How Airway Management’s
TAP
Sleep Care System
Continues to
Revolutionize
SDB
Which Class?
Choosing Education Wisely
by Barb Jacobucci, MEd
PLUS
FALL 2016
Knowledge
is Power
Hold on to those
Reimbursements
by Rose Nierman, RDH
5 Things Top
DSM Practices Do
Supporting Dentists Through PRACTICAL Sleep Apnea Education
by Autumn Bodily, RDA
The Industry’s Leading
Home Sleep Testing Provider
Serving Medical & Dental Communities
Customized prescription for your practice
Simplified apnea risk screening questionnaire
Enhanced prompt reports with multi-night comparisons
Board-certified sleep physicians in all 50 states
Advanced sleep products for trial & co-therapy, like
Apnea Guard Trial Appliance & Night Shift Sleep Positioner
Contact us at: 888-240-7735 or visit ezsleeptest.com
Night Shift & Apnea Guard, designed and manufactured by: Advanced Brain Monitoring, Inc. www.AdvancedBrainMonitoring.com U.S. and Intl Patents and Patents Pending
INTRODUCTION
Narrowing the Gap
D
entists have been told since the first day of graduate school that learning is life-long, that their dental degree is only the beginning, and
that keeping up with what is known is part of the professional’s commitment. Sleep medicine, which has come to be understood only within the
current generation of medical doctors, researchers, teachers, and dentists, is
especially challenging as the volume of ‘what is known’ is constantly, and
rapidly, expanding.
Pankey Institute training used to emphasize ‘Narrowing the Gap Between What is
Known and What is Practiced.’ I’ve always
liked this phrase because it illustrates nicely
the challenge we all willingly and, to varying
degrees, enthusiastically, embrace. Facing
our patients daily with the awesome responsibility of tailoring scientific knowledge to
their clinical presentation and finding solutions for critical medical, social, and behavioral needs demands that we keep up with
what is known and apply that to our work to
narrow the gap.
It’s not enough to just go to class, to only
read the journals, to confine yourself to increasing your treasure trove of details about
medical practice. Education requires implementation to have value.
Fortunately, as soon as you start identifying sleepy patients in your practice or
telling your colleagues that you’ve discovered an exciting new way to serve, you
will be presented opportunities to use this
knowledge. Your staff will look at you in the
team meeting, confident that their leader
will help them navigate new systems, new
conversations, new job skills. Your patients
will ask you about the importance of the
6 they just scored on the STOP-BANG or
the 14 on the Epworth your hygienist handed them in your fresh screening protocol.
They’ll bring in a sleep study to their next
visit and ask you what it means, now that
you’re a declared ‘expert’ – because they
trust you more than they do the sleep doc
they just met.
Ready for that? Some of you are gleefully embracing these opportunities, eagerly
seeking the rewards that accompany solv-
ing clinical riddles posed by our patients
and moving them along the path towards
better health and happier social life. Others
of you are stuck in the learning loop, overly
impressed by ‘how much there is to know’
before beginning to provide solutions to your
patients.
The gap is real. One side, what is known,
is moving all the time – very rapidly in sleep
medicine. Knowing more is not like piling
books on a chair so eventually the cookie
jar becomes within reach. The gap between
what you know and what you put into practice can only be narrowed by action.
Apply your knowledge. Put into play
something you learn from this issue of DSP,
as soon as you read it. Talk to a team member about an idea, solicit one from them,
and make something happen. After it’s
done, talk about it some more – think about
the process, the outcome, the reward, the
lesson learned. What you’ll do next time
the same opportunity comes your way.
Repeat the process for another idea, something you learned or a conversation with a
medical colleague. Involve your team and
watch how they blossom in this exciting
atmosphere of leadership, collaboration,
and reward.
You’ll create a culture of narrowing the
gap. Can you close it? No chance – that
bank of knowledge is growing faster than
you can keep up with and the individuality
of our patients means no one ever precisely matches the case example. Our medical
decision-making is the action that narrows
the gap – forming bridges to the other side.
Making a difference. That’s the life of a professional. And it is spectacular.
Steve Carstensen, DDS
Diplomate, American Board of
Dental Sleep Medicine
Thomas Meade, DDS
DSP is sad to hear
of the passing of
Dr. Thomas Meade,
one of oral appliance
therapy’s pioneers. It
was an honor to profile
Dr. Meade in the Winter
2015 edition. Our
deepest sympathies to
Dr. Meade’s family
and the many friends
he made over decades
in service to his
profession.
DentalSleepPractice.com
1
CONTENTS
8
Cover Story
How Airway Management’s
TAP Sleep Care System Continues
to Revolutionize SDB
by Keith Thornton, DDS
Address every clinical need with a
custom solution.
6
Education Format
Which Class?
Choosing Education Wisely
by Barb Jacobucci, MEd
Organize your thoughts to
maximize your benefits.
40
Nutrition
Helping Sleep Patients
Understand How
to Lose Weight
32
by Dr. Warren Schlott
Understanding nutrition and
metabolism can help you
counsel patients well.
Practice Management
Knowledge is Power
Hold on to those
Reimbursements
by Rose Nierman, RDH
Another case of doing it right
reaping rewards.
48
Practice
Management
5 Things Top
DSM Practices Do
by Autumn Bodily, RDA
Great material for your
next team meeting.
2 DSP | Fall 2016
63
LinkedIn
Verbal Skills that Help
Build a DSM Practice
by John Viviano, DDS, DABDSM
First part of a regular feature.
Introducing a new generation of oral appliance therapy.
2.5x
7 DAY
Faster
Treatment
Turnaround
Time
FASTER
3x faster than
leading competitors*
HEALTHIER
Unique metal free titration
with 3.6x less monomers*
EFFICIENT
Titration requires fewer
steps and appointments†
COMFORTABLE
30% less
overall volume*
MicrO2® Sleep and Snore Device by ProSomnus™ Sleep Technologies, a new
way to help OSA patients wake up refreshed and energized.
Join the growing number of dentists and patients who are benefiting from
MicrO2. Visit ProSomnus.com or call 844.537.5337 for a free starter kit.
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Micro2sleepdevice.com
*Data on File. †Based on a comparison of a meta-analysis, “Is Selecting the Appropriate Sleep Device for You and Your Patient Important?” by Dr. David Carlton III, and New Oral Appliance Titration Protocol using MicrO2 and Mandibular Positioning Home Sleep
Test. Presented at AADSM on June 10, 2016 by Dr. Remmers 1,2 and Dr. Vranjes3 during poster and oral presentations. 1University of Calgary in Alberta Canada, 2Zephyr Sleep Technologies, Calgary, Alberta, Canada, 3The Snore Center, Calgary, Alberta, Canada.
CONTENTS
13 Financial Focus
Is your retirement plan
strategy due for an annual
checkup?
by Tom Zgainer
Understand the benefits of reviewing
your 401(k) plan on a regular basis.
14
Physiology
Expanding Airway Education
by Jeffrey Hindin, DDS
Measuring more than airflow helps
patient assessment.
16
Clinician Spotlight
New Center for Pain and
Sleep Opens in Dallas
Advanced dental sleep education
finds another home.
22
Manufacturer’s Comments
More than Jaw Positioning
36
Team Focus
Patient Education! The
single most important topic.
by Glennine Varga, AAS, RDA, CTA
Your team knows, but the patient has
to learn, too.
38
Organization Spotlight
Learning Sleep from AADSM
An interview with Harold A. Smith,
DDS, president of the AADSM
An unbiased source is always good
to keep in mind.
45
Product Spotlight
eyeCAD-connect®, the
Heads-up Display for
digital dentistry
by Sven Holtorf, DDS
Here’s something you’ve probably
not thought of!
52
Your Sleep Ambassador is
the Difference
26
by Dr. Gy Yatros
The right person is key to a successful sleep practice.
Is your website really working?
by Ian McNickle, MBA
How to convert website visitors
into new patients.
28
Meaningful Conversation
54
Clinical Focus
Maxillofacial-Mandibular
Advancement and Oral
Appliance Therapy
Post Graduate Education
is the Key
by Clark O. Taylor, MD, DDS
The surgery option is best introduced
early.
by Mayoor Patel, DDS, MS
There are many choices. Find the right
one for your team.
56
34
by Ken Berley DDS, JD, DABDSM
Answers to common questions by
our legal expert.
Technology Update
Digitization of Dental
Sleep Medicine
by Tarun Agarwal, DDS, PA
Help your ROI with technology.
4 DSP | Fall 2016
Legal Ledger
Short Stuff
64
Publisher | Lisa Moler
[email protected]
Editor in Chief | Steve Carstensen, DDS
[email protected]
Managing Editor | Lou Shuman, DMD, CAGS
[email protected]
Editorial Advisors
Steve Bender, DDS Ken Berley, DDS, JD Ofer Jacobowitz, MD Christina LaJoie
Steve Lamberg, DDS, DABDSM
Dale Miles, DDS Amy Morgan John Remmers, MD Rob Rogers, DMD Sarah Shoaf, DDS, MSD
Bruce Templeton, DDS, MS Jason Tierney Glennine Varga, AAS, RDA, CTA
Practice Management
by Dr. Mark E. Abramson
Think beyond advancement.
Practice Development
Fall 2016
Sleep Deeply Wake Refreshed
DSP Crossword
General Manager
Alan Lobock | [email protected]
National Account Manager
Donna Aly | [email protected]
Manager – Client Services/Sales Support
Adrienne Good | [email protected]
Creative Director/Production Manager
Amanda Culver | [email protected]
Website Manager
Anne Watson-Barber | [email protected]
E-media Project Coordinator
Michelle Kang | [email protected]
Front Office Manager
Theresa Jones | [email protected]
MedMark, LLC
15720 N. Greenway-Hayden Loop #9
Scottsdale, AZ 85260
Tel: (480) 621-8955
Fax: (480) 629-4002
Toll-free: (866) 579-9496
www.DentalSleepPractice.com
Subscription Rates
1 year (4 issues) $99 | 3 years (12 issues) $219
©MedMark, LLC 2016. All rights reserved. The publisher’s written
consent must be obtained before any part of this publication may
be reproduced in any form whatsoever, including photocopies and
information retrieval systems. While every care has been taken
in the preparation of this magazine, the publisher cannot be held
responsible for the accuracy of the information printed herein, or in any
consequence arising from it. The views expressed herein are those of the
author(s) and not necessarily the opinion of either Dental Sleep Practice
magazine or the publisher.
EDUCATIONformat
Which Class?
Choosing
Education Wisely
by Barb Jacobucci, M.Ed
J
ohn has been your patient for five years. He has mentioned
his snoring problem to you on previous visits. “Doctor, my
snoring has gotten so bad lately and it is really disrupting a
peaceful night’s sleep in my house. My wife said that it is time to
do something about it. I’ve done some research and read about
an oral appliance. Can you help me?”
The next question is
potentially the most
important. It always
starts with “Why?”
This isn’t the first time a patient has wanted to have this conversation with you. You
have been hearing comments amongst your
colleagues, your staff is talking about it and
you are reading about it in trade publications. You have decided that now is the time
to educate yourself and provide a solution for
your patients.
Once you have made the decision to pursue a new educational experience, where
do you start? Who is the authority? Where
do you find a quality educational experience? Will the experience match your style
and meet your needs? The questions can be
overwhelming.
Growing your practice is top of mind for
you every day. Making the decision to add
new learning can be a challenge in time and
commitment. As you contemplate educational choices for this or any other need in
your practice, there are questions you can
ask to find the educational resource with the
solution that best fits into your practice.
1. Why?
The first question you should ask yourself is whether the professional and educational development that you are considering
aligns with your practice mission and goals,
6 DSP | Fall 2016
and does it improve your patient care. If the
answer is yes, the next question is potentially the most important. It always starts with
“Why?” If you want a treatment, product, or
service to succeed in your practice, it is important to start with asking “Why?” Why do
your patients want or need this treatment?
What is their emotional motivator? What is
their desired outcome? Your patients will take
action based more on their emotional needs
than on a detailed reasonable statement of
the treatment benefits. With a solid “Why”,
you are ready to proceed.
2. Educational Outcome
Now that you have clarified your why
and established the need, define the educational and learning outcome that you wish
to achieve. Is this your first step in educating
yourself on a topic? Perhaps you are ready
to complete a learning experience that prepares you to introduce a new method to your
team, immediately implementing it into your
practice.
3. Research and Reviews
You have many resources available to
you to support making your educational decisions. You are holding (or viewing online)
a powerful resource in Dental Sleep Practice
magazine. This magazine and other professional resources are treasure chests of valuable information. These resources provide
you with current information, keep you upto-date on the latest information, and expose
you to like-minded professionals and peers.
Reach out to your peers, staff, consultants, study groups, and online forums for
EDUCATIONformat
references and recommendations. Past experience with their chosen instructional methods can help you in making decisions based
on the elements that are important to you.
Review how they measured the results, the
quality of their educational experience and
their outcome.
Don’t forget to review your past educational experiences and resources. Do any of
these resources provide you with the additional education and information that you
are seeking?
Evaluate and review your resources. Do
you have the time and dollars to commit to
bringing the educational results to your practice? Does the cost associated seem reasonable given the benefit you will receive (remember your Why)?
4. Instructional Method
Evaluate your educational options, and
determine your most effective learning
environment and personal preference. Do
you excel in hands-on workshops with active involvement from the participants? Do
you prefer seminars or lectures? Consider
e-learning, webinars or distance learning options, if available. Also review the educational options available from your professional
associations and conferences.
Other considerations for choosing an instructional method are:
• Cost of the program and evaluating
what is included. It is important to
consider the amount of time away
from your practice, your study time,
travel time and if any members of your
staff will be attending.
• If there are multiple sessions, how often do they meet and what is the typical length of each?
• What is the format of the training? Is
it geared toward a small group, large
group or individual instruction?
• Does the training include demonstrations, theory, and practice? Will you
be conducting hands-on exercises to
enhance the learning experience? Are
new technologies applied that will assist in your learning experience?
• Is the training conducted on-site or
off-site?
• Are the learning outcomes clearly
stated? Do they indicate specifically
what you will be able to do as a result
of the program? This element will help
you determine if the educational offering is a broad overview course or an
in-depth program.
• Determine if the educational offering
meets the need as established in your
Educational Outcome review (Step 2).
5. Instructors Credentials
If you have chosen a structured class environment, review the instructor’s credentials. Instructors take an active part in your
learning experience so you are relying on
their skills as an expert and a professional.
Is the subject matter an area of expertise for
the instructor? Is the instructor a trusted resource and informed professional? Do their
qualifications indicate that a meaningful
program and instructional experience will
be delivered?
6. Follow-up, Implementation and
Instructor Support
Another important consideration is how
quickly you will be able to implement the
new skills into your practice. Will you be
provided with the materials, support and
guidance on how to effectively bring the
new skills back to your office? Will support
be available for implementation beyond the
initial training?
Determine what learning community
you will receive from the educational experience. From collective learning and community support, will you leave with a wider
personal learning network?
And finally, revert back to Step 1. Not only
does it start with why…it ends with why. As
you are participating in your educational experience, remember your Why and your patients Why. During John’s next visit, you will
be able to say “YES, John, I can help you!”
Follow these steps and you will walk
away from your educational experience saying “That was a great choice!”
Another important
consideration is how
quickly you will be
able to implement
the new skills into
your practice.
Barb Jacobucci, M.Ed, has spent her career in training, development and motivation. As an experienced entrepreneur and business leader, she understands the important connection between
marketing, training, sales and patient care. With a focus on the
patient experience, Barb provides insight and training on the
communication skills critical to reach practice goals and objectives. Barb can be reached at [email protected].
DentalSleepPractice.com
7
COVERstory
How Airway Management’s
TAP
Sleep Care System
Continues to
Revolutionize SDB
I
n 1992, an ENT surgeon referred a
patient diagnosed with Sleep Related Breathing Disordered (SRBD)
to me. This patient was non adherent
with CPAP at a pressure of 18. Her
sleep physician stated that since she
had “failed CPAP” and was not a surgical candidate, her only option was
to go to “this dentist who might have
a solution”. Within a week, she
received the only device available
at the time, a Tongue Retaining
Device (TRD). She died two weeks
later in her sleep of cardiac arrest.
8 DSP | Fall 2016
COVERstory
Several lessons were learned from this:
• CPAP failures were common, even
among the most severe patients treated by the most expert specialists.
• Dentists had the education and skills
to treat this problem but needed better
tools.
• The problem was a mechanical collapse of the pharynx which could be
treated by the same principals used
in cardiopulmonary resuscitation and
anesthesia by “airway management”.
This began my quest to develop devices
that would manage all levels of SRBD from
mild snoring to severe obstructive sleep apnea syndrome. Airway Management’s story
begins in 1994, when I built my first adjustable mandibular advancement device to treat
obstructive sleep apnea. I had been very successful in my own clinical trials and decided
to share the device with other dentists and
physicians that were looking for an effective
OSA treatment that patients would actually
use every night.
By 1996, I obtained the necessary patents and regulatory clearance to market
the device to professionals. The TAP 1 was
launched and quickly adopted by the pioneering dentists in the fledgling dental sleep
medicine market. It was the first adjustable
device that was easy to titrate, comfortable
and immediately effective for OSA patients.
The overwhelmingly positive response from
the DSM dentists made the TAP 1 a huge
success thus changing the course of my professional career. I was able to turn an interest in airway management into a mission to
improve the lives of patients with SRDB.
Over the next 20 years, I worked to constantly improve on the design of the appliance, and in May 2016, we introduced the 5th
generation custom appliance, the dreamTAP.
I opened both Airway Labs to fabricate
the appliances and act as my research
and development department; and Airway
Management to distribute to and support
other dental laboratories and professionals worldwide. My philosophy has been
to share the technology with those dental
laboratories who want to offer our products
which in turn has allowed us greater exposure and availability.
Today, Airway Management (AM) offers a
robust product line that includes immediate
delivery devices (myTAP), custom mandibu-
lar advancement devices (dreamTAP), CPAP
masks (myTAP PAP) and combination therapy (TAP PAP CS). From predictor appliance to
custom solutions, the TAP System has a range
of advanced devices covering the full spectrum of SRDB.
Design Principles
When I began to develop the TAP in 1994,
I established three core design principles for
the appliances that have guided all subsequent products; simple, durable, & patient
friendly. These concepts are the foundation
for every custom TAP appliance.
• Simple: Single point adjustment and
custom fit trays
• Durable: Metal injection molded
hardware with the finest dental alloys
and high strength dental grade plastic
trays.
• Patient Friendly: Easy to use and lowrisk advancement mechanism
Over the years, the TAP appliances have
been the subject of over 36 independent peer
reviewed studies, the most of any other appliance. The studies proved that the custom
TAP appliances consistently held up to CPAP
and surpassed other mandibular advancement devices. After twenty years of studies,
the conclusion is, it works.
AMI is very proud to
supply the TAP System
to every branch of the
US Armed Services
The academic studies are excellent
to prove the design principles but market
acceptance by large organizations are another indication of the value of the TAP design in treating OSA. Airway Management
is very proud to supply the TAP System to
every branch of the US Armed Services, including the Veterans Administration, to ensure our service men and women are getting the best treatment wherever they are in
the world. In addition, several of the most
successful dental laboratories, in the USA
and globally, manufacture TAP appliances
for their clinicians.
DentalSleepPractice.com
9
COVERstory
TAP Sleep Care System
myTAP
The TAP System begins with the myTAP
trial appliance (Figure 2). The myTAP allows
the prescriber to provide same day treatment
and immediate relief for their patients. The
myTAP boasts the same midline advancement technology as the proven custom TAPs
with an immense 21 mm range of advancement. This technology allows the prescriber
to truly test the patient’s outcomes, compliance and acceptance of an oral appliance
prior to prescribing a custom appliance.
TAP custom
The core product line in the TAP System
is the custom TAP appliances, beginning in
1994 with the TAP 1. Since then, custom TAP
has evolved into many versions for all types
of patients and levels of SRDB including the
TAP 3, TAP 3 Elite, and the most recent and
all new dreamTAP.
dreamTAP
dreamTAP (Figure 3) is the 5th generation
of the custom TAP appliance. After years of
R&D, the dreamTAP was released in May
2016. For the casual observer, it looks similar to the previous versions of the TAP, but
for the dentists treating OSA patients, it is a
significant improvement.
The core TAP design principles are clearly displayed in the dreamTAP including
the single point adjustment, ease of use for
patients and practitioners and the durable,
custom trays.
The most significant and obvious design
change is the placement of the hardware.
The hardware has been flipped placing the
advancement mechanism on the mandible
and the bars on the maxilla. All the hardware is facial to anterior teeth to maximize
tongue space.
The durability has increased with the
introduction of Chromium-Cobalt (Cr-Co)
hardware. The advancement mechanism
and hooks were redesigned before being
tested for strength and tolerances as the design was fine tuned.
The dreamTAP is a very flexible treatment
tool. Dimensionally, the lateral excursion in
the anterior can be fabricated from about
4mm to 15mm. Airway Labs standard lateral
excursion is approximately 15mm. The vertical height between the trays has been reduced
10 DSP | Fall 2016
myTAPTM
TAP CUSTOM
myTAP PAP
TAP PAP™ CS
Figure 1: TAP system
Figure 2: myTAP
Figure 4: Close up of hook
Figure 5: Long/medium/short hook
Figure 3: dreamTAP
to about 5mm. The clinician can prescribe the
appliance with up to 15mm of vertical opening as determined by his/her preference.
One of the biggest advantages of the
dreamTAP is the vast 15mm of horizontal
protrusive range. The screw mechanism has
a range of 5mm (Figure 4). You can extend
this range with three hooks included with
every appliance (Figures 5-6).
The bottom line is that the dreamTAP has
the largest range of any oral appliance to
treat OSA and SRDB. The dreamTAP is NOT
technique sensitive. It is very flexible to ensure that wherever your starting position is,
the dreamTAP can be adjusted in the practice to fit the patient’s needs.
Medicare vs Quick Release
Figure 6: Protrusion Range
Figure 7: Medicare Release point
Like all the of the custom TAP appliances,
dreamTAP has received approval by PDAC
(Pricing, Data, Analysis and Coding) and is
accepted for reimbursement by Medicare.
The dreamTAP meets the requirements
of PDAC by creating a hook design that is
hinged and cannot be easily unhinged by
the user. We use a 1.3mm bar to create the
hinge with the hook. You must engage the
hook on the side of the bar, where the diameter is reduced to accept the 1mm opening
in the hook (Figure 7).
During R&D and patient testing, it became apparent there was a need to create an
optional version that allowed the patients to
quickly unhook while wearing the appliance.
The “Quick Release” optional bar design was
created to allow for this. The Quick Release
version can be used with any insurance carrier not requiring PDAC listing for coverage.
Quick Release dreamTAP uses a 0.8mm
Cr-Co bar to engage the hook. The patient
simply advances the mandible about 1.5mm
MORE COMFORT.
MORE INNOVATION.
MORE TONGUE SPACE.
dreamTAP FROM TAP SLEEP CARE
To learn more about dreamTAP and the TAP System, register for our FREE
Webinar at bit.ly/TAPwebinar or email [email protected] for more
information.
myTAPTM
TAP CUSTOM
myTAP PAP
TAP PAP™ CS
COVERstory
to release the hook, while wearing the appliance. This eliminates any concerns about being “locked” in and makes it easier to insert
and remove.
Options
Figure 8: TAP PAP CS
Compliance tracking on custom TAP appliances is now available. We have partnered
with Braebon to add the Dentitrac compliance device to our custom appliances. As insurers and government regulators attempt to
increase compliance for OSA, this recording
device will be extremely useful and possibly
required in the future.
We will introduce a mouth shield to encourage nasal breathing, which can be added to the dreamTAP and is now available for
the myTAP.
Blue colored trays will be an option in
the 4th quarter of 2016 as supply becomes
available.
Combination Treatment
Figure 9: Demo box
Most studies have shown the TAP appliances to be very effective on their own, from
simple snoring to moderate obstructive sleep
apnea. To treat severe OSA, the clinician can
use the TAP PAP CS, an add-on product to
connect a dreamTAP (TAP 3 / TAP 3 Elite) to
a nasal pillow CPAP mask (Figure 8).
This allows the professional to combine
oral appliance therapy with CPAP, enabling
most patients to reduce their CPAP pressures.
Many DSM dentists use the TAP PAP CS
to help bridge the gap between the MD and
DDS/DMD. It allows the dentist to discuss
oral appliance therapy with the MD with
a collaborative tangible device. Helping to
create a positive working relationship be-
Many DSM dentists use
the TAP PAP CS to help
bridge the gap between
the MD and DDS/DMD.
12 DSP | Fall 2016
tween the branches of medicine needed to
treat OSA.
Grow your DSM practice
Airway Management is committed to supporting our laboratory and dental customers.
Our goal is education – the more information
we can put in the hands of our customers to
educate the patient, the more the patient will
be fully informed about oral appliance therapy. AM offers two demonstration kits to help
with just that – the dreamTAP Demo Kit and
the TAP PAP CS Demo Kit. They contain both
tangible demonstration models and informational brochures.
Because the majority of adults in the
United States are either afflicted by or know
someone afflicted by sleep disordered
breathing, the normal dental practice has
a large percentage of patients that need
treatment. The simplest method to reach
these patients is with the dreamTAP Demo
Kit (Figure 9) in the waiting room. Also, a
simple screening questionnaire such as the
Epworth Sleepiness Scale can be given to
each patient as part of their semi-annual
dental visit, which can also spark conversation about TAP treatment solutions.
The TAP PAP CS Demo Kit is very effective in informing sleep physicians and medical professionals about the TAP appliance
and combination therapy. Instead of simply
pitting the oral appliance against the CPAP,
the TAP PAP CS allows the best of both treatments, especially in a case where a patient
is a CPAP intolerant or needs more therapy
than CPAP alone.
Summary
Overall, TAP Sleep Care is a systematic, comprehensive approach for managing
Sleep Related Breathing Disorders (SRDB).
Airway Management is extremely proud to
be part of the solution; producing innovative
oral appliances and other sleep therapies.
We have made tremendous inroads in the
dental sleep medicine market and strive to
make oral appliance therapy more readily
available in collaboration with our dental,
medical and laboratory customers.
If you want to learn more about the TAP
system (how to order, additional options,
growing your DSM practice, and more),
please register for our free 1 hour webinar by
going to bit.ly/TAPwebinar.
FINANCIALfocus
Is your
retirement plan
strategy due for an
annual checkup?
R
egular maintenance regarding our health, be it a twice a year teeth
cleaning or an annual physical, allows the experts to determine if we
are as fit as we think we are, or see if there might be some issues under the hood that need attention. Likewise, each April, we are reminded of
whether our tax planning is sufficient or perhaps needs a tuneup. Similarly,
your retirement plan strategy is worth reviewing with a pension plan expert
as well.
Often the original plan and strategy you implemented get away from your
intended individual and corporate goals. Your employee populace may experience turnover, the actual age demographics of your staff may take on a
different makeup, and by the way, you are now a year closer to retirement.
You can find these changes limit your personal contributions due to required
employer contributions or, more positively, open up new opportunities to
design a plan that accelerates your personal contributions.
Retirement plans — whether a 401(k), profit-sharing plan, a defined benefit, or a cash balance plan — all require some give-and-take. For owners,
principals, key associates, or partners to take advantage of the opportunity to
maximize annual contributions, you’ll need to give a proportional amount
that passes all the required compliance tests to eligible employees.
These employer contributions at first might not be palatable to you and
your bottom line. However, utilizing a long vesting schedule — for example
up to 6 years — can help ensure an employee needs to stay and contribute
to your practice that long to earn any 1 year’s contribution. Plus, you receive
the tax deduction benefit of the full amount of employer contributions in the
tax year of the contribution, up to 25% of gross payroll.
A great reason to go through an annual plan design checkup is to see if
there is a better plan type option for you. As you get closer to retirement,
generally over age 45, plan types, such as a new comparability profit-sharing
plan, a cash balance or defined benefit plan, can be paired with a 401(k) to
rapidly accelerate your personal contribution objectives.
For 2016, you can defer $18,000 into a 401(k) plan, with a $6,000
catch-up provision if over age 50. That’s generally the best first thing to try
and accomplish. If your plan demographics are suitable, meaning staff is
younger than the owners, principals, or partners (HCEs), and you are over
age 45, a new comparability profit-sharing plan can provide a maximum
benefit for a select employee group, while providing the lowest possiReceive your retirement plan checkup here: americasbest401k.com/fee-checker-medmark
ble contribution to non-key groups allowed by law. This plan design can help
you add to your deferrals and get up to the
$53,000/$59,000 maximum annual limits
from combined employee and employer
contributions.
To really accelerate your contributions,
consider looking into adding a cash balance
or defined benefit plan to the 401(k). Maximum contributions for these plans range
from $102,000 at age 45 to $237,000 at age
62. When added to the 401(k)/profit-sharing
contributions, it’s like squeezing 20 years of
retirement saving into 10, not to mention the
significant reduction to your tax liability that
you will enjoy.
Just as you might make an appointment
with your physician or CPA, this is a great
time of year to get a retirement plan checkup
as well. It’s easy and painless, as a census
with your current firm demographics will
enable a experienced pension specialist or
actuary help determine if there is a better
way to proceed into the years ahead for your
retirement planning.
Tom Zgainer is CEO of
America’s Best 401(k).
He has helped over 2,800
businesses obtain a new
or improved retirement
plan over the past 13 years
with a focus on strategic plan design to
help achieve individual and corporate objectives. You can learn more at americas
best401k.com/fee-checker-medmark.
DentalSleepPractice.com
13
PHYSIOLOGY
Expanding Airway Education:
Heart Rate Variability and the Autonomic Nervous System
by Jeffrey Hindin, DDS
T
he future of dentistry lies in recognizing the dentist’s role in
understanding and improving patient physiology. Monitoring and assessment of heart rate variability (HRV) and the
autonomic nervous system (ANS) will be key tools to understanding the physiological basis for the inextricable relationship among
dentistry, medicine and other health care practices. “HRV is a useful method to assess cardiac autonomic modulation in patients undergoing dental procedures, because knowledge of physiological
conditions provides greater security to the professional as well as
the possibility of a better plan treatment to patient benefit.” (M.
Santana, et. al. 2013)
The autonomic nervous system (ANS),
composed of the sympathetic nervous and
parasympathetic nervous systems, controls
the cardiovascular system, in part, by releasing neurotransmitters that increase or
decrease heart rate (HR), respectively. The
periodic oscillations in HR and RR intervals of consecutive heartbeats, modulated
by the activity of ANS on the heart is known
as heart rate variability.1-5 The SNS increases
heart rate and respiration rate. Increases in
sympathetic outflow decrease HRV.
A high HRV is a sign of health, depicting the body’s balance and shifting between
sympathetic and parasympathetic pathways.
Lowered HRV is associated with disease
states and poor adaptation to stress, and
physiologic dysfunction.4
In dentistry, malocclusion, TMD, and surgical dental procedures have shown to lower
HRV.6 Maixner et al. (2011) investigated the
association between autonomic variables
and temporomandibular disorder (TMD),
testing the hypothesis that dysregulation
In the near future, of the autonomic nervous system contribdentists will monitor utes to the onset and persistence of TMD.
The authors found that patients with TMD
several physiological at rest showed reduced HRV compared
markers to assess the with the control group. Several articles
have shown that HRV changes with jaw
risks and benefits of position. Relating to sleep, patients with
their treatment. OSA have lowered daytime HRV, even in
the absence of hypertension, heart failure, or other disease states.7
14 DSP | Fall 2016
HindexRV® is FDA approved instrumentation to monitor HRV and the ANS and
add a new level of understanding and care
for patients with airway/sleep disorders. The
HindexRV® system produces objective data
on the physiological effects of jaw position,
tooth positioning, appliance and treatment
efficacy and other dental procedures.
Everything dentists do in their daily practice can influence the airway and physiology of the patient, whether the practitioner
knows it or not. With HindexRV® monitoring, the clinician can objectively view patient physiology, in real time, to evaluate
the efficacy of treatment modalities, e.g.
appliance position, and obtain the “physiological bite”.
It is accepted that HRV is an early warning system that can provide valuable information for more optimal diagnosis and
treatment. In the near future, dentists will
routinely monitor their patient’s physiological functions and assess the risks and benefits of their treatment. In addition, treatment
specifically aimed to promote and enhance
physiological function where appropriate
will be provided.
For information on HindexRV® and Physiology/HRV courses, email info@physiological
dentistry.com.
1.
2.
3.
4.
5.
6.
7.
Task Force of the European Society of Cardiology and the North
American Society of Pacing and Electrophysiology: Heart rate
variability: standards of measurement, physiological interpretation and clinical use. Circulation 1996, 93:1043–1065.
Valenti VE, Guida HL, Vanderlei LC, Roque AL, Ferreira LL, Ferreira C, Silva TD, Manhabusque KV, Fujimori M, Abreu LC: Relationship between cardiac autonomic regulation and auditory
mechanisms: importance for growth and development. J Hum
Growth Dev 2013, 2013:23.
Vanderlei FC, Rossi RC, de Souza NM, de Sá DA, Gonçalves
TM, Pastre CM, Abreu LC, Valenti VE, Vanderlei LCM: Heart rate
variability in healthy adolescents at rest. J Hum Growth Dev
2012, 2012(22):173–178.
Abreu LC: Heart rate variability as a functional marker of development. J Hum Growth Dev 2012, 22:279–281.
Vitor ALR, Souza NM, Lorenconi RMR, Pastre CM, Abreu LC,
Valenti VE, et al: Nonlinear methods of heart rate variability
analysis in diabetes. Health Med 2012, 6:2647–2653.
Ekuni D, Takeuchi N, Furuta M, Tomofuji T, Morita M: Relationship between malocclusion and heart rate variability indices in
young adults: a pilot study. Methods Inf Med 2011, 50:358-363.
Narkiewicz, K. et al. Altered cardiovascular variability in obstructive sleep apnea. Circulation. 1998 Sep 15;98(11):1071-7
September 15, 2016
Airway Summit
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CLINICIANspotlight
New Center for Pain and Sleep
Opens in Dallas
16 DSP | Fall 2016
T
exas A&M University College of Dentistry has
opened a new Facial Pain and Sleep Medicine
center headed by Steven Bender, DDS. One of the
first such centers in a dental school in the country, Dr.
Bender has big ideas for how to change dentistry’s impact
on whole person health. DSP recently sat down with Dr.
Bender to learn more.
CLINICIANspotlight
DSP: Tell me how this all got started,
Steve – this is a big project.
Steven Bender, DDS: After I graduated
from here in 1986, back when it was Baylor
College of Dentistry, I started a general dentistry practice and stayed with it for about 13
years. One of my mentors, Dr. Henry Gremillion, then the director of the University of
Florida’s Parker Mahan Center, allowed me
to sort of intern with him for about two years.
I would travel regularly to Gainesville to see
patients in the clinic and learn from some of
the best minds in pain therapy and research.
Henry eventually told me I should ‘Pick one
thing – Restorative or Pain, but knowing me
the way that he did, he felt that it was best
if I didn’t try to do both.’ So I sold the restorative portion of my practice and started
treating only pain patients here in the Dallas
area where I grew up.
For most of the 16 years since then, I was
focused only on facial pain – I was aware of
sleep problems, often treating insomnia and
movement disorders with medications, but if
there was an airway problem, I didn’t make
the connection to my diagnosis and would
send the airway issues to a colleague, Dr.
Keith Thornton. Anyone who knows Keith
also knows that he doesn’t leave you alone
if he sees promise in creating another ‘sleep
dentist’ so he made it clear that I needed to
add treating the airway myself to my practice.
As many who read DSP magazine would
guess, I started seeing much better results in
my pain patients who had their airway issues
treated, so that became a routine part of my
therapy. What is important to know is that I
think my pendulum swung a bit too far and
I started seeing everyone with pain as an airway problem. Thankfully, my training from
Dr. Steven D. Bender earned his Doctorate of Dental Surgery degree from Baylor College of Dentistry in 1986
and practiced general restorative dentistry for 14 years. He then studied orofacial pain and temporomandibular disorders at the Parker E. Mahan Facial Pain Center at the University of Florida College Of Dentistry under
the mentorship of Doctors Henry Gremillion and Parker Mahan. From 2000-2015, Dr. Bender maintained a
private practice devoted to pain management of the head and face, as well as sleep medicine. Beginning in
2016, he transitioned to a full time faculty member of Texas A&M University College of Dentistry and assumed
the role of director of facial pain and sleep medicine. He has earned Fellowship in the American Academy
of Orofacial Pain, the American Headache Society, the International Academy of Oral Oncology and the
American College of Dentists. He holds the office of immediate past president and current council chair of
the American Academy of Orofacial Pain and is a past president of the Fourth District Dental Society of Texas
and the Dallas Academy of General Dentistry. In addition, he has served as a consultant for the United States Army.
DentalSleepPractice.com
17
CLINICIANspotlight
Dr. Gremillion stayed with me and I was able
to improve my diagnosis so I could treat everyone appropriately.
As a teacher in this field, I get questions
that make me feel that dentists aren’t always
adequately trained in history-taking and can
fall into the trap of seeing only airway issues
(or, in the worst cases, only financial opportunities!) and not recognize other signs and
symptoms as separate. All my teaching included a strong emphasis on diagnostic skills and
hearing the patient’s story. I remember from
years at Pankey and the Mahan Center that
‘knowing your patient’ includes much more
than just the clinical signs and symptoms.
Over the course of a few years, the concept of creating a Center at Baylor began to
take shape. Our Chair of Oral Surgery, Dr.
David Grogan, has long been lobbying for a
pain curriculum and we started talking, and
Keith Thornton has been a big supporter as
well. Along with the strong support of our
Dean, Dr. Lawrence Wolinsky, we set up this
new Center as a multi-disciplinary clinic. It
opened in January this year – so far, we have
limited space but hope to be able to expand
soon. I was able to bring my assistant of 10
years with me, which was a huge blessing!
DSP: Please say more about what
you want to do there. More than
just moving your practice to another
space, right?
SB: Dentists from all over will be able to
come to our Center and see how we work up
a patient history, make a treatment plan, and
follow-through. I hope to replicate what Dr.
18 DSP | Fall 2016
Think
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CLINICIANspotlight
Our goal is for every graduate from our institution
to have at the least a basic understanding of sleep
and pain issues.
Gremillion did for me and offer a preceptorship for committed dentists to gain in-depth
understanding of how facial pain and sleep
problems intertwine and are treated. We also
plan to develop mini-residency type programs in pain and sleep to give the clinician
in practice an educational opportunity beyond the normal weekend type venues. Also
going forward, we plan to develop a CODA
approved facial pain/sleep medicine residency program, which will offer certification as
well as advanced degrees.
It is exciting to be able to offer dentists
who want to put all the resources into a focused practice various educational avenues
to fit their needs. What I’m very excited about
that might have even more impact is that I
get a chance to teach undergraduate dental
students about pain and sleep in their third
year. Also, we hope to be able to provide a
hands on experience for the students in the
diagnostic and treatment planning process
for their pain and sleep disorder patients. I’ll
certainly be looking for the special undergraduate student or two that shows interest
and aptitude to mentor like others mentored
me. Our goal is for every graduate from our
institution to have at the least a basic understanding of sleep and pain issues. I think that
is, at best, rare in most dental school graduates today. I’ve checked with some of the
leaders of other programs around the country
and we are all struggling to get time in the
undergraduate student curriculum. Working
with the grad students is a little easier, but
still a challenge.
DSP: Lucky for the Dallas community.
What else will the Center do?
SB: As someone long-committed to keeping up with the latest research and publications, I hope to be able to participate in projects here at the school that will add to the
body of research involved in treating sleep
and pain disorders, specifically with mandibular advancement devices, but also medically. With the resources of Texas A&M, we will
20 DSP | Fall 2016
be able to bring in our medical colleagues
and create research projects that will help every clinician manage patients better. I’ve had
some very exciting conversations with members of our clinical faculty, our basic scientists, faculty members of the medical school
and some private practice sleep docs who all
want to help create better-trained dentists.
We hope to produce a body of strong research to help the clinician in practice make
the best choices for treating their pain and
sleep patients. I believe that is where our
center will make its mark. Keith and others
here at the school have been instrumental in
gaining support from independent foundations that will help us to begin the process of
developing worthwhile projects. Obtaining
research grants can be a difficult process and
the National Institute of Dental and Craniofacial Research (NIDCR) likes to see some type
of track record before allocating funds.
Its well-known that most patients seek
care in a medical or dental setting due to
pain. One thing I want to emphasize to our
students is that connecting with patients is
very different in a pain/sleep clinic than in
a typical dental office. I spend a lot of time
getting the patient’s story, history, and making
sure they felt cared-for. This came from my
training with Dr. Gremillion – in many situations, I still find myself thinking “What would
Henry do?” This is missing from most dental
training these days. As dentists we are mostly
taught to be therapists as opposed to good
diagnosticians. We often get frustrated if we
cannot “see” a problem to fix. Learning to
connect with our patients is a powerful way
to improve encounters between medical professionals and the people they serve. The better we can do with this, the happier patients
we have. I think dentists trying to become
well-regarded by the medical doctors in their
communities should emphasize this in their
practices. Focus on your patient’s story, create an exceptional experience for them, and
they will tell the sleep docs about you. Here
at the Center, we will always emphasize the
person attached to these often-complicated
pain and sleep problems.
DSP: I would think at a major institution that you also have access to the
latest equipment, too.
SB: Sure, it’s nice to have a radiology department right across the hall, but dentists
CLINICIANspotlight
don’t need a lot of fancy equipment to treat
pain and sleep patients well. As the new guy,
I’m not asking for much yet, but I really don’t
think that it’s about the gadget – it’s about
what you know, what you can learn from the
patient, and how you put those together to
create the right treatment plan.
DSP: What else would you like the
readers to know about your Center
or treating patients in general? Do
all dentists treating sleep need to
study at a place like yours?
SB: Well, like I said, being successful at
helping patients in pain or with sleep problems, or both, requires a thorough diagnosis.
Involving the patient’s medical doctor is a
must. We should also develop working relationships with other physicians and allied
health care providers to ensure the best care
for our patients. Currently, physicians are
better trained in taking a proper history and
performing a physical examination. We need
to work with them to ensure that the patient
is properly diagnosed and receives the most
appropriate care.
Do dentists need to come to the Texas
A&M Center for Facial Pain and Sleep Medicine? Well, certainly I hope that what we
will offer will be a great place to learn. There
are other programs of excellence around the
country, but we do hope to add something
unique. What dentists need to do above all
is to see treating sleep disorders is not just
about making an appliance and getting paid
for it. It’s about creating a patient-doctor partnership. I’ve found that once the patient embraces this partnership, they can gain control
of their conditions and that speeds the healing process. We need to develop a team approach to ensure our patients are well cared
for for their lifetime.
Photos courtesy of Steven Doll, Texas
A&M University College of Dentistry
Physiological Monitoring for Dentistry and Medicine
The future of dentistry lies in recognizing the dentist’s role
in understanding and improving patient physiology.
Visit us and find out more at the AAPMD Airway Summit
“Building A Collaborative Community for Optimal Health”
September 15-17, 2016 at the Hilton El Conquistador Resort
in Tucson, Arizona.
physiologicaldentistry.com
DentalSleepPractice.com
21
MANUFACTURER’Scomments
Jaw Positioning
More than
by Dr. Mark E. Abramson
I
n the recent review of oral appliances in Dental Sleep
Practice I was very happy to see such a positive review
of the unique features in the OASYS Oral/Nasal Airway
System. It remains the only appliance that treats the entire
upper airway and is FDA cleared to function both as a mandibular
repositioner and a nasal dilator. Its ease in using with patients with
upper dentures makes it easy to categorize as a specialty appliance.
Every new patient should be tested for
nasal resistance with the Cottle Maneuver
The greatest body for swimming and a
perfect example of using the mentalis to
close the lips together.
22 DSP | Fall 2016
Nasal resistance is second only to obesity as a cause of OA treatment failure.1 The
top doctors who use the OASYS use the
additional features of the device for more
clinical effect. Pads that dilate the external nasal valve and positioning pads that
lift the back of the tongue and improve the
swallow pattern are value-added features
that improve their treatment outcomes.
OASYS features a movable shield that
extends from the mandibular base under
the upper lip. The shield rests against the
maxilla and is used to reposition the mandible. One of the comments in the review
was that it might be too thick and make
it difficult for the upper lip to seal against
the lower lip, achieve lip competency and
guard against mouthbreathing.
As I was looking at the positives and
negatives of my appliance compared to others, I looked closely at this detail with my
patients and got feedback from other doctors who routinely use the OASYS for their
patients. I began to see the upper shield as
having a great advantages and so I’d like to
take this opportunity to talk about it.
Let’s start off looking at cases with nasal
resistance. John Remmers, M.D. states that
30% of your patients will need treatment
of the nose, 80% would benefit from it and
20% doesn’t really matter that much. So
you can see that the majority of your pa-
tients will receive benefit from having their
nasal obstruction or resistance addressed.
If we look at patients with nasal issues
we see that we might have on one end of
the spectrum a patient who’s facial development looks relatively normal but they have
nasal resistance. They have lip seal during
the day but find the easy path for breathing
during sleep and start to breathe through
their mouth. At the other end of the spectrum are the true mouth breathers who
are going to present with a short upper lip
and a dry, enlarged lower lip. They likely have a narrow high arched palate. The
dry enlarged lower lip comes from air flow
through the mouth. In order to close their
lips they have to use the mentalis muscle
to push the lower lip up to meet the shorter
upper lip.
For anyone on the nasal-resistance
spectrum, when they go into REM sleep
the lining of nasal passage swells up to
increase flow resistance. They are going
to find the easiest route to breathe, which
would be through their mouth. If you
make them a general mandibular repositioner such as a dorsal fin, Herbst, or any
other unattached appliance, as soon as
the mouth is opens and mouth breathing
begins, the tongue has to drop down to
the floor of the mouth. As the mandible
is swung open in a hinge-like movement,
MANUFACTURER’Scomments
Even with lips parting the anterior oral seal
is maintained
O2 OASYS
the tongue and other soft tissues can move
toward the back of throat and all stable
support of the airway is lost.
The OASYS shield allows the lips to
part without losing airway seal. The nasal dilators provide the patient the ability
to continue to breathe through their nose
and support nasal breathing throughout
the night. With nasal breathing the tongue
can go into its proper position in the palate
and complete the oral seal by allowing the
soft palate to seal behind the tongue at the
posterior of the oral cavity. This important
tongue function is like the third leg of a
stool, giving the mandible stability as well
as stabilizing the structure of the throat
and airway.
For patients that we cannot convert to
nasal breathing, the OASYS can be made
with a space to allow mouth breathing but I
prefer to have it made with minimum space
between the stable lower base and the movable shield. This space can be sealed with
orthodontic wax for people who complain
that their mouth is dry, indicating ongoing
mouthbreathing. I also make sure the nasal
dilators are properly adjusted.
Even with patients who have been
chronic mouth breathers and have a short
upper lip, we can use the OASYS as a therapeutic appliance for them with two goals:
converting them to nasal breathers while
maintaining an open airway. Over time,
the shield will actually help them to stretch
out their upper lip so that they don’t have to
use the mentalis muscle to push their lower
up to the short upper lip in order to close
lips together. Initially I might have patients
use some very light paper tape to tape their
lips closed. I do not meet with much resistance, especially after I explain to them the
benefit and give them assurances that most
patients do not find it a problem.
The original idea for making an appliance with the repositioning element in front
of the upper arch was to maximize tongue
space so that the only material on the lingual of the anterior teeth is the thin upper
cushion. The tongue has the soft comfortable feel of the natural dental surface. For
maximum comfort, the shield also acts like
a slip joint allowing mandibular movement
in all directions without binding and translating forces onto the dental arch.
I hope this helps the reader understand
why I designed the OASYS with its unique
features.
1.
Zeng B; Ng AT; Qian J; Petocz P; Darendeliler MA; Cistulli
PA. Influence of nasal resistance on oral appliance treatment
outcome in obstructive sleep apnea. SLEEP 2008;31(4):543547.
Dr. Mark Abramson is a TMJ and Sleep Apnea dentist, serving patients in Redwood City, in the San Francisco Bay
Area. He attended the University of Maryland School of Dentistry where he graduated in 1975. Upon graduation
he came to California to do a general practice residence at the Palo Alto Veterans Hospital. After his residency, he
limited his dental practice to treating the special needs of those suffering with TMJ and headache and facial pain.
Dr. Abramson is a Diplomat, American Academy of Orofacial Pain; Diplomat, Academy of Pain Management;
Diplomat, American Academy of Dental Sleep Medicine; and a Fellow, American Academy of Craniofacial Pain
Management. He is a member of the American Dental Association, California Dental Association, American Academy of Dental Sleep Medicine where he is on the program committee, American Academy of Craiofacial Pain Management, Cranial
Academy and his dental license is extended to include acupuncture treatment.
Dr. Abramson developed the O2 OASYS Oral/Nasal Airway System™ and in 2004 received FDA approval for this device.
Dr. Abramson directs Stanford University’s Mindfulness Based Stress Reduction Clinic and teaches ongoing classes on this program
through Stanford University School of Medicine. Dr. Abramson is a staff physician at Stanford University Hospital.
24 DSP | Fall 2016
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PRACTICEdevelopment
Is your website
really working?
Ian McNickle, MBA,
discusses how to
convert website visitors
into new patients
T
he world of websites and online marketing can be confusing. Dentists and their staff often feel as though their
website could be doing more for them, but aren’t quite
sure how to determine this or what to do about it. The goal of
this article is to help you understand how to get more value and
new patients from your website.
The goal of online marketing
Online marketing is primarily concerned
with the following two objectives:
1. Driving traffic to the website
2. Converting that traffic to take the
actions you want them to take
Driving traffic to your website is achieved
by the use of search engine optimization
(SEO), pay-per-click (PPC) paid ads, social
media, review sites (Google+, Yelp, Facebook, Healthgrades®, etc.), and other methods. Once people arrive at your website,
you’ll want them to take action to contact
your office via phone call, email, or filling
out an appointment request form. These actions are called “website conversion.”
The ultimate marketing goal of the website is to drive new patients to the practice.
This is achieved by maximizing both traffic
and website conversion.
The focus of this article will be on website
conversion, and our next article will focus on
driving traffic.
Improve your website conversion rate
Far too many dental practices use common, templated websites with stock photos
and stock content. This does not differentiate
you from other practices and does not reflect
the unique personality of your practice. In
addition, the calls to action are often poorly
implemented.
Instead, consider implementing the
following items to improve your website
conversion:
• A custom website design should properly reflect your practice.
• Phone number should be easy to find
at the top of every page in large font.
• Appointment request button (or form)
should be easy to find on every page
and be located further up the page
(not at the bottom).
• Use actual photos of the practice,
staff, and equipment with minimal use
of stock photos.
Receive your free marketing consultation today: 888-246-6906 or [email protected]
26 DSP | Fall 2016
PRACTICEdevelopment
• Write unique content that is specific to your treatment philosophy and
approach.
• Embed an overview video of the practice on the home page to help communicate who you are/your personality, what is unique about your practice,
highlight technology and training, etc.
Track and optimize results over time
In order to properly track conversion, we
always recommend using a phone call tracking number that routes to your actual office
phone. Using a tracking number will allow
you to more accurately understand how
many calls are coming from your website.
We also recommend recording the phone
calls for training purposes.
Dental practices that want to get the most
from their online marketing efforts should
make it a regular monthly activity to review
website traffic and conversion. Plotting these
trends over time will allow practices to understand if their activities to increase traffic
are working, if their conversion rate is getting
better, and to determine the return on investment (ROI) for this portion of their marketing.
Marketing consultation
If you have questions about your website, social media, or online marketing, you
may contact WEO Media for a consultation to learn more about the latest industry
trends and strategies. The consultation is
FREE if you identify yourself as a reader of
this publication.
Ian McNickle, MBA, is a national speaker, writer, and
marketer. He is a co-founder and partner at WEO
Media, winner of the 2016 Cellerant Best of Class Award
for Dental Marketing and Dental Websites. If you have
questions about any marketing-related topic, please contact Ian McNickle directly at [email protected], or by
calling 888-246-6906. For more information, you can
visit www.weodental.com.
DentalSleepPractice.com
27
MEANINGFULconversations
Post Graduate Education is the Key
to Sleep Apnea and Craniofacial Pain Treatment Success
by Mayoor Patel, DDS, MS
D
ental Students typically spend eight years total in college
preparing for clinical practice. It’s in the last years where
they learn about sleep apnea and craniofacial pain
treatment. Or do they? With few to no hours dedicated to these
services, postgraduate education remains vital in procuring a
successful sleep apnea and craniofacial pain practice.
Inadequate Education
Students are missing out on the education necessary for advanced services
in sleep apnea and craniofacial pain. A
national survey conducted by Rutgers medical schools, indicated on average, less
than two hours of total teaching time is allocated to sleep and sleep disorders while
37 schools reported no structured teaching
time in this area. In fact, only 8% of medical students trained in the use of sleep
laboratory procedures and 11% have participated in the clinical evaluation of sleepdisordered patients.1
28 DSP | Fall 2016
Dentists are receiving even less education
in school in these areas. Dental students, on
average, are only spending 2.65 hours on
sleep apnea. In fact, a survey sent to general dentists reported 58% could not identify
common signs and symptoms of obstructive
sleep apnea while 55% did not know the
mechanism for mandibular advance devices.
Additionally, only 16% said they were
taught about this issue in dental school and
40% knew little or nothing about sleep apnea treatment for patients. However, 30%
did indicate they learned from postgraduate
training.2 This data shows schools are missing the necessary resources to support sleep
apnea and craniofacial pain courses, but the
availability of postgraduate education can
solve the lack of information for providing
proper treatment.
Postgraduate Education
Unqualified faculty, a lack of curriculum and the need for additional clinical
MEANINGFULconversations
educational resources creates a need for
postgraduate education for dentists. In a position paper published in SLEEP it is mentioned that oral appliances should be fitted by qualified dental personnel who are
trained and experienced in the overall care
of oral health, the temporomandibular joint,
dental occlusion and associated oral structures.3 Meaning, postgraduate education is
key for treatment success.
From introduction courses in the field of
dental sleep medicine and craniofacial pain
to advanced courses and mini-residencies for
those who have completed several seminars
and are ready for in-depth programs, there
are many options available for continuing
education. See Table 1.
If you want to become proficient in dental
sleep medicine and/or craniofacial pain it is
vital that you take quality educational courses. While some courses might claim to provide all of the education necessary to provide
services in the intended fields within a day or
even only a couple of hours, these courses
might simply be out there to make money – it
is imperative to do some research first.
In order to become accomplished in dental
sleep medicine and craniofacial pain, it is important to take the necessary post educational courses for the allotted number of credits
before being able to provide the appropriate
services for patients. Any patient has the potential to become complex, training will help you
provide this critical service with confidence.
Using the summary list in Table 1 and
others, you can find the right educational path
for you. Ask questions and be sure you are
investing your time and money wisely. Treating sleep patients is challenging – but fun
and rewarding! Confident, successful therapy
begins with excellent preparation.
1.
2.
3.
Rosen, RC, M. Rosekind, C. Rosevear, WE Cole, and WC Dement. “Physician Education in Sleep and Sleep Disorders: A
National Survey of U.S. Medical Schools.” Bian, Hui. “Knowledge, Opinions, and Clinical Experience of
General Practice Dentists toward Obstructive Sleep Apnea and
Oral Appliance.”
“Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005”
Table 1: Continuing Education Courses in Dental Sleep Medicine
Organization
Introduction
Advanced
Mini-Residency
Nierman Practice Management (SCOPE INSTITUTE)
3
3
3
AADSM
3
3
American Academy of Craniofacial Pain
3
Dr. Jonathan Parker
3
Rondeau Seminars
3
Sleep Group Solutions
3
Dr. Kent Smith
3
Most Dental Conventions
3
Dental Institutes (Dawson, Pankey, LVI, Spear, etc.)
3
3
3
varies
Tufts University
3
UCLA
3
University of the Pacific
3
University of San Francisco
3
List does not include every course available.
Having a limited practice to Craniofacial Pain and Dental Sleep Medicine, Dr. Mayoor Patel, DDS, MS, D.ABDSM,
D.ABCP, D.ABCDSM, D.ABOP, utilizes his experience and expertise to help dentists across the country excel in these
areas within their dental practices. As Clinical Education Director with Nierman Practice Management, Dr. Patel develops up-to-date curriculum for their sleep apnea and craniofacial pain programs. Dr. Patel serves as a board member
with the Georgia Association of Sleep Professionals, the American Board of Craniofacial Dental Sleep Medicine, American Board of Craniofacial Pain and American Academy of Craniofacial Pain. He also has taken the role as examination
chair for the American Board of Craniofacial Dental Sleep Medicine and American Board of Craniofacial Pain.
30 DSP | Fall 2016
PRACTICEmanagement
Knowledge
is
POWER
Hold on to those Reimbursements
by Rose Nierman, RDH, Founder and CEO Nierman Practice Management
I
t’s wonderful that so many dentists are successfully billing medical insurance to help
their patients with access to care for oral appliances. When billing in this arena, it’s
important to possess knowledge of medical policies which provide your practice with
the “power tools” to more easily receive reimbursements and also to retain those reimbursements. Since misinformation about medical billing and coding that can be detrimental to a dental practice is commonly presented, knowledge of current medical policies for Dental Sleep Medicine and TMD appliances is essential. Misunderstood terms
can also come into play. As an example; during our recent Medical-Billing-for-Dentists
seminar in Atlanta, a participant stated, “we don’t have to worry about following documentation guidelines or requests for refunds because we bill out-of-network.” This statement is
far from the truth. The act of billing or providing a patient with codes opens the door for insurers to verify that the billing is correct. Even when using a third party biller, it’s essential to
have knowledge of the correct codes, ethical billing protocols, necessary documentation and
what’s being billed. The dental practice is, ultimately, responsible for the codes billed and for
generating the necessary narrative reports and documentation.
Thus, training and education in medical
billing for dentists is as important as clinical
training for oral appliance therapy. We have
seen a few audits in Dental Sleep Medicine
(DSM) and Temporomandibular Dysfunction
(TMD) and expect reviews to increase as
progressively more patients are undergoing
these life-changing treatments.
A Few Questions to Consider
Are you up-to-date on documentation requirements that support evaluation and management codes that you bill? Did you know
that the American Medical Association, in
conjunction with The Center for Medicare
and Medicaid Services (CMS) created Guidelines for Billing Evaluation and Management
Codes? This guide shows how to document
the extent of your verbal “Review of Sys-
32 DSP | Fall 2016
PRACTICEmanagement
tems,” specific “Examination Elements” and
the level of medical decision-making.
Are you aware of recent changes in some
commercial insurance policies specifying that
using a “Medicare-cleared” (PDAC approved)
OSA appliance is now a requisite for reimbursement? Do you question whether you can bill on
the date of the impression or upon delivery?
Are you up-to-date with insurance carrier
policies, regarding the need of an MD prescription, Proof of Delivery form and other
documentation for an OSA appliance?
Can you bill for a morning re-positioner
as an accessory to the sleep appliance or is
this “nickel and diming” commonly referred
to as “unbundling”?
Are you sending narrative reports to the
patient’s other physicians – and how important is this to communications when treating
a medical condition such as OSA?
These are important questions to be answered and underscores the importance of
education in medical billing for dentists and
risk management when providing DSM and
TMD services.
Pursue the knowledge and “power tools”
to stay current with documentation requirements for TMD and OSA. To ensure the maximum reimbursement and compliance, consult
an expert or attend an educational program
designed to provide the answers to these burning questions. Empower your practice with the
knowledge to be successful!
Rose Nierman, RDH, is the Founder and CEO of Nierman
Practice Management, an educational and software
company (DentalWriter™ and CrossCode™ Software) for
Medical Billing for Dentists, TMD and Dental Sleep
Medicine advanced treatment, and co-founder of the
SCOPE Institute, a non-profit educational organization
dedicated to the advancement of sleep apnea, craniofacial pain treatment, and medical billing within dentistry.
Rose and her team of clinical and medical billing experts can be reached at
[email protected] or at 1-800-879-6468.
AAPMD Airway Summit
Building a Collaborative Community for Optimal Health
30+ Speakers
Focused
Workshops
Networking
Events
September 15-17, 2016
Hilton El Conquistador Resort | Tucson, Arizona
www.aapmd.org
DentalSleepPractice.com
33
TECHNOLOGYupdate
DIGITIZATION
of Dental Sleep Medicine by Tarun Agarwal, DDS, PA
E
verywhere you turn dentistry is going digital. Now
even dental sleep medicine is going digital! This is
just the beginning, but the fact that digital dentistry
is placing its mark on OSA therapy gives me great confidence in the growth potential of dental sleep medicine.
Let’s take a look at a few areas where digital dentistry makes OSA therapy more efficient, predictable, and profitable. The beauty
of this digitization is that it is not exclusive to
just sleep therapy. This is technology that you are or could
already be using for many different areas
within your practice – diagnostics, implant
planning, orthodontic planning, and restorative dentistry. Now it has the ability to add
dental sleep medicine to the mix.
Creating Patient Awareness It’s great to work with the low hanging
fruit of CPAP failures, but the real growth in
your OSA practice comes when you can help
get the roughly 80% of undiagnosed sufferers
on their way to healthier sleep breathing. To
do this you must find a way to create awareness and urgency in those unaware. For me
Figure 1: Airway segmentation from 3D CBCT used to create awareness of undiagnosed patient.
34 DSP | Fall 2016
this is best done by utilizing 3D CBCT imaging (Figure 1).
While NOT diagnostic for OSA, it certainly creates an avenue to having a conversation
and encouraging your patient to have either
an HST (Home Sleep Test) or in lab PSG.
Since implementing airway segmentation
into regular hygiene recare visits and new
patient visits we have seen an increase of unaware patients entering into our OSA therapy
workflow.
Reducing Chairtime
Digitization also helps increase your
profitability by reducing chair time. Nothing
is more expensive in your practice than your
chair time. Adjustments and remakes can
wreak havoc on your profitability and not to
mention patient confidence.
The fit of your OSA appliance is an important part of patient comfort, compliance,
and effectiveness. Too often we spend time
adjusting appliances due to poor quality impressions and general inaccuracies of analog
fabrication methods. We can now leverage
digital impressions to produce appliances
that are more accurate and minimize adjustments (Figure 2).
Figure 2: CEREC used to create ‘distortion free’ impression to minimize adjustments and provide a better fit.
TECHNOLOGYupdate
Another unrealized benefit of digital impressions is faster turnaround time. It is often hypocritical of me to tell the patient the
importance and urgency of getting into an
appliance and in the same breath tell them
it will take several weeks for the lab to make
the appliance. Digitization has allowed
us to get appliances back in about a week
(Figure 3).
Figure 3: Combination of 3D CBCT along with airway
segmentation to provide a direct digital appliance fabrication – resulting in quicker turnaround times.
The Bigger and Complete Picture
Dental sleep medicine is truly an area
where we can begin to help patients with
overall health improvement. As with any
health therapy there are potential complications and/or side effects. 3D imaging gives
us an opportunity to evaluate many of these
areas prior to commencing therapy.
One area that has long been a concern
for OAT has been its potential affect on the
joint. While there are many reasons for this,
most commonly it’s due to undiagnosed joint
issues prior to treatment or an inappropriate
bite putting the joints in an uncomfortable
position. 3D imaging allows you to visualize
the joint pre-treatment and avoid potential
issues (Figure 4).
Being able to evaluate the joint is a
worthwhile benefit of 3D imaging. At the
same time we can also measure potential
airway change. Using the same 3D image
we can also measure the airway with the
bite and/or appliance in place. Personally, I
prefer to take it with the bite in place. This
allows me to compare the potential airway
changes prior to having the appliance fabricated (Figure 5).
Figure 5: Here we can see our pre-appliance treatment position creates an increase in the minimal cross section of 16mm2 to 40mm2 – nearly a 3x increase in airway opening.
Please don’t misunderstand me. A post
treatment HST or PSG is the ideal and standard measure of treatment effectiveness.
Having the ability to measure airway,
evaluate joint position, and see anatomical
deviations gives me a more complete picture
of airway therapy. This leads to more predictable results and better communication between dentist, physician, and patient.
Digital dentistry has made restorative and
implant dentistry more predictable, efficient,
and improved clinical outcomes. It is poised
to do the same for oral appliance therapy.
This is just the beginning and it’s exciting to
see what is in store for the future.
Dr. Tarun Agarwal is a nationally recognized lecturer in
the field of aesthetic and restorative dentistry. He practices in Raleigh, NC. In July 2002, he co-founded the Dentaltown “Townie Meeting” an annual event considered one
of the most progressive educational opportunities in dental education. Dr. Agarwal has assisted numerous dental
manufacturers in new product development and review.
He has been featured on ABC, NBC and CBS news and several consumer
magazines for his pioneering use of technology, philanthropic events, and
aesthetic dentistry. In 2003, Dr. Agarwal was voted the “Townie of the Year”
for his contributions to the growth and dynamics of the dental community.
Figure 4: A view of the joint in treatment position.
DentalSleepPractice.com
35
TEAMfocus
Patient Education!
The single most important topic.
by Glennine Varga, AAS, RDA, CTA
D
ental Sleep Medicine is an industry that is taking off in
leaps and bounds. Many dentists in the US and abroad
are becoming educated on sleep airway and the importance of a good night’s sleep. Some of these dentists are offering
oral appliance therapy to their patients and very few are solely
focusing on dental sleep medicine with their patients. Regardless, if an office is occasionally offering oral appliances or is
exclusively dental sleep medicine, patient education is the key
to long term success.
In 1960, dental insurance companies offered benefits to enrolled subscribers which
was equivalent to approximately $1,000.
Today, most dental insurance companies
offer the exact same benefits as in 1960. In
56 years most dental insurance companies
have not increased benefits to keep up with
inflation and the cost of living. How has the
dental field survived? How have dental of-
36 DSP | Fall 2016
fices become successful? Only doing simple cleanings and yearly exams? NO. For
decades dental educational entities have
focused on one important factor…patient
education! The dental profession learned
early on it is imperative to educate patients
regarding needed treatment especially when
needed treatment costs extend past insurance benefits.
Patients that are in need of oral appliance
therapy need it whether insurance is involved
or not and an educated patient will make educated decisions. When patients understand
they may have benefits with their medical insurance for oral appliance therapy, the focus
tends to shift toward benefits instead of the
need for therapy. You can reinforce the good
news that your solution for their problem has
benefit with most insurance policies, but the
real message needs to be that treating their airway is more important than whether the oral
appliance is part of their insurance contract.
TEAMfocus
Here are 3 ways to focus on educating
your patients and empowering them to make
educated decisions toward therapy.
1. Communicate and educate keeping
your patient as the main focus. As
dental team members we are given
many tasks and responsibilities which
can bog down our daily thoughts and
actions. It is important to keep your
patient’s perception in mind and focus on what he or she may feel is important. For example, if a patient asks
why sleep is a topic of conversation in
the dental practice, a typical response
may be “because we make oral appliances for patients with sleep apnea”.
This could be perceived by the patient
that sleep is a conversation topic because it’s a sales tactic instead of a
genuine concern. So if the question
of why sleep is a topic comes up, a
great response would be “because our
office is concerned with your overall
health and wellness.”
2. Educate patients before referring
them for a primary diagnosis. It is appropriate for a sleep physician to diagnose patients with sleep breathing
disorders as a result of a sleep test.
Therefore, referring patients to obtain
a diagnosis is common for most dental
sleep medicine dentists. It is important
that the patients understand the process and, depending on what is diagnosed, oral appliances may be a great
therapy option. Dentists complain that
after referring patients out most don’t
come back and most are only given
Positive Airway Pressure (PAP) therapy as a treatment option. So educate
your patients before referring them
out. Hand them an oral appliance brochure. The focus of a high risk non-diagnosed patient is to obtain a diagnosis with mention of oral appliances as
a possible option.
3. Educate normal sleep study results
versus patient results. In dentistry, patients respond better when they understand what is wrong and why it needs
to be fixed. The same should be said
for sleep. Most obstructive sleep apnea (OSA) diagnosed patients cannot
explain AHI, SPO2 levels or percentage of N3 sleep. Most of these patients
WE can educate patients to make educated decisions
toward therapy!
are only told if they have apnea or not
and what level of severity was diagnosed. If we give patients the opportunity to learn what normal sleep looks
like and compare their sleep measures
to that standard, we will help patients
lean toward therapy.
Educating patients is the single most important topic. Four out of four of my immediate family members have been diagnosed
with a sleep breathing disorder. Only one
originated from a medical entity, was diagnosed with mild OSA and was told no treatment was needed. As a family member and
dental professional, I couldn’t let that go
and talked with them until all four were diagnosed; now they are all in OSA therapy.
My point is medical offices do not have time
to evaluate every patient for sleep breathing
disorders and unless a patient’s chief concern
is sleep breathing, most times sleep will never be discussed. WE dental team have time!
WE can have conversations with patients
and screen for this! WE can educate the importance of obtaining a diagnosis! WE can
educate patients to make educated decisions
toward therapy!
Editor’s Note: This Sleep Team Column will be dedicated
to the team and provide practical tips and resourceful
information. Let us know your specific issues by email
to: [email protected], while we can’t respond
to every individual. Your feedback will help us create the
most useful Sleep Team Column we can!
Glennine Varga is a certified TMD assistant and educator with an AA of sciences. She is a certified TMD
assistant with the American Academy of Craniofacial
Pain. She has been employed in dental education for
over 19 years. Glennine has been a TMD/Sleep Apnea
trainer and speaker with emphasis on medical billing
and documentation for over ten years and a trainer of
electrodiagnostic equipment for five years. Glennine
is CEO of Dental Sleep Medicine Boot Camp and a Total Team Training
instructor for Arrowhead Dental Lab. For more information, visit www.
dsmbootcamp.com or email [email protected].
DentalSleepPractice.com
37
ORGANIZATIONspotlight
Learning Sleep from AADSM
An interview with Harold A. Smith, DDS, president of the AADSM
A
s more dentists are choosing dental sleep medicine as a
way to expand their practices and help patients, there is
an increasing number of education and training opportunities in oral appliance therapy provided by dental schools
and professional associations.
A commitment to
ongoing education
benefits dental
sleep medicine
professionals and
enables them to
provide quality care.
38 DSP | Fall 2016
The American Academy of Dental Sleep
Medicine (AADSM) offers several educational courses for both novice and seasoned
dentists, ranging from literature reviews
to practical clinical applications. In an
interview with AADSM President Harold
A. Smith, DDS, he discusses the AADSM
educational courses and how they can help
dentists excel in dental sleep medicine.
There is a lot of education available in
sleep today – probably once a month in
major cities across the country a dentist can
find a sleep course.
What makes AADSM courses different, something to seek out? Why is
AADSM involved?
The American Academy of Dental Sleep
Medicine is the only non-profit national professional society dedicated exclusively to the
practice of dental sleep medicine. We offer
continuing education because we know it’s
extremely important for our members to stay
up-to-date on advances in oral appliance
therapy and provide quality treatment for
snoring and sleep apnea.
All AADSM courses are recognized by
the ADA Continuing Education Recognition
Program (CERP), acknowledging them as
quality continuing dental education. AADSM
courses offer introductory and advanced-
level education in dental sleep medicine,
providing a comprehensive approach to oral
appliance therapy. Courses cover the knowledge needed to treat a medical disease, the
clinical skill required to fabricate and adjust
oral appliances, and the fundamentals of
dental sleep medicine practice management.
Dentists must continuously identify ways
to demonstrate their proficiency in the
fast-growing field of dental sleep medicine to
be successful in networking and generating
patient referrals. A commitment to ongoing
education benefits dental sleep medicine
professionals and enables them to provide
quality care – and the AADSM is proud to
play a role in helping dentists optimally treat
their snoring and sleep apnea patients.
Please tell us about your faculty –
how were they chosen? What type of
practice do they come from? What’s
special about them? Do dentists hear
from just other dentists? Is there an
MD perspective? What do they teach?
AADSM faculty are chosen due to their
outstanding credentials in the fields of dental
sleep medicine and/or sleep medicine. Lecturers speaking as dental experts are licensed
dentists (DDS or DMD) with significant experience treating sleep-disordered breathing
patients with oral appliance therapy, and they
are either a board-certified Diplomate of the
ABDSM, director of an AADSM-accredited
facility or an educator in dental sleep medicine. In addition to dental sleep medicine,
some faculty members have a background in
other related fields such as oral surgery, pulmonology and respiratory care.
ORGANIZATIONspotlight
Many AADSM courses also feature an
MD lecturer who discusses sleep-disordered
breathing from a medical perspective, including an overview of sleep-related breathing
disorders, polysomnogram reports, medical
terminology, the comorbidities of untreated
sleep apnea, and the development of a team
approach to patient management. All of the
medical lecturers are passionate about the role
of dentists in the management of sleep-disordered breathing patients and represent a
diverse mix of backgrounds in sleep medicine.
Faculty members represent a variety of
practice settings, such as dental sleep medicine private practices, combined dental sleep
medicine/general dentistry practices, sleep
medicine clinics, hospitals and universities.
Both dental and medical faculty members
often have demonstrated leadership in the
field as board members of relevant professional associations, editors or contributors to
peer-reviewed journals, awarded researchers, and clinic and department directors.
I see you have not only intro courses
but advanced, team, and practical
courses. Is this designed as a group –
do dentists take all the courses before
they are ready to treat patients?
Dentists are not required to take AADSM
courses in order to administer oral appliance therapy, nor are they required to take
the courses in a particular order. For those
who are seeking a holistic approach to
dental sleep medicine, we recommend that
they start with our Essentials of Dental Sleep
Medicine Course, followed by the Practice
Demonstration Course. Dentists of all experience levels also are encouraged to attend
the AADSM annual meeting, which is the
premier educational event in dental sleep
medicine. The AADSM 26th Annual Meeting
will be held in Boston from Friday, June 2,
through Sunday, June 4, 2017.
In addition to in-person courses, the
AADSM offers Q&A webinars, online modules, practice management support and
online study clubs to provide a simple, convenient way to earn CE credits and become
more knowledgeable in the field.
What about sleep tests – do dentists
get hands-on learning with how to
use home sleep monitors?
AADSM courses may provide information about how home sleep apnea testing
(HSAT) is used by physicians to diagnose
sleep apnea. However, the AADSM does not
promote the use of HSAT by dentists as a
screening or diagnostic tool.
Many dentists are interested in
becoming Diplomats of ABDSM. Do
the AADSM courses count toward
the required CE and prepare the
attendee to take the examination?
Yes, AADSM courses count toward the
continuing education prerequisite for ABDSM
board certification applicants. Additionally,
the AADSM hosts an annual Board Review
Course to help applicants prepare for the
ABDSM certification exam. The one-and-ahalf-day course helps participants understand
the scope of the exam based on the weight
given to each topic, review journal articles
on the ABDSM reading list, discuss mock
questions, determine appropriate investigative strategies and develop a comprehensive
patient treatment plan.
Through continuing education and earning dental sleep medicine designations, such
as ABDSM Diplomate certification, dentists
can demonstrate to physicians, patients and
payers that they are dedicated to providing
optimal patient care with oral appliance therapy to treat obstructive sleep apnea.
All of the medical
lecturers are
passionate about
the role of dentists
in the management
of sleep-disordered
breathing patients.
Harold A. Smith, DDS, is the president of the American
Academy of Dental Sleep Medicine (AADSM). He has
provided oral appliance therapy since 1993 and is currently the clinical director of Dental Sleep Medicine of Indiana. He also serves as the dental consultant to the major
Indianapolis hospital sleep disorder centers and is on faculty at Indiana University School of Medicine’s Fellowship
program in sleep medicine.
As a distinguished speaker and ABDSM Diplomate, Dr. Smith has lectured
nationally on the dentist’s role as part of a medical team in sleep medicine. He
also has served on many levels of organized dentistry throughout the years.
Dr. Smith is a Fellow of the American College of Dentists and is an active
member of the AASM, ADA, IDA, IDDS and AGD. He is a graduate of the
Indiana University School of Dentistry.
An active and passionate dental sleep medicine professional, Dr. Smith
served as president of the AADSM from 2002 to 2004, received the AADSM
Distinguished Service Award in 2006 and was president of the ABDSM from
2008-2010.
DentalSleepPractice.com
39
NUTRITION
Helping Sleep Patients Understand
How to
Lose Weight
by Dr. Warren Schlott
O
ne of the most effective treatments for obstructive sleep
apnea is weight loss. However, as the medical community struggles with dynamic changes and as physicians
become busier and busier, less time is spent counseling sleep
patients about weight loss. If the sleep dentist truly wishes to
help his sleep patients improve, the sleep dentist should know
the basics of weight loss and be able to counsel patients when
appropriate. Staying with the science can help with what can be
an uncomfortable subject.
40 DSP | Fall 2016
Understanding weight loss requires
knowledge of the physiology of weight gain
and weight loss, and subsequent behaviors
that can lead to physiological change in the
body. People eat foods that consist of carbohydrates, protein, fats, and/or fiber. Each of
these has a different effect on the body.
Carbohydrates
Not so long ago, excess fat consumption
was thought to be the leading cause of weight
NUTRITION
gain. Today, we know that carbohydrates are
the culprit.1 Even though carbohydrates are
the main source of energy for the body, it is
known that not all carbohydrates are created
equal. Simple carbohydrates, also known as
refined carbohydrates, found in such foods
as table sugar, white flour bread, cakes, fruit,
candy, potato chips, breakfast cereals, and
the like, are made up of only one or two glucose molecules. These simple molecules are
rapidly absorbed by the digestive tract and
cause a spike in blood sugars. These foods
have little nutritional value, and if eaten in
excess the body sends these carbs to the liver
to be stored as fat throughout the body.2
On the other hand, complex carbohydrates, made up of three or more glucose
molecules linked as a chain, and found in
such foods as vegetables, legumes, and
whole grains, take longer to digest. Usually,
these foods contain vitamins and nutrients
that are beneficial to the body.
For every 10 calories of carbohydrates
eaten, the body burns 1 calorie to convert
the carbohydrate to sugar.3 Typically, about
70% of the sugars are rapidly absorbed into
the bloodstream and burned off as energy in
about 6 hours. The remaining 30% is converted to triglycerides and stored in fat cells.
Carbohydrates raise the blood sugar which
triggers insulin release from the pancreas.
Insulin clears the glucose (sugar) from your
bloodstream. As the blood sugar drops, craving for more carbohydrates increases. If more
carbs are eaten, insulin production spikes
and then falls and these cycles can become
persistent. In many cases, over time, excess
production of insulin leads to the body becoming immune to the effects of insulin and
type 2 diabetes occurs. Fortunately, not all
carbohydrates digest at the same rate. Some
raise blood sugar levels faster than others.
The ability to raise blood sugar is defined by
the glycemic index.4 The higher the index
number, the more elevated the blood sugar
level becomes when eaten. Generally, carbohydrates with a number higher than 70,
cause an extremely fast rise in blood sugar
resulting in spikes of insulin that encourages
fat storing. Carbohydrates with a glycemic
index below 55 cause a lower rise in blood
sugar and insulin, and hence, make you feel
not hungry longer. Carbohydrates between
55 and 69 cause a moderate rise in blood
sugars and insulin. There are reference books
that list the glycemic index for most foods.
Obviously, it is beneficial to eat carbohydrates that have a lower glycemic index.
Fats
Fat, once thought to be the bane of diets, are now understood to have beneficial
and needed requirements for a healthy diet.5
Of course some fats are better than others.
Monounsaturated and polyunsaturated fats
are considered healthy. Monounsaturated
fats improve cholesterol levels, enhance insulin sensitivity, and help stabilize blood sugar levels. Foods such as olive oil avocados,
almonds, and other nuts contain
monosaturated fats. PolyunsatStaying with the science
urated fats contain omega-3
and omega-6 fatty acids and can help with what can be
help reduce inflammation. Soyan uncomfortable subject.
bean oil and fatty fish such as
salmon contain polyunsaturated
fats. Saturated fats are found in
meats, cheese and butter, and in
some plant oils such as coconut and palm oil.
These fats are beneficial in small amounts.
Trans fat, on the other hand, is the worst fat
for you. These fats are man made by hydrogenation of unsaturated fats. These fats are
made to increase shelf life of certain foods
such as baked goods. Trans fat has been implicated in rising LDL (bad cholesterol) levels
and decreasing HDL (good cholesterol).
All fats are high in calories. Whereas, carbohydrates contain 4 calories per gram, fat
has 9 calories per gram; and it only takes 1
calorie to digest 100 calories of fat. Fats are
energy storehouses.
Warren J. Schlott has been a practicing dentist in Brea,
California since 1978. Dr. Schlott developed a thriving
restorative dental practice and then in the early 2000’s
developed a busy full time sleep practice. He has published numerous articles, and has helped other dentists establish sleep practices. Dr. Schlott is a member
of the American Academy of Sleep medicine and is a
Diplomate of the American Academy of Dental Sleep
medicine. Dr. Schlott can be reached at [email protected].
DentalSleepPractice.com
41
NUTRITION
Protein
Protein provides the building blocks for
the body. Protein is needed for the body to
grow, repair, and maintain itself. Protein is
usually ingested as meat, but can be obtained from dairy products and some plant
sources. Protein contains 4 calories per
gram, but it takes one calorie to burn four
calories of protein. It takes longer to digest
protein than it does carbohydrates or fats.
Because of this and because protein reduces the levels of the hunger hormone Ghrelin
and triggers the release of the digestive hormone CCK, which reduces hunger, proteins
discourage overeating.6 Protein helps maintain lean muscle mass to boost metabolism
and the amino acids from protein are essential for cellular health and building.
Fiber
There are two kinds of fiber. Insoluble fiber consists of items the body cannot digest.
It does not absorb water. Insoluble fiber type
helps speed food through the digestive tract
and reduces the risk of constipation and
hemorrhoids. The second type of fiber is soluble fiber. A by-product of complex carbohydrates, soluble fiber attracts water and becomes a gel like substance that swells. This
Carbohydrates, fats,
protein, and fiber
are all necessary for
a proper diet.
42 DSP | Fall 2016
slows digestion to increase satiety. It also
helps modulate blood glucose levels and
lowers cholesterol. Inulin, a type of soluble
fiber, promotes the growth of gut bacteria
that improves bowel function and improves
absorption of vitamins and nutrients. It also
decreases the body’s ability to manufacture
certain kinds of fat.7
E&M
Most overweight people are judged by
their body mass index.8 While this can be
appropriate, some are labeled as overweight
even though they may be a specimen of perfect health. Muscle weighs more than fat.
Hence, a muscular person could be marked
as overweight even though they are healthier than most. Perhaps a better method is to
calculate the waist to height ratio. The waist
circumference measurement should be less
than half of a person’s height. The waist measurement should be taken about an inch
above the belly button.9 If the measurement
is greater than one half of the height, the individual is at a greater risk for type 2 diabetes, high blood pressure, heart disease, and
sleep apnea.
If food metabolism is understood, it becomes easy for the dentist to counsel patients about weight loss. Many nutritionists
maintain that weight loss is 90% diet and
10% exercise. To burn the calories provided by eating a cupcake, it would require
heavy exercise for over an hour. Nonetheless, exercise is important for a variety of
reasons because among other things it can
increase energy and stamina, create better
moods, reduced stress, enhance memory,
lower blood pressure, and improve sleep.
A moderately active person should attempt to achieve 6000 steps per day,
with a goal of 10,000 steps per day
as measured by a pedometer.10 Pedometers may be purchased at sporting good stores or as a phone app. Instead of attempting to exercise to a lean
body, the main goal of weight loss should
be to limit caloric intake. To maintain body
weight, caloric intake should be about 1416 calories per pound of body weight for
men, and 12-14 per pound of body weight
for women. To lose weight, caloric intake
should be less.11 To find the ideal calories
NUTRITION
for an individual, caloric calculators found
on the web can be useful.
The best way to lose weight is to eat the
right foods. Generally, most people eat too
many carbohydrates. Limiting their intake
goes a long way towards healthier living.
Avoiding carbohydrates that have a high glycemic index is encouraged. Carbohydrates
should comprise about 45% of one’s
total calories. Protein should total
30-35% and fat 25-30% of the diet.
One of the bigger secrets to weight
loss is to eat 5-6 meals per day. The
three “main meals” should be eaten at “normal times”. About 2.5
hours after a meal, a snack should
be consumed. Since proteins tend
to mute hunger, the snack should
contain protein. Many feel that at least
15-20 grams of protein should be eaten at
the snack. This helps avoid gorging at the
main meal. Simple carbohydrates as snacks
should be avoided. An example of an good
snack would be a piece of turkey wrapped
in cheese. Main meals should include complex carbohydrates, protein, and some fat.
Purchasing a book or using the web, the
caloric value of the foods can be determined. The goal would be to consume fewer calories than required for weight maintenance. With practice an individual can be
proficient at estimating their caloric intake.
Another secret of weight loss is to drink
plenty of water. Many times dehydration is
interpreted by the body as hunger. Drinking
50-60 oz. of water per day eliminates this.
Avoiding sodas, even diet sodas, and alcohol is wise. Simple sugar is a major ingredient of sodas. Artificial sweeteners in diet
soda have been implicated with interfering
with digestion and have not been shown to
reduce weight. Alcoholic drinks amount to
empty calories. “Many a dietician will tell
you “For every drink you have, you have to
subtract something else from your diet, or
add another mile on the treadmill.” Another
secret for weight loss is the lack of vitamin
D. Where appropriate, Vitamin D supplements may help with weight loss.12 Others
advocate avoiding foods made from wheat.
Wheat is usually refined and used in baked
goods. These simple carbohydrates are often unnecessary calories with little nutri-
Generally, most people
eat too many carbohydrates.
Limiting their intake goes
a long way towards
healthier living.
It’s Here!!
Wear it. Trac it ®. DentiTrac ®
DentiTrac is now available in
the USA for use with select appliances.
For more information
call 888-462-4841 x218
www.braebon.com
@braebon
DentalSleepPractice.com
43
NUTRITION
tional value. Losing weight and maintaining
weight loss is simple with a little knowledge
and common sense.
In the dental sleep office, weight counseling can be beneficial. If the dentist is pushed
for time, an auxiliary can be trained to as1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
44 DSP | Fall 2016
sist patients. Remember, “People with severe sleep apnea who lost the recommended amount of weight were three times more
likely to experience a complete remission of
sleep apnea symptoms compared to people
who didn’t lose weight.”13
Diabetes Solution, Richard Bernstein, MD, Little, Brown and Company 1997
The End of Diabetes, Joel Fuhrman, MD Little Brown and Company 2003
Biochemistry The Molecular Basis for Life, Trudy Mckee, James Mckee, Oxford Press 2013
Glycemic Index, Glycemic Index Foundation, www.gisymbol.com/aboutglycemic-index
Lean for Life Cynthia Stamper Graff, Reginald Allouche MD. Harlequin Enterprises 2014
Hormones of the Gut users.rcn.com/jkimballimaultranet./BiologyPages/g/guthormones
How Fiber Helps Your Digestive Health, Lisa Fields, David Kiefer MD, WebMD 2015
Body Mass Index Medline Plus, US National Library of Medicine
Lean For Life, Cynthia Stamper Graff, Reginals Allouche MD, Harlequin Enterprises 2014
Wen, Chi Pang, et al, Minimum Amount of Physical Activity for Reduced Mortality and Extended Life Expectancy: A Prospective Cohort
Study. The Lancet 378 (9798): 1244-53
Erin Coleman RE, LD, The Average Calorie Intake By a Human Versus the Recommendation, Demand Media
Tremblay, Angelo, Jo-Anne Gilbert “Human Obesity: Is Insufficient Calcium/Dairy Intake Part of the Proble?” Jurnal of American College
of Nutrition 30 (5Suppl 1):449S-453S
Henri Tuomilehto, Et al The Impact of Weight Reduction in the Prevention of the Progression Of Obstructive Sleep Apnea: An Explanatory
Analysis of a 5-Year Observational Follow-up Trial,
Sleep Medicine, 2014: DOI: 10.106/j.Sleep.2013.11.786
PRODUCTspotlight
eyeCAD-connect®, the Heads-up Display
for digital dentistry
by Sven Holtorf, DDS
30
years ago, with the introduction of digital scanning,
a new window was opened for dentistry. Since
then, the design and handling of the scanning units
have gotten smaller, faster and more accurate, but the way
they are used hasn’t changed significantly. The dentist scans
the patient’s teeth and checks the monitor at the same time for
the correct scanning outcome. This requires a constant change
of the dentist’s posture and creates non-optimal ergonomic
movements.
We are by nature comfortable with
keeping an eye on what we are doing with
our hands. Scanners generally require us
to watch the screen for scan results while
manipulating the device in the mouth. If the
patient presents with challenges, (e.g. irregular teeth, reduced intraoral access) the need
to turn our heads towards the screen while
moving the hands can lead the operator to
feel inept and the patient to a less-than-optimum experience.
Related problems are known in automotive production or aeronautical engineering
in which the industrial cooperation between
human beings and machines is vital – for this
the solution is the ‘Heads-up Display.’ The
important data about the task at hand and
relevant measurements (automotive production) or information about speed, altitude,
course, etc. (in aeronautical engineering) are
projected into the heads-up display so that
the wearer has the information directly in his
or her field of vision and can concentrate on
the task at hand. Recently, heads-up display
is entering the world of medicine in surgery,
where the doctor can monitor patient data
while operating.
This principle is the basis for eyeCADconnect®, implemented into digital dentistry and first launched in March of 2015
at the IDS (International Dentistry Show)
in Cologne, Germany. The scanned images
DentalSleepPractice.com
45
PRODUCTspotlight
While performing
the scan the
practitioner can
see both the
scan screen and
the patient at the
same time.
are transferred in real time onto the display
device so the hand/eye coordination of the
operator improves significantly. The risk of
inadvertent, uncomfortable contact with the
patient while looking away is eliminated.
While performing the scan the practitioner
can see both the scan screen and the patient
at the same time. The ‘screen size’ of the scan
image is adjustable, according to his or her
needs, right in their field of vision.
Video glasses have been available for
years, enabling dental patients to enjoy
movies and other content as a distraction
from the dental appointment. These are
universally opaque, bulky, and completely
different from the Epson Moverio BT-200,
an advanced imaging system commercially
available. What was missing was the ability to connect the scanner in real time, so
Dr. Holtorf developed the eyeCAD-connect®
software to take advantage of this advanced
video system. Using a nano router to create
a tiny local network, there is no interaction
with vulnerable and unreliable wireless networks or slow Bluetooth connections.
This innovative German dentist wanted
to stay in contact with his patients during
the appointments, cut the patient’s time not
only in the dentist chair but also their time
waiting for their new milled dental restorations. Other benefits include improved
workflow and overall quality of the scans.
Patients can even wear the glasses to see
how their crowns, inlays or especially
orthodontic plans are being created in the
software. For full arch study models and 3D
bite records for sleep appliances, the patient
can see their teeth appear on screen and get
a nice visual representation of the forward
jaw position chosen as a starting place to
open their airway.
The glasses run on an Android system
and come with all consumer apps (camera,
Bluetooth, GPS, WiFi, etc.) They can be used
outside the office for remotely connecting to
any screen. The integrated software provides
a secure connection between the scanning
unit and the smart glasses using the nano
router. By creating its own WiFi network
around the unit, sensitive patient data stays
in the office -no outside internet connection
is needed. The glasses and the nano router
operate wirelessly for maximum freedom of
positioning the scanning unit and ease of
movement for the dentist and patient.
eyeCAD-connect® can be used for any
PC-based intraoral scanner. There are also
international market versions.
Clinician feedback has reported improved
scan times, better patient experience and
more comfortable use, leading to a faster
integration of digital impressions in the
daily practice. Delegating this task to trained
team members enhances their contribution
to office goals. This improves the return on
investment for the technology.
Visit http://eyecad-connect.de for more
information.
Sven Holtorf, DDS, graduated 1992 with a Doctor of Dental Surgery from Christian Albrechts University in
Kiel, Germany. Since 1992, he is a resident doctor in Bad Segeberg with his own practice. Since 2003, he has
been an avid CEREC user. In 2008, he graduated with a Master of Science in Oral Implantology from Steinbeiss
University, Berlin. In 2014, he became a Certified Trainer for the DGCZ – Deutsche Gesellschaft für computergestützte Zahnheilkunde (German Association for computerized dentistry) and ISCD (International Society
for Computerized Dentistry). He is a member of the CEREC Mentorship program and an international CEREC
Advocate with lectures and continuing education in Germany and Europe in order to spread new dentistry innovations including new techniques and technology. Also in 2014, he founded the company iDent in order to promote continuous
education. In 2015, he developed eyeCAD-connect – the head-up display for intraoral scanners.
46 DSP | Fall 2016
PRACTICEmanagement
5
Things
Top DSM
Practices
Do
by Autumn Bodily, RDA
Y
ou bought the gym membership. It was on special and
you were all amped up from the motivational speaker
touting “extreme fitness and taking control of your life.”
But like so many things in life, it ended up just a little plastic
piece of guilt on your keychain. But seriously, how do some
people do it?! How is it we buy the same system as that guy
and his practice grows and grows? Why does his staff seem so
“on board” with making new things work and others’ seem to
be sabotaging themselves from the inside out? In this edition we
thought we’d take a look at the 5 things successful practices do
to treat OSA.
1. They screen EVERYONE.
You’ve heard it before, “we screen all of
our adult patients.” These practices hand out
screenings like Ez Sleep’s Sleep Health Questionnaire or the Epworth to every patient.
This is a matter of course; just like updating
the health history. However, far too many
practices call me up and ask the best way
48 DSP | Fall 2016
to approach and screen the obese patient,
or the man with the diminished chin. I get
my answer from those successful practices,
“We screen everyone.” Patients in the waiting room are always thumbing through magazines or fiddling with their phones. Why not
give them something meaningful to read?
It’s amazing how often a patient will approach the dentist saying they were reading
the symptoms and risk factors of obstructive
sleep apnea and ask if maybe they should
be tested.
2. The dentist connects with the
patient.
The difference between a dentist and a
successful dentist is sometimes referred to
as chairside manner. Your patients come and
sit in your chair. Despite whatever is going
on in their lives, they have made their health
and well-being a priority. Successful practices understand that in many cases, their patients have never even heard of Obstructive
Sleep Apnea. They’ve certainly never imag-
Test. Trial. Treat.
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TEST
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patient-friendly, convenient, in-home testing device &
easily identify qualified Apnea Guard® patients
TRIAL
Improve your custom appliance outcome, reduce chair
time and provide immediate therapeutic benefits by
using Ez Sleep & Apnea Guard® together
TREAT
Easily and quickly transfer settings from Apnea Guard®
directly to your custom appliance & successfully continue
your patient’s therapy
Improves Outcomes
of a Custom Appliance
Details
Apnea Guard
Conventional
% with a 50% AHI reduction (n)
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Days to successful outcome (n)
34 ± 7.6
136 ± 53.1
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www.AdvancedBrainMonitoring.com U.S. and Intl Patents and Patents Pending
Contact us at: 888-240-7735 or visit: ezsleeptest.com
1. Treatment Efficacy Using a Trial Oral Appliance to Determine the Optimal Jaw Forward Position
for a Custom Appliance. Morgan T, Meyers A, Melzer V, Levendowski D. Sleep 2014; 37:A361
PRACTICEmanagement
ined it could be something that affects them.
The dentist is there to answer a few questions
about OSA and dispel their fears. After all, he
isn’t even sure if his patient HAS OSA. “We’ll
cross that bridge when we get to it. Let’s
first have you tested by a top notch Home
Sleep Testing company like Ez Sleep. Once
we get the results we’ll have something to
talk about.”
3. It takes a village.
You want
patients to ask
“Should I be
tested?”
I hear it all the time, “I’d be nowhere
without my amazing staff.” This one orders,
this one is a gem on the phones, this one
can soothe even the most fearful patient.
The person who can take a patient’s
money and still laugh with them like
they were high school buddies is
a rare personality. That’s why they
man your front desk. The most successful practices know when Mr.
Smith’s next cleaning is, when Mrs.
Barnes’ RCT is ready for a crown,
and how old her grandson will be.
These highly organized, ever-smiling
front desk personnel are geniuses when
it comes to scheduling a follow up consultation for the patient at risk for OSA. Yes,
this consultation is 3-4 weeks out. However, that patient is far more likely to accept the
testing from Ez Sleep, take the test the night
they receive it, and ship it back right away.
After all, they want to know the results too!
According to reception here at Ez Sleep, we
get upwards of 8-10 patient calls per week
asking for their results. We assure them their
results were sent to their dentist weeks ago.
Successful practices make that call far before
their patient can call us.
Autumn Bodily, RDA, is a writer, a twenty year veteran
of dentistry, and Ez Sleep’s Director of Education and
Training. She knows a good Oxford comma when she
sees one.
50 DSP | Fall 2016
4. They introduce partners.
A memorable introduction can go a long,
long way. I love seeing a new patient walk
into an office and be introduced to their hygienist, the treatment coordinator, the assistants, even the scrub tech. They get to see
how a well-oiled machine runs. I know patients who want to see which lab the practice
works with. In every successful OSA treatment case I can recall, the patient was introduced to us as Ez Sleep, their home sleep
testing diagnostic company. When they see
their trusted dentist trusting us…well, you
see the pattern. This way, when an Ez Sleep
scheduler calls to verify the shipping of their
home testing device, the patient is confident
they are still in good hands.
5. They can’t leave well enough alone.
When doing a root canal do you just remove the nerve and say to yourself, “yeah,
I’m sure I got it all.” Umm. No. Proof, right?
You want empirical evidence to show your
skill and competency as the professional you
are. Same goes for sleep testing. You screened
the patient and they showed risks. You prescribed a sleep test, told them the necessity
of their cooperation and they smoothly took
the Ez Sleep Home Test. You got the results
from the Board Certified Sleep Physician and
promptly shared them with your curious patient. You fitted them for an oral appliance
and their symptoms have disappeared. Now,
here’s what sets you apart: successful practices don’t stop there. They efficacy test their
OAT patients. They show, without a shadow
of a doubt, that this patient’s life has been
ever changed. Consequently, that patient is
now a lifetime wearer of the oral appliance
to treat their sleep apnea. All because you
went the extra mile.
Practices that are in this for the long haul
have established themselves as strongholds
in their community. More and more people
are looking to their dentist for the treatment
of snoring and they don’t even realize how
their health is being improved. But we do.
We’re just like you. We want to screen and
test every person showing risk. The more we
expose this epidemic of obstructive sleep apnea, the healthier and safer our communities
will be. Ez Sleep raises a tiny little key fob to
the successful practices we work with. We
may not run into each other at the gym, but
we all have to sleep sometime.
PRACTICEmanagement
Your Sleep Ambassador is the Difference
by Dr. Gy Yatros
I
have worked with hundreds of dental practices over the past
several years, providing education and training about how to
effectively implement efficient dental sleep medicine production. There is one glaring difference between the practices that
attain success and those that flounder. It doesn’t have anything
to do with device titration, side-effect mitigation, or the dentist’s
height. That one glaring difference is the existence of a DENTAL
SLEEP AMBASSADOR in the practice. Call them what you will;
ambassador, manager, guru, quarterback, spearhead. It doesn’t
matter. What does matter is that this person is accountable for
the sleep portion of your practice.
So who is this person? What are their
responsibilities and what traits should they
possess?
• Manages all aspects of your dental
sleep production. Will be intimately
familiar with the patient workflow.
• Has to be responsible, accountable,
organized, AND they have to be granted the autonomy and authority to
make decisions.
• Charged with training & ensuring protocols are in place AND being followed.
• Must be able to delegate required responsibilities.
• Possess critical thinking abilities, problem solving skills, drive, ambition, and
a desire to continually learn.
To grow dental
sleep production,
you have to have
the right people
to manage the
complexities
involved.
Dr. Juliet Bulnes
Dr. Gy Yatros has been practicing dental sleep medicine
for over a dozen years and is a well-respected international lecturer in the field of sleep-disordered breathing and
dental sleep medicine. He has offices in Bradenton, Sarasota and Tampa, Florida devoted exclusively to the treatment of sleep disordered breathing. He is a Diplomate of
the American Board of Dental Sleep Medicine (ABDSM)
and is an Affiliate Assistant Professor of the Department of Internal Medicine
with the University of South Florida, College of Medicine. He is a Co-Founder of the Dental Sleep Solutions system.
52 DSP | Fall 2016
A Sleep Ambassador will help you establish a better working relationship with other
healthcare providers because they’ll be your
practice’s primary contact. They will garner
a greater understanding of the entire process
and be able to discuss the results of a sleep
test and confidently articulate to patients
the financial aspect of oral appliance therapy. They will be the go-to person for your
patients when they have questions and for
your staff as well. If your Sleep Ambassador
is savvy enough, they may even be able to
perform some marketing duties such as lunch
and learns or health fair presentations.
After floundering with two or three devices per month, one of our DS3 Members,
Dr. Juliet Bulnes of Tampa, FL made what
she refers to as a “leap of faith” and hired
Stephanie, her part-time Dental Sleep Coordinator, aka Sleep Ambassador. “I hired
Stephanie part-time and within two weeks,
we changed that to full-time. To grow dental sleep production, you have to have the
right people to manage the complexities involved”, says Dr. Bulnes. She also commented, “It was so tough for my team to juggle
dental sleep while also ensuring their other jobs were done properly. Since joining
us a year ago, Stephanie and my assistant,
Jill, have been the driving forces behind
our growth to an average of 10 devices per
month. This has also enabled the rest of the
team to focus on their jobs which makes everyone more productive. I’ve crunched the
numbers and this change has ensured that
Stephanie has paid for herself over and over
again. It’s been tremendous and we’re just
getting started.”
Identifying a team member to spearhead
the DSM aspect of your practice will ensure a
much smoother implementation process. The
Sleep Ambassador can be an assistant, a front
desk person, or a new hire BUT this has to
be their primary focus. Your investment in this
person will pay long-term dividends for you,
your patients, and your practice.
CLINICALfocus
Maxillofacial-Mandibular Advancement
and Oral Appliance Therapy
Creating A Pathway To Successful Treat
by Clark O. Taylor, MD, DDS
C
hoosing the appropriate sleep apnea treatment for your
patients depends on a number of factors, including the
cause and severity of their condition, their medical history, and their personal preferences. Understanding when to
utilize an oral appliance or when to explore the option of maxillofacial-mandibular advancement (MMA) surgery is vital to
your practice and to the health of your patients.
Our Oral Appliance Protocol
MMA surgery
has a much higher
success rate than
other sleep apnea
surgeries, including
UPPP.
54 DSP | Fall 2016
An oral appliance may be an ideal solution for patients with mild to moderate obstructive sleep apnea, especially those who
do not need to use or do not wish to use a
CPAP device. However, it is important to approach oral appliance use deliberately, so as
to best understand its effectiveness with each
patient. We follow this protocol:
• The patient undergoes an attended sleep
study to determine the diagnosis and apnea-hypopnea index (AHI). If the patient
has an AHI of 15 or under and otherwise
seems like a good candidate for oral appliance therapy, that treatment option is
pursued.
• The patient undergoes a 3D airway scan.
This scan, which is done before the appliance is made as well as after the appliance is made, correlates the sleep study
findings and analyzes the anatomical effects of the appliance. The fit is assessed
by noting the position of the condyles
with respect to the articular eminence.
The goal is to keep them in as normal
alignment as possible. The airway volume and anatomy is evaluated with and
without the appliance. This information is
combined with the home study and clinical parameters to assess the effectiveness
of appliance therapy.
• An oral appliance is fabricated with the
assistance of an experienced dentist.
Dr. Clark Taylor with a patient
• The patient participates in three home
sleep studies: two without the appliance
and one while using the appliance. These
three sleep studies help determine the
effectiveness of the appliance. The appliance may need to be altered or another
type of treatment may need to be pursued
if the patient continues to have mild to
moderate sleep apnea symptoms and
their AHI remains elevated. The first two
nights are utilized to establish a baseline,
as there is some inherent disruption of
sleep from simply using the apparatus. It
is not unusual to find that the first night
is the most severe with some stabilization
during the second night. Hopefully, the
third night with the oral appliance will
give a true assessment with minimum disruption from the testing apparatus.
Maxillofacial-Mandibular Advancement for OSA
For patients with moderate to severe obstructive sleep apnea – and for those who
are not helped by oral appliances, maxillofacial-mandibular advancement surgery, also
known as bimaxillary advancement surgery,
may be the best solution. This OSA surgery
pulls both the upper and lower jaw forward,
opening the airway, and increases the rigidity
of the air column, making it easier for patients to breathe at night.
MMA surgery is an ideal option for symptomatic patients with an AHI above 20 and
who have not responded well to other forms
CLINICALfocus
of therapy such as oral appliances and CPAP.
MMA surgery has a much higher success rate
than other sleep apnea surgeries, including
UPPP. MMA surgery should only be considered for patients who are in good health and
who have a full understanding of the procedure and its likely results.
At Surgical Sleep Solutions, we have
been performing MMA surgery for 25 years,
and over the past 11 years have performed
this procedure as an outpatient procedure.
During this time, we have had a success
rate of above 90 percent with no unplanned
hospital admissions. Our treatment model
results in shorter recovery times and a result
that often allows patients to forego the use of
their CPAP device.
In some cases, patients with severe sleep
apnea may still have an above-normal AHI
after surgery. In this case, an oral appliance
is an excellent way to further treat symptoms
after the MMA procedure. This is especially
true if the patient chose the surgery because
they had difficulty with CPAP therapy (for
any number of reasons).
The Financial Aspects of OSA Surgery
Despite its many advantages for some
patients, Maxillofacial-mandibular advancement surgery is understandably a more expensive treatment and solution than oral appliances and some other types of therapies.
While the health and quality of life of the
patient is of first importance, patients are understandably concerned with whether they
can afford the procedure and which of the
procedure’s costs are covered by their health
insurance policy. We have been successful in
obtaining insurance coverage for the majority of our patients. Originally, our outpatient
treatment model, which takes place in our
private facility, was developed so that the
patient could benefit from having a single
surgical team comprised of experts on the
procedure; an anesthesiologist specifically
trained for the operation; and one-on-one,
minute-to-minute nursing care following the
operation. But not only did all three of these
aspects greatly improve operating times,
blood loss, postoperative pain thresholds, it
also dramatically reduced the cost of the procedure. In addition our patients returned to
light normal activity and a soft chewing diet
in 7-10 days. A retrospective evaluation of
the costs associated with outpatient delivery
revealed that in most cases, the costs were
reduced by more than half over having the
procedure done in a hospital. In most cases,
costs were reduced by more than half.
The combination of factors
listed above has made the utilization of this procedure much We have had a success rate
more acceptable to the average
of above 90 percent with
patient. It is because of these
factors that it is our procedure no unplanned hospital
of first choice in the treatment
of moderate to severe obstruc- admissions.
tive sleep apnea in patients who
wish to eliminate CPAP therapy
for any number of reasons.
Making the Right Choice for Patients
When seeking the best route to health for
each patient, it is imperative to take the following steps:
• Understand the patient’s medical history.
• Learn about the patient’s sleep apnea presentation and severity.
• Learn about the patient’s sleep apnea
treatment history.
• Start with less invasive and expensive
treatments, such as oral appliances (for
less severe cases).
• Consider MMA surgery in cases of moderate to severe OSA and in cases where
CPAP use is not possible or not preferred.
• Analyze the effectiveness of your chosen
treatment and act accordingly. Consider
the use of oral appliances if mild symptoms persist following surgery.
Clark O. Taylor, BA, MD, DDS, has been practicing medicine and performing surgery for three decades and is the
Founder and Director of Surgical Sleep Solutions. He received his bachelor’s degree from Wichita State University,
his Doctor of Dental Surgery (DDS) from The University of
Missouri, Kansas City, and his Doctor of Medicine (MD)
from Northeastern Ohio Universities College of Medicine.
Dr. Taylor has been actively involved with the teaching of residents and
postgraduate training fellows in the field of maxillofacial surgery. Throughout
the course of his career, Dr. Taylor has maintained active academic appointments at major teaching hospitals where he provides training and continuing
education for a variety of surgical specialties. He also treats patients and
continues to educate physicians through his practices in Missoula, Montana,
and Palm Desert, California.
DentalSleepPractice.com
55
LEGALledger
Short Stuff
by Ken Berley DDS, JD, DABDSM
A
s I write this article, I have just returned from the AADSM
meeting. I enjoyed reconnecting with old friends and
making many new ones. However, it was challenging
to find adequate time to answer all the questions which came
rapid fire from every direction. Not that I mind answering questions, obviously that is not the case or I would not be writing
this column. However, I admit it, sometimes I do get tired of
answering the same questions over and over. Since, there does
seem to be recurring themes, I thought that I would attempt to
cover several topics that do not warrant a full article devoted to
them. I apologize in advance for the lack of continuity on display. However, using this approach I will attempt to cover a lot
of territory in this one article.
56 DSP | Fall 2016
Terminating Treatment
“What should I do if a patient leaves my
practice in the middle of treatment?”
A dentist is obligated to discuss with a
patient the treatment being recommended and any reasonable alternatives that
exist. That disclosure allows the patient to
make an informed decision concerning the
treatment that he or she will receive. This
information sharing is all part of informed
consent. That same philosophy should be
followed if a patient decides to abandon a
course of treatment that has already begun
(or refuses to accept any treatment). In such
cases, the dentist should provide the patient
with a description of the potential risks and
consequences of failing to treat OSA. This
disclosure should include any reasonable
risks to the patient’s health including, high
blood pressure, stroke, heart attack, demen-
LEGALledger
tia, motor vehicle accidents, etc. Once the
patient is informed of the seriousness of untreated OSA, the patient has the legal right
to refuse treatment or discontinue treatment
at any time. Where treatment is refused or
discontinued, the dentist should make sure
that the patient’s record reflects the advice
given, including any health warnings or
risks that were relayed to the patient. The record should reflect that the patient was fully informed of the potential risks of refusing
treatment and therefore made an “informed
refusal” of treatment. For OSA patients, the
dentist is further obligated to make sure that
the patient is referred back to his or her sleep
physician or PCP for alternative care.
“What do I do if the patient refuses to follow protocol?”
This question typically arises in the context of patients refusing to go for a final PSG
or complying with recall instructions or
appointments. AADSM Practice Parameters
2006 states:
3.4.2 To ensure satisfactory therapeutic
benefit from OAs, patients with OSA
should undergo polysomnography or an
attended cardiorespiratory (Type 3) sleep
study with the oral appliance in place
after final adjustments of fit have been
performed.
I think we all agree, it is best if our patients return to the sleep lab after in-office
titration for a final PSG where the MAD is
further titrated for maximum medical improvement. Unfortunately, many patients do
not enjoy the friendly confines of the local
sleep lab and are resistant to comply with
this recommendation. As stated previously,
the patient should be fully informed of the
protocol for the treatment of OSA utilizing
Oral Appliance Therapy. The patient should
be made aware of the medical and other
benefits of a final in-lab titration to achieve
the best results of MAD therapy. However,
if after being fully informed of the risks and
rewards associated with refusing to attend a
final in-lab PSG, you should then document
the patient’s informed refusal. You should list
the risks and benefits which were shared with
the patient before refusal. This list should include the fact that the patient’s MAD may
not be adequately titrated due to the patient’s
refusal to follow protocol. In my office, I involve the referring physician. I send a letter
informing the physician of the refusal and I
ask the sleep physician to send the patient a
letter or call the patient and explain the need
for a final PSG. Rarely do I have a patient
stubbornly refuse to comply after the benefits
are adequately explained.
3.4.3 Patients with OSA who are treated
with oral appliances should return for follow-up visits with the dental specialist.
Once optimal fit is obtained and efficacy shown, dental specialist follow-up at
every 6 month is recommended for the
first year, and at least annually thereafter.
The purpose of the follow up is to monitor patient adherence, evaluate device
deterioration or maladjustment, evaluate
the health of the oral structures and integrity of the occlusion, and assess
the patient for signs and symptoms ... After the patient
of worsening OSA.
I personally take the recall of my is fully informed, they
patients very seriously! It is amazing have a legal right of
how frequently at a recall appointment
I discover that the patient is no longer self-determination.
completely compliant with my treatment. Yet, we struggle to get our patients
to comply with recall. When a patient
does not return for recall, we make at least
three different attempts to reappoint that patient. We go to great lengths to explain the necessity of recall to insure the fit, function and
effectiveness of our treatment. However, after
the patient is fully informed, they have a legal
right of self- determination. The patient can refuse your attempts at recall. These attempts to
appoint the patient must be well documented
with the response of the patient included in
your notes. After the patient is fully informed
and the “informed refusal” is documented in
your records, send the patient’s sleep physi-
Dr. Ken Berley is a practicing general dentist with over 30
years of private practice experience focusing on complex
reconstruction and 20 years of experience as an attorney
licensed to practice law in Arkansas and Texas. He has
extensive experience as a litigator and was a full partner
in Travis, Borland and Berley, Attorneys’ at Law before
moving to Northwest Arkansas. Dr. Berley is a Diplomate
of the American Sleep and Breathing Academy and a
Diplomate for the ABDSM. He lectures in the area of sleep medicine risk
management. He has provided TMD treatment for many years and has incorporated Sleep Medicine in his office for the last 3 years. DentalSleepPractice.com
57
LEGALledger
cian a letter explaining that the patient has
removed himself from recare. Be sure to send
the patient a copy of the letter.
Our office makes final PSG’s and recalls
such a big deal we rarely have a patient refuse. This past year I only had one patient
refuse a final PSG.
HST Ownership
I have been involved in
numerous hearings before
different state boards and if
discipline or sanctions are
imposed, it never involves
the loss of your home.
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58 DSP | Fall 2016
“Will I lose my house if I own HST equipment?”
The short answer is NO! Despite what
you may have experienced at the AADSM,
I have been involved in numerous hearings
before different state boards and if discipline
or sanctions are imposed, it never involves
the loss of your home. First, if a treatment
or condition falls broadly within the definition of the practice of dentistry, there is a
legal presumption that you can explore any
means within your expertise to treat that
condition. As I am sure you are aware, very
few state dental boards have taken up the
subject of HST. Therefore where HST usage
has NOT been addressed, you have a legal
right to assume that HST usage is not illegal
until such time that your state board determines otherwise. However, if you practice in
Oregon, Georgia, Connecticut, New Jersey,
New Hampshire, Alabama or Virginia, your
state boards have taken some action or published an opinion on the treatment of OSA
or HST usage. The next question is how are
you using your HST equipment? In my office
I utilize both HST and High Resolution Pulse
Oximetry to screen and titrate. I do not order
diagnostic home sleep testing in my office,
nor do I employ a remote Sleep Physician
who has not seen the patient to provide a
diagnosis. Not because it is illegal for me
to do that, but because it would make the
sleep physicians that I work with mad. Additionally, I would be accepting all the risks of
treatment. Personally, I want to share liability
with other healthcare providers, therefore, I
would never treat an OSA patient without
the involvement of a physician. When I
screen patients for OSA, I always refer those
patients to a local sleep physician. This allows for a good working relationship with
the Sleep Physicians in my area. I refer to the
local sleep physicians and they reciprocate.
Yes, this arrangement is a “quid pro quo”
but it is not illegal. If I refer patients to local
sleep physicians for diagnosis and treatment,
I then routinely receive referrals of CPAP in-
LEGALledger
tolerant patients for OAT. If I were using HST
for diagnosis, it would jeopardize this relationship. I’m not going there!!!
Now let’s briefly discuss the new Georgia
Dental Board ruling. It states:
Depending upon the diagnosis of the type
and severity, one possible treatment option
for obstructive apnea is the use of oral appliances. The design, fitting and use of oral appliances and the maintenance of oral health
related to the appliance falls within the scope
of practice of dentistry. The continuing evaluation of a person’s sleep apnea, the effects
of the oral appliance on the apnea, and the
need for, and type of, alternative treatment
do not fall within the scope of dentistry.
Therefore the prescribing of sleep apnea appliances does not fall within the scope of the
practice of dentistry. It is the position of the
Board that a dentist may not order a sleep
study. Home sleep studies should only be
ordered and interpreted by a licensed physician. Therefore, only under the orders of a
physician should a dentist fabricate a sleep
appliance for the designated patient and
conduct only those tasks permitted under
O.O.G.A. Title 43. Chapter 11.
When you look at the Georgia Rule in its
entirety, a number of things jump out. First it
attempts to define not only the scope of practice for dentists, but also the scope of practice
for physicians. This is an obvious overreach.
With that aside, the one thing that is certainly
When I screen patients for
OSA, I always refer those
patients to a local sleep
physician. This allows for a
good working relationship
with the Sleep Physicians
in my area.
clear is that a dentist cannot provide Home
Sleep Testing in his office which is read by
a remote Sleep Physician and then fabricate
a MAD without any other involvement by a
physician. From a risk management strategy, if
any readers are routinely employing this type
of model where they are performing HST and
providing OAT without a prescription from a
physician, you are putting yourself in a position of significant risk. DON’T DO THAT!
With that said, this paragraph is very poorly
drafted and creates a great deal of uncertainty.
If I read this statute literally, which attorneys
are taught to do, it seems to state that it is not
illegal to utilize HST in the state of Georgia
in some circumstances. This statute states that
a dentist cannot order a sleep study utilizing
HST. By definition a sleep study is for the diagnosis of OSA and not for patient screening
or oral appliance titration. So the question is:
“Can a dentist in Georgia utilize HST equipment for the titration of oral appliances?” My
answer would be YES. When oral appliances are titrated, most dentists do not send this
data to a sleep physician for scoring and the
data is not being utilized to diagnose the existence or severity OSA. Computer scoring
is typically utilized, therefore, I would argue
that a titration study does not meet the definition of a “sleep study”. If the board wanted
to ban ALL usage of HST that statute would
have been simple to draft. The wording of this
statute does not ban the ownership of HST
equipment or the utilization of HST for titration of Oral appliances. The Georgia Board
of Dental Examiners chose not to incorporate
verbiage banning all HST ownership. This
statute prohibits a dentist from ordering a diagnostic home sleep test only. In my opinion
the verbiage of this poorly drafted statute certainly opens the door for legal interpretation
and confusion.
As a side note, I personally feel that this
statue would not withstand a legal “constitutional” challenge. Not because the board
does not have the legal authority to limit the
use of HST, it certainly does, but, this statute is so poorly written a Judge would likely
throw it out as ambiguous.
Informed Consent
“Does consent have to be in writing?”
I am aware that some lecturers in Dental
Sleep Medicine routinely declare in lectures
that verbal informed consent is a breach of
60 DSP | Fall 2016
LEGALledger
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62 DSP | Fall 2016
the “standard of care”. That is a common
misconception among healthcare providers. You should know the standard of care is
determined by law not by the misinformed
lecturers. Sadly as a result, there is still
confusion in the area of informed consent.
Frequently, I am asked about whether “the
law says that consent has to be in writing?”
The Law of informed consent has been settled for many decades. Under the Law, Informed Consent generally DOES NOT have
to be written. Now before you go nuts, you
need to be aware that each state has statutes
and case law that list certain procedures
where consent MUST be in writing. The
types of medical procedures that are historically found in these state statutes are: procedures that could result in the sterilization
of the patient; breast biopsies, in vitro fertilization, and HIV testing. All other medical
procedures can be verbal. That is the LAW!
However, you should be aware that in this
day and time, juries expect consents to be in
writing. While that is not the law, it certainly the perception of juries. Therefore, from
a risk management prospective, consents
should be in writing! It is my experience that
if you do not have a written consent when a
plaintiff’s attorney reviews your records, you
will likely be sued! Most plaintiff’s attorneys
do not know if you did anything wrong. They
just know if the patient suffered a “bad” outcome and whether a written consent lists the
“bad” outcome as a possibility. Therefore, it
is not a breach of the standard of care for
consent to be verbal, but the lack of a written consent makes it virtually impossible to
prove what was discussed with the patient to
obtain consent. In my legal opinion, the lack
of a written consent greatly increases your
risk of being sued!
E-codes
“Can I use an e-code to file medical insurance for this product?”
To be continued! I was asked by several vendors if it is legal to employ certain
E-codes to file medical insurance for different products and have the dentists distribute
that product. I hope to answer this question
in the winter edition. There, I will discuss
the products and the codes involved and let
you know my thoughts. Stay tuned! More
to come!
LINKEDIN
Excerpt from “Consensus on Verbal Skills that
Help Build a Dental Sleep Medicine Practice”
by John Viviano, DDS, DABDSM
T
he LinkedIn Discussion Group, “SleepDisordersDentistry” has just
completed an open discussion on “Verbal Skills” that help build a
dental sleep medicine practice. The full consensus statement is available at the LinkedIn group.
What was asked
“Building a Dental Sleep Medicine Practice has proven to be both exceedingly rewarding and exceedingly difficult. Obstacles abound; physician
resistance, re-imbursement resistance, misinformation about oral appliances, fear of side effects such as bite changes, the learning curve involved, etc. Let’s share our personal experiences, tips, suggestions, and in particular,
“Verbal Skills” that effectively deal with these barriers…”
What was said
Tony Soileau posted links to videos he created, directed at the layperson, to communicate sleep issues with patients. Kent Smith shared that he
viewed these videos repeatedly to glean phrases that may come in handy in
his practice.
Rob Suter feels that inadequate “Verbal Skills” is one of the primary reasons more patients don’t get diagnosed and treated.
“University of Chicago hospital used the Stop-Bang on 1,000 patients and
tracked only 8% getting treatment! So 92% with high risk for OSA fell out of
the sleep channel at one of our top Academic Hospitals.”
Rob insightfully suggested that if this is the success rate experienced in
a top-tier Health Centre, as dentists we have to work that much harder to
motivate to therapy. His company, OSA University, softens the term ‘Sleep
Apnea’ to “Airway Health.”
“Instead of saying you could die of an MI or have a stroke, focus on things
people really care about: Weight, Energy, Cognition, Skin Quality, etc. Those
are the things people spend tons of money on and are motivated by.”
Rob shared: “Many DDS teams can’t handle sleep phone calls if they
aren’t trained or experienced to collect key pain points and verbalize what
OAT or PAP can do to relieve that pain point.”
Steve Carstensen joined in and provided something he learned at
the Pride Institute many years ago.
“The first point is to learn what is the Chief Complaint. Nobody wants a
“MAD”, they want to “Stop Snoring”, for example. This communication is
not unique to medicine, it’s universal human connectivity. We must address
others where their concerns lie. For patients, it is the symptoms. For our
colleagues, it is a mixture of their commitment to improving their patients’
health and their business. When we take time to learn what other’s hot buttons are, we can shape our responses to keep them involved in the conversation. If a patient calls and says “I want to stop snoring’ and we talk about
‘AHI’, we’re not meeting them where they are. Doesn’t mean our clinical
wisdom isn’t important, it just means we are not giving the encounter enough
chance to be successful.
If our collaborating physicians perceive that we do care about them, their
patient outcomes, and their desire to remain in the treatment loop (no matter
what their motivation for that is) then we have
a better provider team. Better communication
comes with focusing on the other person.”
Todd Morgan stressed the importance of
a well-trained team and the “Hand Off” approach he uses in his office. Todd’s assistant
acts much like a PA in the sense that they
work-up the patient’s Chief Complaint (CC)
and History before he sees them. The assistant will then “Hand-Off” the patient to Todd
while reciting the CC, prior issues and History. Todd finds that this system saves time and
the patients feel like they have been heard!
Kent and his team listen for the “M&M”,
or “What Matters Most” to the patient. Kent
places the patient’s M&M in the chart note
to refer to when following up as the patient’s
progress through therapy. The M&M is also
passed on to the physician and the financial
coordinator (if needed), so the patient is kept
aware of why they actually made the appointment in the first place and how far they
have come as therapy progresses.
Once again, I would like to thank all
those clinicians that took the time to participate in this discussion, this consensus article
is intended to provide guidance for those that
are new to this area of practice and also to
provide valuable insights for those of us that
have been at this a while. I look forward to
your participation in future SleepDisordersDentistry LinkedIn discussions.
John Viviano, DDS,
DABDSM, obtained his
credentials from the University of Toronto in 1983.
His clinic is accredited by
the American Academy
of Dental Sleep Medicine and is limited to
providing conservative therapy for Sleep
Disordered Breathing and Sleep Bruxism. A
member of various sleep organizations, he is
a Credentialed Diplomate of the American
Board of Dental Sleep Medicine.
DentalSleepPractice.com
63
SLEEPdeeplyWAKErefreshed
CLUES
Across
4. Sleep noisily
5. Ensuring a device is the
correct size
6. Sleep study test to diagnose
obstructive sleep apnea, abbr.
7. Thing referred to
8. Take steps
10. _____ advancement, MMA
11. One of five stages of sleep
14. It’s used to measure the severity
of sleep apnea, abbr.
15. Condition that causes breathing to
stop and start during sleep, abbr.
16. Sleep ____, aka polysomnography
18. Effective treatment for snoring and
obstructive sleep, abbr.
19. Record of medical events
21.Concealed
24. Disorders characterized by
abnormal respiratory patterns or
insufficient ventilation during
sleep, abbr.
25. Test to diagnose sleep disorders
26. Patient’s tag shows it
27. It can cause pain in the jaw joint,
abbr.
28.Function
30. It’s often a major factor in sleep
apnea conditions
31. It might be used to reduce the size
of 30 across
32. It’s used for screening sleep apnea
patients, goes with 18 down
Down
1.Rest
2. Passage that gets blocked
during sleep apnea
3. How old a patient is
4. Street, for short
5. Hold in place
6. Appliance that can be
effective for those with
sleep disorders
9. Common treatment for
sleep apnea cases
12. Sleep apnea _____ guard
13. Obesity is a _____ of sleep
apnea in patients
16. ____ position- on the side is
best for sleep apnea patients
For the solution, visit www.dentalsleeppractice.com/crossword.
64 DSP | Fall 2016
17.www.medmarkaz.com
is one
18. See 32 across
20. It’s been used as an
alternative treatment for
patients that don’t adhere to
the CPAP treatment
22. Overall term for dental
treatment of sleep disorders,
abbr.
23. Retain in place
28. Sleep disorder characterized
by airway resistance to
breathing during sleep
29. Steady, as in pressure
30. Mandibular advancement
device, abbr.
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