomnograms are not being performed. The wait time for treatment is unacceptably long. Dental

sleep medicine providers can play a vital role in minimizing risk factors for patients with untreated obstructive sleep apnea by fitting these patients with a provisional oral appliance until they are able to visit a sleep physician. Early treatment is crucial in normal circumstances, but now it is vital to save lives.

PROTOCOL FOR DENTAL SLEEP MEDICINE

Treatment: Providing Immediate Protocol Introducing the PMAD The current protocol for treatment of sleep-related breathing disorders requires that all dentists screen their patients for symptoms and then refer positive-screened patients to a sleep physician or other knowledgeable physician for definitive diagnosis and plan of care.1 The American Academy J.D., of SleepDDS, Medicine by Ken Berley, (AASM) RN, J.D. has determined that Neal, dentists and Jennifer are inadequately trained and, therefore, unqualified to elldental.com chairside@glidew determine the necessity of screenings or the best treatment for their patients with airway issues. The current protocol requires that all positive-screene why every dentist must d patients be showed to a knowledgein this series, the authors ablewell as aexamined simplifiedbymethod n the previous articles evaluate breathing disorders, as physician tothat with a whether patients opinion legal sleep be screening for sleep-related authors’ professional test is indicated. If an overnight It is the emergency treatshould sleep conduct this screening. risks testreceive is performed and we the patient or significant medical In this article, disorders. is diagnosed severe daytime sleepiness breathing with sleep-related obstructive for positive sleep will allow your patients This change ment when they screen the supervising protocol.apnea, physician will revision to the current propose an important more quickly. to receive treatment much

By screening for sleep-related breathing disorders and therapy, dentists can play providing provisional a vital role in minimizing risk factors for patients.

initiate therapy.2 The current protocol and the shortage of appropriately trained physicians is resulting in an unacceptable backlog and wait times for physician evaluation, testing and treatment initiation. This has been especially true during the COVID-19 lockdown, as sleep testing is unavailable.

There are approximately 4,000 sleep physicians practicing in the U.S.6 This HOW BIG IS THE is a significant barrier to treatment, as PROBLEM? sleep physicians are currently the only health care providers Most recent estimates who can diagconservatively nose sleep-related breathing suggest that 13% of men and 6% disorders. If 33 million patients of women have clinically are referred by significant practicing dentists, this obstructive sleep apnea would result in with an 8,250 new patients per apnea-hypopnea index sleep physician. of more than These numbers, while 15 events an hour.4 only estimates, A recent Swiss paint a dim picture of study also found that extensive wait 50% of men times for evaluation appointments over 40 with an average BMI of 25 and testing. Currently, even had clinically significant if a health care obstructive practitioner is lucky enough sleep apnea.5 Assuming to have a conservaa sleep physician within tive estimate of 10% reasonable prevalence of driving distance, patient clinically significant obstructive evaluation sleep can still take weeks apnea in the U.S., we or months. It is can estimate unlikely that most sleep that more than 33 physicians are million patients prepared for this influx of patients. chairsidemagazine.com

PART 3 “Providing Immediate Treatment: Introducing the PMAD Protocol”

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Providing Immediate Treatment: Introducing the PMAD Protocol by Ken Berley, DDS, J.D., and Jennifer Neal, RN, J.D. chairside@glidewelldental.com

In the previous articles in this series, the authors showed why every dentist must be screening for sleep-related breathing disorders, as well as a simplified method to conduct this screening. It is the authorsâ&#x20AC;&#x2122; professional legal opinion that patients with severe daytime sleepiness or significant medical risks should receive emergency treatment when they screen positive for sleep-related breathing disorders. The following article proposes an important revision to the current protocol. This change will allow your patients to receive treatment much more quickly.

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uring the COVID-19 pandemic, we have learned that the need for immediate treatment of suspected obstructive sleep apnea has become even more pressing. Sleep apnea, along with other chronic respiratory conditions, is a known risk factor for COVID-19. The virus rapidly attacks alveoli in the lungs that perform the life-sustaining gas exchange of oxygen and CO2. This damage leads to severe pneumonia and, in many cases, death. Complicating the situation even further, as a direct result of the pandemic, most sleep labs have shut down and polysomnograms are not being performed. The wait time for treatment is unacceptably long. Dental sleep medicine providers can play a vital role in minimizing risk factors for patients with untreated obstructive sleep apnea by fitting these patients with a provisional oral appliance until they are able to visit a sleep physician. Early treatment is crucial in normal circumstances, but now it is vital to save lives.

PROTOCOL FOR DENTAL SLEEP MEDICINE The current protocol for treatment of sleep-related breathing disorders requires that all dentists screen their patients for symptoms and then refer positive-screened patients to a sleep physician or other knowledgeable physician for definitive diagnosis and plan of care.1 The American Academy of Sleep Medicine (AASM) has determined that dentists are inadequately trained and, therefore, unqualified to determine the necessity of screenings or the best treatment for their patients with airway issues. The current protocol requires that all positive-screened patients be examined by a knowledgeable physician to evaluate whether a sleep test is indicated. If an overnight sleep test is performed and the patient is diagnosed with obstructive sleep apnea, the supervising physician will

By screening for sleep-related breathing disorders and providing provisional therapy, dentists can play a vital role in minimizing risk factors for patients.

HOW BIG IS THE PROBLEM? Most recent estimates conservatively suggest that 13% of men and 6% of women have clinically significant obstructive sleep apnea with an apnea-hypopnea index of more than 15 events an hour.4 A recent Swiss study also found that 50% of men over 40 with an average BMI of 25 had clinically significant obstructive sleep apnea.5 Assuming a conservative estimate of 10% prevalence of clinically significant obstructive sleep apnea in the U.S., we can estimate that more than 33 million patients

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need immediate care. As of 2018, there were 199,486 dentists working in the U.S.3 Therefore, every dentist in the U.S. could have more than 250 patients with significant symptoms of sleep-related breathing disorders. There are approximately 4,000 sleep physicians practicing in the U.S.6 This is a significant barrier to treatment, as sleep physicians are currently the only health care providers who can diagnose sleep-related breathing disorders. If 33 million patients are referred by practicing dentists, this would result in 8,250 new patients per sleep physician. These numbers, while only estimates, paint a dim picture of extensive wait times for evaluation appointments and testing. Currently, even if a health care practitioner is lucky enough to have a sleep physician within reasonable driving distance, patient evaluation can still take weeks or months. It is unlikely that most sleep physicians are prepared for this influx of patients.

From a medical-legal perspective, once a patient has been screened and identified, time is of the essence. Obstructive sleep apnea is a highly prevalent condition with major health consequences.2 It is a risk factor not only to patients with the condition, but also to the millions of innocent bystanders who happen to share the road with patients who have undiagnosed or uncontrolled obstructive sleep apnea.7 Additionally, the treatment of sleep-related breathing disorders has been shown to improve the clinical outcomes of patients who suffer from atrial fibrillation8 and hypertension,9 and studies have even found that treatment reduces overall mortality rates in men10 and women.11

SEVERE OBSTRUCTIVE SLEEP APNEA IS AN EMERGENCY With the adoption of the ADA policy statement on the dentist’s role in the treatment of sleep-related breathing disorders, all dentists should now be screening their patients for obstructive sleep apnea. If you are unsure of how to screen your patients, see our previous article in this issue of Chairside® magazine about screening techniques. The most important question that we now ask is, what are our ethical and legal responsibilities when a dentist discovers that a patient is dangerously sleepy after the obligatory screening? It is the authors’ professional and legal opinion that patients with signif-

icant sleep-related breathing disorder symptoms, such as severe refractory high blood pressure, heart disease, stroke or severe daytime sleepiness, should be provided immediate care. In 1993, the Louisiana State Court found that the risks associated with obstructive sleep apnea are lifethreatening and therefore constitute a medical emergency that requires immediate therapy. The current treatment protocol does not provide for timely therapy without a sleep physician providing a diagnosis and directing emergency therapy. For the safety of patients and society, this protocol should be modified to allow for provisional therapy when severe symptoms are present.

Provisional therapy for sleep-related breathing disorders can be life-saving not just for patients but also for fellow drivers.

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EMERGENCY TREATMENT FOR SEVERE OBSTRUCTIVE SLEEP APNEA Upon determining that a patient is severely sleepy or is at risk for serious medical consequences, proactive therapy should be initiated. The Epworth Sleepiness Scale (ESS), which was discussed in our previous Chairside article, is a screening tool used to determine if a patient is dangerously sleepy. The ESS features a series of questions to determine the likelihood of a patient falling asleep in various situations. Patients who score 10 or higher on the ESS should be considered unacceptably sleepy and, therefore, present a legal risk for the screening dentist.

PROVISIONAL MANDIBULAR ADVANCEMENT DEVICES Patients who are excessively sleepy or are medically compromised should be fitted with a provisional appliance to minimize symptoms. A provisional mandibular advancement device is indicated for patients who present with an ESS of 10 or greater, significant difficulty sleeping, severe refractory hypertension, a recent history of stroke or heart attack, or a history of falling asleep at unexpected times. These patients need immediate help and should be treated as emergency cases. After a qualified dentist evaluates a patient for sleep-related breathing disorder symptoms, the patient must be informed of the assessment results and a plan should be discussed. The assessments made by a dentist when examining a patient may result in a provisional or working diagnosis of severe obstructive sleep apnea. A provisional diagnosis is made by a professional based on currently available information. These diagnoses are based on subjective and objective signs and symptoms, and confirmation frequently requires ad-

Patients who are dangerously sleepy and have a recent history of stroke or heart attack need immediate help. They should be treated as emergency cases.

ditional testing and consultation with colleagues. Appropriate testing is then ordered to provide the information required for a definitive diagnosis. The provisional diagnosis will exist until it is replaced. Ideally, a provisional diagnosis becomes an exact diagnosis after completion of initial testing and gathering of more information.12 Without a provisional diagnosis of sleep-related breathing disorders based on subjective symptoms and objective evaluation, referral to a sleep physician would be inappropriate. A trained dental sleep medicine provider should inform the patient of the screening results and the danger associated with obstructive sleep apnea. If the patient’s symptoms raise concern, the discussion should include the fabrication of a provisional mandibular advancement device. Provisional or initial therapy should be initiated based on a working diagnosis of severe obstructive sleep apnea, de-

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pending on the nature of the patient’s symptoms. Seriousness of symptoms frequently drives provisional therapy: The more disruptive and lifethreatening the symptoms, the more likely some type of provisional therapy will be initiated based on those symptoms. Treating “symptoms” without a definitive diagnosis is a common protocol in the medical and dental professions.

COVID-19 and CPAP Historically, continuous positive airway pressure (CPAP) therapy has been considered the gold standard for treating obstructive sleep apnea. Most physicians prescribe CPAP initially, with oral appliance therapy considered only if CPAP is not effective. However, with the spread of COVID-19, the AASM has indicated that CPAP therapy may increase the risk of spreading the virus or causing a reinfection of the patient. CPAP potentially exposes individuals who

are in close proximity by generating aerosols, potentially spreading the coronavirus.13 There have been a number of studies demonstrating that the COVID-19 virus can stay suspended in the air once aerosolized.14 Further complicating CPAP therapy are reported shortages of distilled water and various disinfectants needed for cleaning and utilization of CPAP systems. If the COVID-19 virus contaminates a patient’s CPAP equipment, the coronavirus can remain in the CPAP device and the patient is at risk of reinfection from contaminated CPAP tubing, filters or masks.

Silent Nite® Sleep Appliance and EMA® sleep apnea device (Frantz Design Inc.; Austin, Texas). These appliances are comfortable and can easily function for the period between the dental office screening and the sleep physician evaluation. Silent Nite and EMA appliances are custom-fabricated from impressions or scans of the patient’s dentition, and can be provided quickly and without great expense. If the patient’s dentition is scanned, the Silent Nite or EMA appliance can be provided after just three in-lab working days.

SPEAK WITH YOUR LOCAL SLEEP PHYSICIAN Discuss this protocol with the sleep physicians you work with. Do not initiate this protocol unless all of your supervising sleep physicians understand and approve. It is important that your referring sleep physician understands that the provisional mandibular advancement device is not a definitive therapy, and that all screened patients will be referred for a definitive diagnosis and treatment based on their evaluation and testing. Your sleep physician should be aware that they are in total control of the diagnosis and

As a result of the ongoing complications of CPAP usage during this pandemic, oral appliance therapy has become the first-line treatment to safely control obstructive sleep apnea without generating aerosols. In response to these concerns, the AADSM has issued the following statement: It is the position of the American Academy of Dental Sleep Medicine (AADSM) that oral appliance therapy (OAT) should be prescribed as a first-line therapy for the treatment of obstructive sleep apnea (OSA) during the COVID-19 pandemic.15

Silent Nite® Sleep Appliance

Appliances Although there are a number of temporary appliances available, we would like to draw a distinction between “temporary appliances” and “provisional appliances.” Temporary appliances have been well studied and have not been very effective. They are not custom-fabricated and are designed to be used for a short period of time (e.g., 30 days). The provisional appliances that we recommend are custom-fabricated appliances, which can be provided quickly and are relatively inexpensive for the patient. Examples of provisional mandibular advancement devices include the

EMA®

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REFERENCES

treatment of the patient, and that the provisional mandibular advancement device is provisional therapy only.

(OBIT-AF). Am Heart J. 2015 May;169(5):647-654.e2.

1. American Dental Association [internet]. Chicago: American Dental Association; c2019. The role of dentistry in the treatment of sleep related breathing disorders [cited 2019 Aug 25]. Available from: https://www.ada.org/~/media /ADA/Member%20Center/FIles/The-Role-of-Dentistry-in -Sleep-Related-Breathing-Disorders.pdf.

CONCLUSION Obstructive sleep apnea is rampant and is a known complicating factor in COVID-19. Any delay in the treatment of patients with severe sleep-related breathing disorders can only result in more suffering. A provisional mandibular advancement device may be custom-fabricated to minimize symptoms and reduce risk until a definitive diagnosis and permanent treatment can be initiated. Dental sleep medicine practitioners are encouraged to discuss this treatment option with local sleep physicians. Adopting this protocol can only improve patient outcomes. CM

2. Levine M, Bennett K, et al. Dental sleep medicine standards for screening, treating and managing adults with sleep-related breathing disorders. J Dent Sleep Med. 2018;5(3). 3. American Dental Association [internet]. Chicago: American Dental Association; c2020. Available from: https://www.ada.org. 4. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013 May 1;177(9):1006-14. 5. Heinzer R, Vat S, Marques-Vidal P, Marti-Soler H, Andries D, Tobback N, Mooser V, Preisig M, Malhotra A, Waeber F, et al. Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respir Med. 2015 Apr;3(4):310-8. 6. Phillips B, Gozal D, Malhotra A. What is the future of sleep medicine in the United States? Am J Respir Crit Care Med. 2015 Oct 15;192(8):915-7. 7. Tregear S, Reston J, Schoelles K, Phillips B. Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: systematic review and meta-analysis. Sleep. 2010 Oct;33(10):1373-80.

Disclaimer: The information provided in this article is not intended to be taken as legal advice and is not guaranteed to be correct, complete or up-to-date. Laws change rapidly, and the authors cannot guarantee that all of the information in this article is completely current. The law differs from jurisdiction to jurisdiction and is subject to interpretation by different courts. The law is a personal matter, and the general information provided in an article cannot fit every circumstance. Therefore, if you need legal advice for your specific problem, you should consult a licensed attorney in your area.

8. Holmqvist F, Guan N, Zhu Z, Kowey PR, Allen LA, Fonarow GC, Hylek EM, Mahaffey KW, Freeman JV. Chang P, et al. Impact of obstructive sleep apnea and continuous positive airway pressure therapy on outcomes in patients with atrial fibrillation — results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation

9. Fava C, Dorigoni S, Dalle Vedove F, Danese E, Montagnana M, Guidi GC, Narkiewicz K, Minuz P. Effect of CPAP on blood pressure in patients with OSA/hypopnea: a systematic review and meta-analysis. Chest. 2014 Apr;145(4):762-71. 10. Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005 Mar 19-25;365(9464):1046-53. 11. Campos-Rodriguez F, Martinez-Garcia MA, de la Cruz-Moron I, Almeida-Gonzalez C, Catalan-Serra P, Montserrat JM. Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: a cohort study. Ann Intern Med. 2012 Jan 17;156(2):115-22. 12. Reference.com [internet]. New York: IAC; c2020. What is a provisional diagnosis? [cited 2020 Jun 4]. Available from: https://www.reference.com/world-view/provisional -diagnosis-e4a215469ba7888d. 13. American Academy of Sleep Medicine [internet]. Darien (IL): American Academy of Sleep Medicine; c2020. COVID-19: FAQs for sleep clinicians [updated 2020 Apr 7; cited 2020 Jun 4]. Available from: https://aasm.org /covid-19-resources/covid-19-faq. 14. Liu Y, Ning Z, Chen Y, et al. Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals. Nature. 2020 Apr 27. https://doi.org/10.1038/s41586-020-2271-3. Online ahead of print. 15. Schwartz D, Addy N, Levine M, Smith H. Oral appliance therapy should be prescribed as a first-line therapy for OSA during the COVID-19 pandemic. J Dent Sleep Med. 2020;7(3).

RELATED ARTICLES Pause to establish a screening protocol that can identify patients may have airway or sleepiness who issues. These patients can receive tially life-saving intervention potenthrough provisional mandibular advancement devices. Screening for sleep-related breathing disorders requires no additional equipment, and this important service can expand your practice’s revenue streams.

Complaints relating to sleep and wakefulness are ubiquitous dental patient populations. in our Both adult and pediatric patients suffer.1 As a result of the high incidence of sleep-related breathing disorders, the American Dental Association (ADA) has resolved that all dentists must institute a program to screen

EXAMPLE QUESTION S FOR SCREENING 1. Do you snore? 2. Have you ever had a sleep study? 3. Have you ever been diagnosed with sleep apnea or another sleep disorder?

The previous statement clearly places all dentists on legal notice that sonable and prudent practitioner a reawould screen all patients for SRBDs. This is particularly true for patients presenting with a high probability of SRBDs.2 SRBD is an umbrella term used to describe several chronic sleep-related conditions in which there is a partial or complete blockage of airflow during sleep. Unfortunately, these events Dental practitioners should can occur many times routinely screen all patients throughout immediate care for patients for SRBDs and provide the night.3 The tongue, with significant SRBD tonsils, uvula symptoms. and soft palate may act in concert to restrict or completely block a patient’s both a prevalent phenomenon5 airway during sleep. These airway and described by bed associated with serious restrictions are a direct partners, and health conresult of disturbed sleep. Obstructive sequences.5,6 When anatomical Jesse Teng, DDS sleep patients have J.D., andcharacteristics, negative apnea (OSA), which is Ken Berley, DDS, an SRBD, their sleep inspiratory pressure by far the most is interrupted and gravity. A common form of sleep-disordered by repetitive events in partial airway blockage chairside@glidewelldental.com which their can present as breathing, is associated breathing stops and snoring. In more serious with many starts. These cases, the other adverse health airway events frequently patient’s airway can consequences, be completely result in including an increased daytime sleepiness or blocked for more than risk of death.8 fatigue, which a minute.4 may interfere with a patient’s ability of treatment Untreated and to function and reduces sleep apnea has been Numerous on the screening studies have demonstratthe patient’s diwhy all of articles that will focus rectly linked to hypertension, quality of life.7 Symptoms article will outline Thissleep-disordered ed that This is the first in a series strokes, may breathing disorders (SRBDs). breathing is heart attacks, Type 2 diabetes, legal implications. include snoring, pauses potential as patients with sleep-related well as cancer, in breathing their patients for SRBDs dementia, industrial dentists must screen and automobile

Screen for Why Every Dentist Must Disorders hing Sleep-Related Breat

PART 1 “Why Every Dentist Must Screen for Sleep-Related Breathing Disorders”

their patients for airway and sleepiness issues.2 Screening can be accomplished in various ways. The most effective technique may be to add a few questions to your health history.

4. Have you ever used ted -Relaa CPAP device? Sleep 5. Have you ever awakened gasping or Screening Patients for ders choking? Has anyone ever told Breathing Disor 6. stopped you that you breathing during sleep? 7. Do you doze easily or feel sleepy in quiet situations? by Ken Berley, DDS, J.D., DDS, FAGD 8. Do you take naps? and Jennifer Hathaway, chairside@glidewelldental.com 9. Do you feel rested after a night’s sleep? 10. Do you frequently have The first launched. series to get this up since at time night the to use dramatically in of initiathe world has changed the necessity covered the legal restroom? ® magazine Vol. 15, Issue 1) Now, as

treated for hypertension could be described as “Snore + Hypertension.” That patient would be referred for an evaluation by a sleep physician. Other examples include “Snore + Diabetes” and “Snore + Obesity. ” If a patient’s answers regarding airway health point to a possible airway or sleepiness risk, further screening and examination are indicated.3 Patients with a sleep disorder frequently present with a complex medical history. It is common for patients with uncontrolled obstructive sleep apnea to have previous diagnoses of certain health conditions and dental signs,3,4 such as those in the following lists.

COMMON PREVIOUS DIAGNOSES 1. Hypertension 2. Stroke 3. Heart disease 4. Type 2 diabetes 5. Obesity (body mass index > 30) 6. Depression 7. Gastroesophageal reflux disease (GERD) 8. Sexual dysfunction 9. Dementia/Alzheimer’s disease 10. Cancer 11. Atrial fibrillation

breathing disorders. article (Chairside all patients for sleep-related this is a particularly ing a program to screen COVID-19 shutdown, apnea (and our practices after the of dentistry and sleep we focus on rebuilding to study the intersection favorable time for clinicians other sleep disorders).

PART 2 “Screening Patients for SleepRelated Breathing Disorders”

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