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No Patient Left Behind Continuing Education

Punishment for “Needing“ a MAD by Dr. Kevin Kwiecien

Special Section

AADSM Preview SUMMER 2017


Education in Sleep Medicine

by Michael Simmons, DMD, MSc

Jaw Position

Why Start There?

Supporting Dentists Through PRACTICAL Sleep Apnea Education

by Mayoor Patel, DDS, MS, RPSGT


Knowing What We Know, Doing What We Do


eeing what needs to be changed, updated, refreshed, and relearned can be challenging for a busy dental office. Take a class, make some sleep appliances, and set that aside as a system and move on to some other learning challenge. Does that describe your sleep breathing practice? Do you consistently see great results or are there patients you’d rather not find on the schedule? Maybe you haven’t yet developed the systems you need. You are interested, but haven’t quite reached the confidence point to offer the service to your patients. Like every other endeavor worth doing, getting started is the hard part – finding the footing needed to reach out and up to stretch, to grow, to achieve something that requires more. More of all parts of our professional lives – more knowledge, more service, more skills, more time, energy, and focus. Some dentists and their teams never find this solid base to stand upon, but reach anyway. They lack the learning and commitment needed; soon they find the limits of their preparation and face a patient, team member, or medical colleague with questions they have no answers for. Such poor results diminish the excitement and dim the prospects for ongoing success. Many dentists focus only on the base – they convince themselves that more classes, more learning, more study or memberships are necessary before they dare treat a paying patient. Plagued by lack of confidence, the hours, dollars, and effort invested are never rewarded with patient health improvements and team excitement. Living in a world of paralysis by choice, the reality of rewards by action escapes them. Team members, anxious to help, lose enthusiasm as their leader takes one more class only to fail to gain rewards from patient success. DSP is dedicated to helping raise community health by empowering dental teams to solve the practical barriers to providing

the service to people at risk for sleep breathing problems – this issue celebrates our third anniversary of this effort! We’ve put together this special edition to give the dentist looking for a solid foundation some tools to address common concerns. If you need education, there’s a descriptive article and a challenge in these pages. Recognizing a shortcoming and seeing a path to solving it can generate the confidence to move forward. If you have taken plenty of classes, I hope that checking through these articles will help you realize that you’ve learned what is presented. What remains is to act. Good for you if you’ve studied well. Excellent that you have prepared yourself and your team for impact on your patient’s lives. Superb that your professionalism requires only the most ethical behavior by you and everyone on your team. The focus is always on building value in the patient encounters. It’s time to make those encounters meaningful, to put to use what you know, to stand on those excellent values and declare that you are ready to help. The journey begins when the patient asks, “Why do you want to know about my sleep?”

Steve Carstensen, DDS Diplomate, American Board of Dental Sleep Medicine

Dental Sleep Practice subscribers are able to earn up to 2 hours of AGD PACE CE in each issue by completing questions about an article (see page 32) and submitting to our website. Sponsored by Medmark and Seattle Sleep Education.




Cover Story

No Patient Left Behind by Elias Kalantzis and Ryan Javanbakht Working through the barriers to OSA treatment

Continuing Education


Punishment for “Needing” a MAD: Condemned to Suboptimal Treatment? by Kevin Kwiecien, DMD, MS It’s not ‘either-or’.



Special Section

AADSM Preview


Jaw Position

Why Start There?

by Mayoor Patel, DDS, RPSGT Where to set the MAD to begin.


Education Spotlight

Education in Sleep Medicine

by Michael Simmons, DMD, MSc A Pathway and a Challenge.

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844 537 5337 Data on File. 2Based 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 and Dr. Vranjes during poster and oral presentations. University of Calgary in Alberta Canada, Zephyr Sleep Technologies, Calgary, Alberta, Canada, The Snore Center, Calgary, Alberta, Canada.


CONTENTS Practice Management

Knowing Your Patients Trains Them to Make Healthy Choices


10 Practice Development

Top five dental marketing scams by Cory Roletto, MBA Some marketing tactics to avoid.



Does Medical Insurance Cover Oral Appliances for Sleep Apnea & Snoring? by Rose Nierman, CEO Nierman Practice Management Vital tips for an unfamiliar but necessary service.


Practice Management

Conversations about Real Insurance in OAT can be Different by Mark T. Murphy, DDS, FAGD Your system limitations can keep patients from vital therapy.


Choosing Appliances

Choosing the best oral appliance for treating Obstructive Sleep Apnea... by Dr. Steve Lamberg 110+ choices, endless human variation.


Appliance Delivery

Getting it in Their Hands: The Delivery Appointment by Erin E. Elliott, DDS, and Brianne Bove Adherence to therapy starts here.

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by Amy Morgan Patients often need a boost to choose for their best interests.


Summer 2017

Starting Early

Sleep Disordered Breathing in the Pediatric Population is a Silent Epidemic Your team can open the door to health.


Practice Growth

“SELL” is a 4 Letter Word by Chris Bez Introducing our newest regular feature: Practice Growth.



Marketing to MDs: Building Strategic Alliances to Treat More Airway Patients by Rob Suter How to break into your market.


Editor in Chief | Steve Carstensen, DDS Managing Editor | Lou Shuman, DMD, CAGS 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

National Sales Director Kristin Sammarco | Manager – Client Services/Sales Support Adrienne Good |

Patient Motivation

Uncovering the Why Behind OSA Treatment Acceptance by Steven Wick People decide based on their own motivations.

60 Legal Ledger Medicare DMEPOS: Friend or Foe? Part 2

by Ken Berley, DDS, JD, DABDSM, and Courtney Snow


Publisher | Lisa Moler

Sleep Game

DSP Word Search

Creative Director/Production Manager Amanda Culver | Website Manager Anne Watson-Barber | E-media Project Coordinator Michelle Kang | Front Office Manager Theresa Jones | MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Subscription Rates 1 year (4 issues) $129 | 3 years (12 issues) $349

©MedMark, LLC 2017. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Dental Sleep Practice magazine or the publisher.



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Patient Left Behind T

here’s an epidemic that’s 85% undiagnosed, affecting people all around us. Every medical professional has responsibility, but, so far, patients are suffering. As our country settles into a new norm and political direction, we find ourselves facing unique realities and engaging in new ways of processing and thinking. We are left with an understanding that the way things were done in the past may bear little weight on our current management or new way of business. FAKE NEWS. Even new vocabulary has been introduced and streamlined into everyday lingo. National leadership campaigns have shockingly challenged the reporting giants of our country. The supreme, conventional agents of media reporting on truths are no longer accepted with full certainty. New news, old news or lack of news — can no longer be accepted without question. It’s no surprise that even in our industry, this logic applies. Large dental sleep organizations are declaring new standards for accreditation and participation. When can we blow the ‘fake news’ whistle on these targets, which seem devoid of consequential benefits and significance regarding our greater goal? No Patient left behind. That’s our goal. Isn’t that the essence of the pledge that we made as professionals in dentistry and medicine? We have an obligation to serve people to the best of our ability. Furthermore, as dental sleep medicine practitioners, we have a moral responsibility to help struggling patients with their airways and sleep disordered breathing.

by Ryan Javanbakht and Elias Kalantzis

Dental sleep medicine has become even more important because in 2015, the Center for Disease Control (CDC) released clear and indisputable information regarding sleep apnea: It declared that sleep apnea had become a national epidemic.  A homeland crisis of a grotesquely evergrowing sleep apnea epidemic has been happening for years, and now the light has been turned toward this disease. Unfortunately, we have also come to know from studies1 that approximately 85% of people who have Obstructive Sleep Apnea remain undiagnosed. We are faced with an epidemic and 85% of us are still in the dark about it.  Even more alarming may be the declining number of Sleep Medicine specialists available to treat this epidemic. In 2007, the American Board of Internal Medicine (ABIM) first administered the examination for certification in Sleep Medicine. In many ways, this recognition by the ABIM was crucial to legitimize the field of sleep medicine. Many thought that adding Sleep Medicine to the ABIM would not only increase the awareness for quality sleep health but also increase the number of patients who would have access to a sleep test. Unfortunately, the disheartening reality is that the reverse is occurring and very few people are aware of it. Unfortunately, the acceptance by the ABIM has inadvertently restricted the access of care for patients. How is this possible? According to the ABIM, in 2011, there were 1,575 new physicians who were boarded in sleep medicine. Many were physicians able to


COVERstory utilize a “practice pathway” program that ended that year. These practicing physicians were ‘grandfathered in,’ but since then, the number of newly-boarded physicians depends on how many apply for fellowships and then take the certification exam. Since then, approximately 300 new physicians are boarded in sleep every other  year, and 25% of fellowship training ‘slots’ go unfilled. No one has statistics on how many board certified sleep physicians retire or otherwise stop seeing patients every year, but no matter the precise numbers, we can be confident there are not enough to meet the epidemic of untreated people. These untreated patients end up suffering from heart disease, diabetes, obesity, stroke and/or increase their chance of sudden death by 46%. More people need help and we have fewer sleep physicians to screen, test, and treat patients in need. Furthermore, we have newly proposed guidelines from organizations requiring OSA patients to have a face-to-face visit with a board certified sleep physician. How is this not restricting the access to care?   Perception is Reality — another trending topic. Not only are we becoming more aggressive in voicing national ‘truths’ but new perceptions are shaping global realities. Whether this is a strategic leadership approach, an intentional diversion or brilliant fusion of both, things are different. They are becoming what they appear to be.  We can find the same in our industry. For instance, let’s look at Home Sleep Test (HST) and the New Jersey state dental board from a few years ago. In 2015, dentists in the state of New Jersey heard that they were not able to recommend, distribute, or handle a home sleep test to patients due to the board voting to adopt this position. Some took that to mean that they couldn’t treat sleepy patients at all. New Jersey dentists began to fear discussing the topic of sleep and airway issues with their patients, but it was Fake News. Perception is Reality. Restricting access to care for sleep apnea and airway issues has a tremendous effect on our country. “Approximately one in four patients in a dental practice is at risk of sleep disordered breathing. Dentistry has long been proactive in ensuring that patients are seen on a biannual basis for early disease detection and prevention,” states John Tucker, DMD ( He added, “The dental profession is a logical partner to the sleep physicians in continuing

8 DSP | Summer 2017

Untreated patients end up suffering from heart disease, diabetes, obesity, stroke and/or increase their chance of sudden death by 46%. More people need help and we have fewer sleep physicians to screen, test, and treat patients in need. website

this practice of primary screening for sleep disordered breathing. If the sleep physician diagnoses a sleep disordered breathing problem, the dental professional can then provide appropriate treatment based on the sleep physician’s recommendation as well as the patient’s treatment preference.” Dr. Tucker is referring to the “Prevalence of Symptoms and Risk of Sleep Apnea in the US Population” study2 from the chest physicians. This information leads us to consider the diagnostic options for patients of a dental practice. On the positive side, a full in-lab Polysomnogram (PSG) measures more channels than any home sleep test device currently on the market.  Sadly, many patients who are prescribed a PSG for suspected OSA never follow through with the sleep test. This is why home sleep testing is a great option for patients that don’t have access to a local sleep lab or who refuse to stay overnight in one. Regardless of what vehicle is used as a sleep test for patients, a board certified sleep physician is needed to read and diagnose the sleep test. The best case scenario for a dentist is to have a local sleep lab that is HST-friendly, and have a board certified sleep physician who is aware of the clinical validations for oral appliance therapy and willing to work with a dentist in a multidisciplinary approach to treating patients. Because these relationships are not always easy to foster, practitioners are encouraged to utilize home sleep testing in conjunction with working alongside a board certified sleep physician to obtain a diagnosis and the patient’s primary care physician for treatment.  No Patient Left Behind  means fighting for your patients and not allowing them to continue to be in jeopardy of sub-optimal health. If they won’t attend an overnight

COVERstory sleep study at a lab, it’s your obligation to push for their health. If a patient won’t agree to testing, treatment is not possible. When treatment is not possible, the epidemic continues and patients’ airway issues worsen to the extent of strokes, cardiac arrest, and even fatality. Sleep testing is not a “one size fits all” game…just like choosing your oral appliance. It is imperative to consider your state’s protocols, your training and clinical readiness, clinical benefits, and medical coverage. Just like a patient must own their diagnosis before accepting treatment for obstructive sleep apnea, a dentist must own his or her treatment plan. In fact, they must own every choice they make when “practicing” dentistry and/or medicine, then remain accountable for those choices and actions. With the increasing number of sleep labs closing and insurance payers that won’t support reimbursement for sleep studies, it is time to get on board with new options that will ensure more patients get the care they need. If not, we will continue to see the rise in co-morbidities linked to sleep apnea and airway obstruction. On that note, how about some good news? Dr. Sharon Keenan, PHD, RPSGT, the Founder of The School of Sleep Medicine Inc.™, recently mentioned, “We enthusiastically embrace the opportunity to welcome our dental colleagues in the fight against ignorance about healthy sleep and sleep disorders. Because dentists have a unique role in helping patients maintain, indeed maximize health, it is critical that we share and exchange knowledge to move forward in the quest of optimal health and well-being for our patients.” This instantly made my heart smile. Having the distinguished Dr. Keenan embrace the dental community has no doubt solidified our common goal to work in a multidisciplinary approach to treating patients. Organizations like The School of Sleep Medicine, Inc.™ (http://www. ) will no doubt help propel dentists to work more closely with physicians for their patients needing sleep medicine services. Too often, we hear of dentists who are highly educated and motivated to treat dental sleep patients encountering wasteful roadblocks/barriers along the way. They may spend tens of thousands of dollars (we have heard up to $150,000.00) just to get involved in dental sleep medicine. Recently, I spoke with a doctor who spent 14K for himself and his partner to attend a mini-residency program, only to hear that they cannot facilitate, administer, or even order a sleep test. This by the same orga-

nization that provided the education. Dentists feel dismayed with the process and may stop screening patients altogether. If we all agree on the thought process of “No Patient Left Behind,” we must go beyond educating patients. We must create a “movement.” How does one help facilitate change? Let’s look beyond the status quo. If you ask Dr. Howard Hindin, DMD, MS, he says: “How we breathe, as well as the structure and Just like a patient must function of our airway, determines our health, performance and quality own their diagnosis of life. Today still only 15% of men, women and children have their “hid- before accepting den” airway / sleep problems recog- treatment for obstructive nized and adequately diagnosed and treated. Addressing this detrimental sleep apnea, a dentist condition can offer solutions to many must own his or her of the widespread health problems in our society today. The dental team treatment plan. can and must play a “frontline” role in diagnosis and treatment of airway dysfunction. In the near future it will be the standard of care.” These are phenomenal words spoken by a true thought leader in our industry. Words that can transcend into motion can be used as a catalyst to activate change. If we all want to help more patients get diagnosed and treated, let’s do it together! We all need to realize that we need to use a multidisciplinary approach to help treat patients. We approach the “tipping point,” when barriers of identifying patients and maximizing opportunities for treatment will become the way things used to be done, but not anymore. Keep an open mind and remember your purpose, and you will help more people. “No patient left behind.” Become the movement. Fight the fight. Make a difference. Patients need you.   1. 2. Quote source:

Ryan Javanbakht is a Co-Founder of – an organization built on the foundation of their core values to conduct a more effective sleep testing model. His mission is to minimize barriers to testing, increase awareness, and help more people. His vision is a movement assembled around: “No Patient Left Behind”. Elias Kalantzis is a Co-Founder of and Founder of OSA University. He has made it his life’s mission to spread awareness for quality sleep and airway health. Elias is a board member of the American Academy of Physiological Medicine & Dentistry and heavily involved with the Foundation for Airway Health.



Knowing Your Patients Trains Them to Make Healthy Choices by Amy Morgan


our patients don’t want to feel overwhelmed. Your team doesn’t, either! Leading your patient to know more about what you know while you learn about them is what Pride Institute believes is the best way to form a long-term relationship based on value, commitment, and accountability. My team gets asked “How?” by dentists all the time. One of my favorite quotes that helps to definitively answer that question is: “Patients carry their OWN DOCTOR inside. They come to us not knowing that truth. We are at our best when we give the physician who resides within each patient a chance to go to work.” Albert Schweitzer Since patients may not know what the best course of treatment is, it’s important to explain the pathways and options to them from a perspective that’s not mystifyingly clinical, nor just fact-based. Remember that every patient satisfaction survey that has been done in the medical/dental world highlights the same reasons that patients say no

10 DSP | Summer 2017

to treatment, or no show or cancel, or fail to follow through with their care: • They don’t feel listened to! • They don’t understand how and why we are treating them. • Since they don’t understand what we are doing, or why, they think it’s too expensive or unnecessary. • Therefore, they choose other ways to spend their time, money and energy In this era of You Tube videos, Wikipedia, and WebMD, it is safe to assume that your new patients may have done some online research before picking up the phone. This tends to confuse them more and it definitely does not mean that they fully understand sleep issues. Nor do they understand the breadth and scope of potential sleep solutions! Therefore, the ultimate goal of every new patient interaction is to educate, motivate and help them find their own reasons to value care. Co-diagnostic partnerships grow when potential patients learn what questions to ask

IS SLEEP BRUXISM WEARING YOUR PATIENTS DOWN? Are your patients continuing to brux even after you have created uniform contacts on their teeth? Have you considered airway obstruction as a contributing factor for sleep bruxism? There are many studies that show sleep bruxism is related to the patient’s subconscious attempt to protect the airway during sleep. The new Gem Pro screening system provides a quick and easy way to compare oxygen saturation levels during bruxing activity. The data can be instantly emailed without the patient leaving home. You can review without having the GEM unit.

Designed for Dentists The GEM PRO • Captures five channels of data while sleeping • Links bruxism and airway* • Includes body position and audio recording for behavioral therapy


Ask your Whip Mix representative for more information on this home screening system and service.


• Captures two channels of data while sleeping • Screen for potential airway obstruction before treatment • Titrate sleep appliances on-line, reducing number of office visits *


“Patients carry their OWN DOCTOR inside. They come to us not knowing that truth. We are at our best when we give the physician who resides within each patient a chance to go to work.” – Albert Schweitzer

and then hear better answers than they can find on their own, which makes all the difference! The following is a list of key questions that we hope your educated patients want answers to. To train your patients in advance of their first appointment, these can be included on your website on a custom FAQ tab, in a mailed or virtual welcome packet or in marketing materials to be used in coordination with your allied health care community. Use them well and build commitment! In order to get the most from your new patient evaluation, please consider your thoughts about these questions. Sharing this with your dentist/sleep solution provider will be a great start. Please add any other questions that will help us discover how we can best work together. • What are my short and long term goals for my oral health/overall health? • What do I currently do to maintain my health? (Exercise, medications, etc.) • What is my chief concern, issue or problem that led me to make this appointment? • What in my life is worse because of this problem? • Was I referred by another medical/ dental professional? And if yes – what did they want me to learn? • What symptoms am I experiencing and what’s the most likely cause of my symptoms?

Amy Morgan is CEO of Pride Institute, a nationally acclaimed results-oriented Practice Management consulting company. Amy and her team of highly qualified consultants have revitalized thousands of dental practices using Pride’s time-proven Management Systems, resulting in dentists becoming more secure, efficient and profitable. Pride Institute, founded in 1976, is dedicated to substantially improving doctor’s professional, financial and personal lives. Specifically, Pride has taught over 20,000 dental offices how to excel in effective Leadership, Staff Management, Treatment Presentation, Scheduling, Patient Financing, Cash Flow/ Goal Setting, Social and Traditional Marketing and Transition Strategies. For more information, please contact the Pride Institute at 800-925-2600 or

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• How does this issue/problem affect my current and future health or lifestyle needs? • What research or advice have I already gotten on this issue/problem? • What are all the options for treating my symptoms/problem? What treatments are available? • What kinds of tests do I need? Do these tests require any special preparation? • Is my condition likely temporary or long lasting? • Of the treatment choices I know, this is the one I think so far would be best for me. • What obstacles or challenges could get in the way of getting the best results from this treatment? • I have other health conditions. How can I best manage these conditions together? • I have other life-stress or issues that may be contributing to the issue, does this effect treatment? • Should I see only a certified specialist? • What will my responsibilities be, in order to derive the longest term benefit from treatment? What about home-care? • Is there an upper limit to what I’m willing to do to solve my problems? Is there an upper limit to what I’m willing to pay for the treatment that could solve them? • What is the cost for the ideal treatment and does your team work with patients to help make the treatment affordable? • Does your team work with patients to understand their insurance benefits, so that it can help cover the cost of care? • Are there any brochures, videos or other printed material that I can take home with me? What websites do you recommend? • What in my life will be better when my problem is solved? An educated patient will want to do what you want them to do. They will rise above finance, insurance and scheduling obstacles to get the treatment they deserve and desire. So, if you want better patient conversion and retention… train your patient and help them connect to their internal Doctor!


Top five dental marketing scams by Cory Roletto, MBA


e have all received the letters, seen the emails, and may have even answered a call from a company claiming something that is not true or promising something too good to be true. Over the past 7 years working with dental offices, we have seen our share of less than reputable marketing practices. In this article, we will talk about the top five dental marketing scams. 1. You receive a letter that your domain is expiring and needs to be renewed. This letter may look very official, and many have the word domains in the company name. The form asks you to fill out information about your domain, give your approval to renew the domain, and send payment. The payment request is often $100 or more. With rules established by The Internet Corporation for Assigned Names and Numbers (ICANN), the governing body for domain purchase and transfer, you are unlikely to actually lose control of your domain, but you may not even notice your money didn’t go to pay for domain renewal. If you are in doubt, you can verify the domain registrar by doing a WHOIS lookup on your website domain; most domain registrars have this feature. Here is a link to the WHOIS lookup page on Network Solutions: whois/index-res.jsp 2. You receive an email that they have evaluated your website, and it has not been SEOed. These emails are often automated spam emails with wording that makes it sound like they have evaluated your website, but upon closer inspection don’t give any specifics about what they found — because no one actually evaluated your website. They will often make nonsensical statements such as your website is not web 2.0 compliant and have a link to test

Receive your free marketing consultation today: 888-246-6906 or

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your site, or one of the following blanket statements: a. You have low online presence for many competitive keyword phrases. b. Your social media accounts are unorganized. c. You have many bad back links to your website. d. Your website is not compatible with all mobile devices. e. Your website is being penalized by Google. These types of spam emails have become more sophisticated often using search scrapers to pull some easy-to-obtain data about your website that is added to the email to make it appear legitimate. They may also have a graph showing made-up metrics; for example, social media completeness. One other obvious red flag that is the email will not have any information on the company that supposedly evaluated your website, giving just a callback number or a Gmail email to respond. 3. A review directory representative states he/she can get negative reviews removed or make your positive reviews show up more, if you sign up for an advertising package. We have actually had salespeople for a very large, well-known review directory system state this to us and many of our clients. This is always stated over the phone, and they have never put it in writing — because it is flat-out not true. I am sure the directory involved would not condone this type of sales tactic, but we have seen it so many times, it had to be mentioned. The

PRACTICEdevelopment truth is any reputable directory does not let advertising dollars influence what reviews do or do not show up when searching for a service. 4. They say they have a special relationship with Google. In this instance, the claim is that due to a special relationship, they can do things others cannot, such as getting special pricing on Google pay-per-click (PPC) campaigns or obtaining a No. 1 ranking on Google search. They may also misuse Google Partner to imply special treatment. Being a Google Partner means that personnel at the company have passed one or more Google certification tests showing they are proficient in some aspect of SEO or PPC. Being a Google Partner is a good thing, but it does not provide any special privilege or advantage other than the fact that the company has taken the time to be certified. 5. They assert that your Google PPC campaign is showing up in Europe because it is using the default settings. This was one of

the most outlandish claims we have seen. To start, Google requires the region for the PPC campaign be set as part of the creation of the PPC campaign. Second, there is no way for someone to accurately detect Google PPC campaign settings. Also, if someone guarantees a No. 1 ranking in Google, they can only be referring to Google PPC where the No. 1 ranking can be bought by paying more per click, which is less than optimal. If a salesperson makes any of these claims, run.

Cory Roletto is partner and co-founder of the dental marketing firm WEO Media,, where he leads the operations team. He holds a MBA and BS in Chemical Engineering from the University of Washington.

We’ve saved patients time and money and created higher treatment plan acceptance. — K.B., Office Manager, Raleigh, NC

At Lending Club Patient Solutions, we’ve spoken with thousands of patients and practices. During our conversations, we’ve learned that straightforward payment plans lead to more satisfied patients. That’s why we only partner with banks that offer simple, budget-friendly payment plans. When you’re looking for payment plans to complement your care, give us a call.

To see how straightforward patient financing can be: Call (855) 770-6673 ■ Visit

© 2017 Lending Club Patient Solutions products and services provided through Springstone Financial, LLC, a subsidiary of LendingClub Corporation. Payment plans made by issuing bank partners.

Lending Club Patient Solutions Dental Sleep Practice, June 2017 Half page horizontal ad

Size = 7.375” x 4.875”



Why Start There? by Mayoor Patel DDS, MS Finding the Starting Jaw Position

One challenge, and point of many discussions, is the starting position for oral appliance therapy in the management of obstructive sleep apnea (OSA). A question that often comes up is “where do I set the first jaw position?” If I had the answer to this question, I would look like a genius. We seem to forget that our bite position, whether it be a phonetic bite, George gauge, ProGauge, pharyngometry, or any other method, is a relative starting position. This bite position allows us to start at some point in space while considering a comfortable position for the patient.

The Oral Appliance – How it Works

Oral appliances (OA) are designed to improve upper airway configuration and prevent collapse through alteration of jaw and tongue position. These appliances are often termed “mandibular advancement devices (MAD),” “mandibular advancement splints (MAS),” or “mandibular repositioning appliances (MRA).” The posterior airway is opened with an OA by advancing the mandible relative to the maxilla, and repositioning the many connected soft tissues in a forward position. While these devices are thought to increase upper airway caliber, activate upper airway dilator muscles, and decrease upper airway compliance, their precise mode and site of action are unknown. The velopharynx was revealed to be a principal site of enlargement by the action of MAD by many authors using cephalometric analysis,1,2 or fiber-optic video-endoscopy.3 Choi et al showed that both the retropalatal (velo-pharynx) and the retroglossal areas of the oropharynx are significantly enlarged with mandibular advancement in most patients with obstructive sleep apnea.4 Imaging studies show that mandibular advancement with OA enlarges the upper airway space, most notably in the lateral dimension of the velopharynx.5 Lateral expansion of the airway space is likely mediated through tissue movement via direct connections between the lateral walls of the pharynx and the ramus of the mandible.6

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The Treatment Outcome

Various patient factors have often been associated with the treatment outcome. Less severe disease and supine-predominant OSA (a higher AHI in supine compared to lateral sleeping position), have been considered favorable predictors for treatment success.7,8 Younger age, female gender, and less obesity (lower BMI and neck circumference) can even be positive predictors of treatment success.7,9 Craniofacial features assessed by lateral cephalometry, including shorter soft palate length, lower hyoid bone position, greater angle between the cranial base and mandibular plane, and a retrognathic mandible, are also associated with favorable treatment outcome.7,10,11 Although various patient phenotypes have been related to a higher likelihood of treatment success, these are not universal, meaning that patient response is not predictable using phenotype details. If we can’t predict where the jaw needs to be at the end, it means we have to randomly choose where to start, also.

OA Design Parameters

Even the most experienced clinician universally uses titratable appliances, because of this need to select among the many start position choices. Numerous prefabricated or custom-made MAD have been designed and developed for OSA patients that allow adjustment after delivery.12-14 While there are many different design parameters, we must determine the degree of mandibular protru-

JAWposition sion and vertical opening. These crucial design parameters have been extensively investigated, but the ideal amount of therapy has not yet been defined.4,15,16 I’m sure we will get to a better definition, but for now it is left to our interpretation. A dose-dependent effect of mandibular advancement was demonstrated using 4 randomized levels of advancement (0%, 25%, 50%, and 75% maximum), with the efficacy of 50% to 75% advancement greater than 25%, and 25% greater than 0%.3 However above 50% of patient’s advancement range,, there was an associated increase in reported side effects. A titration approach to determine optimal level of advancement with gradual increments over time is thought to optimize treatment outcome.17 Titration can be guided by subjective symptomatic improvement, consumer-level 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

devices and apps, and objective monitoring by overnight oximetry, all the while limited by patient comfort, to (unofficially) find the optimally effective advancement level. 17 Assessment of pharyngeal collapsibility during mandibular advancement has also shown a dose-dependent effect in improvement of upper airway closing pressures.18 Gao et al.19 reported an expansion of 7.5% in the upper airway for every 25% increase in mandibular protrusion after 50% mandibular protrusion. Generally, the greater the level of advancement, the better the treatment effect. However, it is vital that this is balanced against a potential increase in side effects. We can’t say what the perfect starting jaw position is, but we can take proactive steps in helping us find an optimal solution for each individual patient.

Tsuiki S, Almeida FR, Lowe AA, Su J, Fleetham JA. The interaction between changes in upright mandibular position and supine airway size in patients with obstructive sleep apnea. American Journal of Orthodontics and Dentofacial Orthopedics 2005;128(4):504-12. Tsuiki S, Hiyama S, Ono T, et al. Effects of a Titratable Oral Appliance on Supine Airway Size in Awake Non-Apneic Individuals. Sleep 2001;24(5):554-60. Lowe A, Sjöholm T, Ryan C, et al. Treatment, airway and compliance effects of a titratable oral appliance. Sleep 2000;23:S172-8. Choi J-K, Hur Y-K, Lee J-M, Clark GT. Effects of mandibular advancement on upper airway dimension and collapsibility in patients with obstructive sleep apnea using dynamic upper airway imaging during sleep. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 2010;109(5):712-19. Chan ASL, Sutherland K, Schwab RJ, et al. The effect of mandibular advancement on upper airway structure in obstructive sleep apnoea. Thorax 2010;65(8):726-32. Brown EC, Cheng S, McKenzie DK, et al. Tongue and Lateral Upper Airway Movement with Mandibular Advancement. sleep 2013. Hoekema A, Doff MHJ, de Bont LGM, et al. Predictors of Obstructive Sleep Apnea-Hypopnea Treatment Outcome. Journal of dental research 2007;86(12):1181-86. Chung JW, Enciso R, Levendowski DJ, et al. Treatment outcomes of mandibular advancement devices in positional and nonpositional OSA patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(5):724-31. Liu Y, Lowe AA, Orthodont D, Fleetham JA, Park Y-C. Cephalometric and physiologic predictors of the efficacy of an adjustable oral appliance for treating obstructive sleep apnea. American Journal of Orthodontics and Dentofacial Orthopedics 2001;120(6):639-47. Liu Y, Lowe AA. Factors related to the efficacy of an adjustable oral appliance for the treatment of obstructive sleep apnea. The Chinese journal of dental research: the official journal of the Scientific Section of the Chinese Stomatological Association (CSA) 2000;3(3):15-23. Lee CH, Kim J-W, Lee HJ, et al. Determinants of treatment outcome after use of the mandibular advancement device in patients with obstructive sleep apnea. Archives of Otolaryngology–Head & Neck Surgery 2010;136(7):677-81. Barthlen G M, Brown LK, Wiland MR, et al. Comparison of three oral appliances for treatment of severe obstructive sleep apnea syndrome. Sleep Medicine 2000:299-305. Rose E, Staats R, Virchow C, Jonas IE. A comparative study of two mandibular advancement appliances for the treatment of obstructive sleep apnoea. The European Journal of Orthodontics 2002;24(2):191. Warunek S. Oral appliance therapy in sleep apnea syndromes: a review. Seminars in Orthodontics 2004;10(1):73-89. Choi J-K, Kee W-C, Lee J-M, Ye M-K. Variable site of oropharyngeal narrowing and regional variations of oropharyngeal collapsibility among snoring patients during wakefulness and sleep. CRANIO® 2001;19(4):252-59. Almeida F, Bittencourt L, Lowe A, et al. Effects of Mandibular Posture on Obstructive Sleep Apnea Severity and the Temporomandibular Joint in Patients Fitted with an Oral Appliance. Sleep 2002;25(5):505-11. Ryan C, Love L, Peat D, Fleetham J, Lowe A. Mandibular advancement oral appliance therapy for obstructive sleep apnoea: effect on awake calibre of the velopharynx. Thorax 1999;54(11):972-77. Tsuiki S, Lowe AA, Almeida FR, Kawahata N, Fleetham JA. Effects of mandibular advancement on airway curvature and obstructive sleep apnoea severity. European Respiratory Journal 2004;23(2):263-68. Gao X, Otsuka R, Ono T, et al. Effect of titrated mandibular advancement and jaw opening on the upper airway in nonapneic men: a magnetic resonance imaging and cephalometric study. American journal of orthodontics and dentofacial orthopedics 2004;125(2):191-99.

Having a limited practice to Craniofacial Pain and Dental Sleep Medicine, Dr. Mayoor Patel, DDS, MS, RPSGT, D.ABDSM, DABCP, DABCDSM, DABOP, 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.

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Does Medical Insurance Cover Oral Appliances for Sleep Apnea & Snoring? by Rose Nierman, CEO Nierman Practice Management


ral appliance therapy is not only a lifesaver but can also save relationships. Hence many dental offices find it highly rewarding to help patients manage obstructive sleep apnea (OSA). Most medical plans offer coverage for custom-made oral appliances, and it’s helpful to prepare for insurance requests for paperwork. The following Q & A provides answers to the most common questions I receive about medical insurance reimbursement for oral appliances.

What documentation do insurance companies require for oral appliances? Documentation and paperwork can vary by the insurer, but the minimum is a copy of the sleep study, sleepiness questionnaire scores (Epworth Sleepiness Scale), clinical notes from the sleep apnea screening appointment and a CPAP refusal or intolerance affidavit. Many of the insurers are asking for a copy of the physician written order (prescription for the oral appliance) and require that you have the patient sign a “Proof of Delivery” form. Also, include medical history details that were noted such as high blood pressure or other comorbidities.

How can I predetermine if medical insurance covers an oral appliance? Start by making a call to the eligibility & benefits department using the contact numbers from the patient’s medical insurance card. It’s important to have sleep study information before the benefits verification call because the severity of OSA must be known before the benefits can be determined. Most health insurance plans categorize oral appliances for OSA as medical equipment, so reimbursement is typically under the coverage for Durable Medical Equipment (DME). DME is the benefit category for medical equipment such as electrical stimulators for pain, wheelchairs & walkers. The information to receive during the benefit verification: • Deductible amount • How much of the yearly deductible has been met

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• Copayment amounts or percentages • Preauthorization requirements • Is a Medicare-approved oral appliance necessary (ask this of commercial carriers since some require a Medicare-approved appliance)? • Is a “GAP exception” allowed for out of network providers (to lower the out of pocket costs for the patient)?

What are the billing codes? Currently, there is only one medical diagnosis code available for OSA, so if the patient has this condition, the diagnosis code on the sleep study will be ICD diagnosis code G47.33, which stands for Obstructive Sleep Apnea (adult) (pediatric). To receive preapproval, the insurance will also want to know the billing code for the custom sleep appliance which is: E0486 – ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NONADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT There is a good possibility that the oral appliance will need to be preauthorized in advance, so be sure to inquire about preauthorization rules. If a preauthorization is required, it’s important to wait for the approval before delivering the oral appliance.

What type of oral appliances are covered by medical insurance? There are over 100 FDA-approved oral appliances available to dentists for custom

INSURANCE sleep appliances. Medicare and even some commercial insurers specify that an oral appliance must be on Medicare’s published Product List to be covered.

Will medical insurance tell me how much they cover for a mouthpiece or appliance? The insurance representative may not be able to determine the exact dollar amount of reimbursement in advance, but they will be able to tell you if they offer the benefit as part of the plan.

With the tools to navigate medical insurance billing, What about deductibles. Are they as you can help many high as for other procedures? The deductible can differ from the yearmore of your ly deductible for other services since most patients receive the carriers categorize oral appliances for OSA care they need. as Durable Medical Equipment (DME). Equipment such as oral appliances and CPAP may carry a separate or different deductible from the usual one. That is why it’s important to make sure that you check the policy for DME benefits.

Does insurance cover snoring mouthpieces? It is important to know that while most medical insurers do offer coverage for oral appliances with a diagnosis of OSA, snoring alone is not a covered benefit. Custom mouthpieces for OSA may be considered “medically necessary” for mild to moderate OSA. Also, oral appliances are generally covered for severe OSA if the patient cannot tolerate CPAP or in some cases if the patient refuses CPAP.

Does Medicare offer coverage for sleep apnea oral appliances?

Medicare, the program for seniors and people with certain disabilities, does provide coverage for custom oral appliances for OSA and covers specific oral appliances. For a dentist to receive reimbursement from Medicare or to bill Medicare for an oral appliance for sleep apnea, the treating dentist must enroll their practice location as a Medicare DME Supplier. An application can be submitted to become a licensed DME supplier using the form CMS 855S. Once a facility becomes a DME supplier, all dentists practicing in that location are authorized for Medicare reimbursement. We get many questions about DME supplier credentialing. For those practices who are wanting to simplify the process, contact Maura Lovett at 561-575-0737 ext. 1001.

Can we get reimbursed for our sleep screening exam? We would also like to bill for a panorex and possibly a cephalometric radiographic view?

Most commercial carriers reimburse for an OSA screening exam with the submission of evaluation and management codes. There are also cross-codes from dental to medical for the radiographs. When billing for exams, it’s important to keep detailed clinical notes showing your medical history and clinical exam so that you can use a medical office visit code. The good news is that there is no frequency on the exam and x-ray codes with medical insurance like there is for dental so if a patient had an exam three months ago and you need to do another, the insurance typically will reimburse for both.

Can we bill follow-up visits for adjustments to the oral appliance? 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 or at 1-800-879-6468.

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Yes, you can bill commercial carriers, using a medical office visit code, for the adjustments to the oral appliance. Most carriers bundle the first 90 days of adjustments into the code for the custom appliance (E0486). With the right tools to navigate medical insurance billing, you can help more of your patients receive the care they need – saving lives and relationships. Your patients will thank you!

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Conversations about Real Insurance in OAT can be

DIFFERENT by Mark T. Murphy, DDS, FAGD


uccessful dental and medical treatment depends on several variables working together harmoniously: • Agreement on the Desired Outcome • Accurate Diagnosis • Selecting the Appropriate Treatment For The Diagnosis [Medical Decision Making] • Treatment Recommendation and Case Acceptance by the Patient • Patient Compliance (Adherence to Therapy) • Payment from Third Parties And Patients Although these steps are true for both, there is a BIG difference in how they are closed and financed. In dentistry, there is NO real insurance. Real Insurance is defined as when a third party takes a risk for a catastrophic loss. There is nothing catastrophic about $1200-$2000. It is more than I carry with me, but far from a catastrophe. House swept away by a tsunami or total your car? That would be catastrophic! Similarly, “insurance” coverage in dentistry covers the same as it did upon its inception in 1955; we forgot to index it for inflation. Dental “plan” or “benefits” are better names than “insurance”. As a dentist, I also often work through the deductibles, co-payments and pre-authorization discussion hoping to get patients to say YES!

Sometimes, how we look at the problem is the problem! Consider a different paradigm. On a trip to Las Vegas in December my wife and I had a little scare. Denice had experienced intermittent tingling in her left arm, perhaps her lower leg and maybe a portion of her neck. She had a ‘feeling’ that her grip was weak but it really wasn’t. Some say that knowing a little medicine is a dangerous thing, but we felt it was important to get to the hospital fearing a TIA, Stroke, MS or something along those lines. The emergency room staff agreed with our concern and said that far too many ignore early signs and symptoms that lead to a sorry ending. All the tests were negative (urinalysis, blood work, CAT Scan, MRI, MRA, carotid ultrasound and more) and she is fine. We still do not know what caused these transient symptoms but we know, with her stats, she is certain to outlive all of us! Further analysis and good news, it looks like it was just a pinched nerve under her scapula. During the day and a half we were in the hospital, no one spoke with us about our insurance coverage, what was covered or not, how much our deductible was or what our out of pocket cost would be. They took our

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insurance information at the registration in emergency, but no one asked us if we wanted to proceed with diagnostics, testing, analysis or eventual treatment. In medicine, unlike dentistry, there is Real Insurance by a third party for a catastrophic loss. That is what insurance is. Oh, there may be deductibles and co-payments for a while, but when the proverbial yoghurt really hits the fan you have coverage. Dental benefits run out at $1200 or so for most plans. That is not insurance; a preventive benefit or maintenance plan, yes, but NOT Insurance!

What Should We Say or Do Differently? We should NOT cheapen obstructive sleep apnea treatment and the subsequent oral appliance therapies by talking about them like we would dental benefits. Patients deserve a medical diagnosis, treatment, and good outcomes. OAT is a medically necessary treatment that the patient will not live well without. We all can recite the co-morbidities and decreased life expectancy statistics in our sleep (pun intended). This is the time to step up, think beyond the paradigm that shackles us about insurance and simply tell the patient what is needed and expect them to schedule. If the patient asks, of course we should answer as best we can. But almost 100% of the dentists I have observed and spoken with, LEAD with the fee and what will be covered by insurance. This somehow makes it seem optional. Or at least lets the patient feel it is optional. It ‘feels’ to patients like we are having yet another dental

PRACTICEmanagement treatment discussion like we do about bite splints, implants, crowns and other discretionary purchases. That is how so many of those in our care view dentistry…as an option, not a necessity. When we become involved in patients with OSA we have an opportunity to have a paradigm shift. We can change how we discuss the need for the treatment., the role of insurance and how we will exact payment. It is life threatening, not optional. Patients have real insurance for this. They may have deductibles and co-pays to be sure, but we should act more like physicians in this arena. We will do more and help more. Will there be collection problems down the road when they experience co-pays, deductibles and fee exceptions? Of course, there will be. The Dentists who have made the leap successfully often use third party billing partners and they are excellent at supporting this model. I am fortunate to work for a company completely dedicated to helping dentists treat

more patients with efficiency and effectiveness. At ProSomnus Sleep Technologies, we assume all your patients deserve the best sleep appliance. We want to help you succeed. This discussion may help you have a few more good conversations with patients about OSA.

Mark T. Murphy, DDS, FAGD, is the Lead Faculty for Clinical Education at ProSomnus Sleep Technologies, Principal of, serves on the Guest Faculty at the University of Detroit Mercy School of Dentistry and is a regular presenter on Business Development, Practice Management and Leadership at the Pankey Institute. He has served on the Boards of Directors of the Pankey Institute, National Association of Dental Laboratories, the Identalloy Council, the Foundation for Dental Laboratory Technology, St. Vincent DePaul’s Dental Center and the Dental Advisor. He lectures internationally on Leadership, Practice Management, Communication, Case Acceptance, Planning, Occlusion, Sleep and TMD.


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Choosing the best oral appliance for treating Obstructive Sleep Apnea... for both you and your patient

by Dr. Steve Lamberg


hat is “the best” for the patient is unquestionably “the best” for the doc. Determining what may be “the best” oral appliance for a particular patient is based on the outcome. If you have found a device that will satisfy compliance and efficacy...and durability, no one would argue with your selection. So let’s take a look at this appliance selection process and help you navigate the myriad of choices we all have.

Author’s Suggested Starting Appliances • • • • • • • • •

SomnoDent MAS Sleep Herbst TAP Lamberg SleepWell* Narval Panthera D-SAD EMA OaSys

*Dr. Lamberg is the inventor and owner of the Lamberg Sleep Well.

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At this point in the evolution of appliances it is recommended to only use a custom appliance that has been cleared by the FDA specifically for OSA. Additional qualities that you will need to judge include (not in order of significance): 1. Durability (3-5 years) 2. Ease of use and cleaning by the patient (stains or retains odors) 3. Cost 4. Freedom of motion both laterally and vertically 5. Ability to control occlusal stops (anterior), relates to TMJ health 6. Ability to control occlusal stops (posterior), relates to TMJ health 7. The smallest vertical possible interocclusal space 8. The ability to limit the vertical opening 9. If the appliance is suitable for parafunction (strong enough or permissive enough) 10. Where the advancement mechanism is (lateral or anterior palate) 11. The esthetic nature of the design 12. Can the patients manage using the parts and/or adjustment tools 13. Is the appliance Medicare approved (on PDAC list)

14. Length of time it takes to receive appliance back in office 15. Ability to be milled or printed from digital acquisition 16. Quality consistency of your laboratory 17. Possible allergies to materials 18. Ease of modifying appliance if dental work becomes necessary 19. Ability to adapt device to use implant attachments as necessary 20. Effectiveness at controlling sleep metrics 21. Issues of retention based on number and location of teeth 22. Impact the appliance will have on nasal breathing 23. Comfort for patients sleeping on their side 24. Amount of tongue space consumed by the adjustment mechanism 25. Does the appliance accommodate lip seal This is just the beginning of what you should consider when prescribing a particular appliance. Of course the main effect, and side effects, result from mandibular advancement…which all of the appliances achieve in a similar way, and to a similar degree. A great place to gain experience with appliances is to order demos from your lab and examine them critically. Imagine wearing one of them yourself every night for the rest of your life. Try some of the common appliances on your patients, or yourself, and see how it goes. After making a 100 or so appliances you will begin to appreciate there are many ways to skin the cat. Additionally it must be stated that if a patient has been wearing

CHOOSINGappliances an appliance successfully in their past, and they need a new one, it makes sense to offer them the same device they had already been happy with. In the contest between evidenced based science versus opinion, opinion seems to have the leg up on this topic due to the lack of head to head scientific studies. I participated in a blog recently on this very topic. There were over 175 “influencers” who read or contributed to the thread. I don’t believe there was absolute agreement on using a particular appliance on any particular patient, however it was generally stated that the many qualities of appliances listed above should be considered and that having familiarity with a few different appliances would be a benefit over just making one appliance. You may also have to switch appliances sometimes due to breakage, patient comfort, or to satisfy some of the other qualities listed above which may have been missed. My opinion is that the practitioner who does thorough follow-ups

and adjustments for patient comfort will ultimately have the highest compliance. Select a few appliances and perform careful follow-ups to see how comfortable you can make your patients. In the end, if you stay curious and critical when evaluating efficacy and compliance, you’ll be the happy one and your practice will thrive.

Dr. Steve Lamberg has been practicing all phases of dentistry in New York for over 30 years with an emphasis on cosmetic, reconstructive and implant dentistry, and has developed a passion for dental sleep medicine over the last 11 years. He lectures nationally on topics including: occlusion, esthetic dentistry and dental sleep medicine and developed his own FDA-cleared sleep appliance. Dr. Lamberg is a Diplomate of the American Board of Dental Sleep Medicine and the Academy of Clinical Sleep Disorders Disciplines. He lives and practices in Northport, New York. Contact Information: 631-2616014, or

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Getting it in Their Hands: The Delivery Appointment by Erin E. Elliott, DDS, and Brianne Bove   


am not a jogger. I DESPISE jogging. I have a 0.0 sticker on my car. That’s funny because most triathletes and marathoners like to brag about their mileage. Me? I like to brag about the fact that I do NOT jog. So why is it that I love Dental Sleep Medicine? DSM is kind of like a marathon. You must be patient, you have to build endurance and you must train your “body,” or team. Once you have a patient sitting in your hygiene chair you discuss dentistry and restorative needs, then introduce an entirely new concept – sleep. You finally get them to have an awareness and maybe admit a problem, then a consult, then a sleep study, then possibly a trial of CPAP, then medical insurance financials, then records, then lab time, then FINALLY a delivery. Phew… are you tired yet? 28 DSP | Summer 2017

Delivery is my favorite appointment for two reasons. One is that the patient can finally get treatment and two is that we can finally bill it out. Many dentists new to sleep apnea ask me how to do a delivery. Honestly? I don’t know. My awesome team handles that. We never pre-appoint deliveries because we don’t want to disappoint them. We do a great job of creating urgency and then, suddenly, we tell the patient to wait for three weeks! Once we get the appliance in our hot little hands we call the patient right away. We have appointments reserved for immediate delivery. It’s for this reason I am going to hand over this article to Brianne Bove, my DSM Champion for our office. This is exactly what I do in real life too… hand everything over to Bri.

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APPLIANCEdelivery Hello, everyone, this is Bri. The first thing I do once I receive the case from UPS or FedEx (our delivery men love us by the way because we are always so happy to see them and there is always a fishing or hunting story to share) is to check the ledger to make sure the pre-auth is back, the referral is back and that financial arrangements have been discussed and are in order. I call the patient and schedule the appointment Our goal in the first couple as soon as possible. We used to pre-appoint about 3 weeks after of weeks is to have them get we send out impressions however used to the appliance and to there were too many disappointments and unmet expectations at have them attempt to wear no fault to the lab or us. It’s fun it every night and all night. making these calls because I feel like Santa Claus. The patients are I stress that it is not failure pumped. I’m careful to make a to have to take it out. note in our software to make sure we keep records of everything. Prior to the patient even coming in, I set out a nosecone with acrylic or stone burs depending on the type of appliance being delivered. If it’s an acrylic based appliance, I pre-soak the appliance in an alcohol-free based mouthwash to remove the nail salon smell. You don’t want your first impression to leave a bad taste in the patient’s mouth. Pun intended.

Dr. Erin Elliott grew up in Southern California but went away to a small NAIA school in Western New York where she played collegiate soccer and graduated summa cum laude from Houghton College. After Creighton Dental School, she settled in north Idaho to begin her general dentistry career. She has a special interest in Dental Sleep Medicine and Short Term Orthodontics (Six Month Smiles). She has lectured extensively on this topic and loves to help general dentists extend this life saving service to their patients. She is an active member of her local American Dental Association, the American Academy of Sleep Medicine, American Academy of Dental Sleep Medicine and is past-president and diplomate of American Sleep and Breathing Academy. She’s teaching sleep apnea with 3D-Dentists and Dr. Tarun Agarwal as well as privately coaching practices about sleep. Brianne Bove grew up in northern California and quickly followed her parents up to north Idaho, where she could never see herself living anywhere else. It is her fishing/hunting paradise! Brianne spends her weekends chasing big fish with her husband, Mark, and beautiful new daughter, Mira. She has had the pleasure of working with Dr. Elliott for 4 years now and has been exclusively doing sleep apnea for 3. Finding passion in your career is not only a must but a blessing she enjoys.

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At the impression appointment, my patient signed the financial arrangements, the CPAP waiver, and the informed consent. I review these and make sure I have them. I begin with the warranty. The appliances and labs we use offer a 3-year warranty; however, I stress to the patient that negligence such as dog chews and loss or major changes in dental work are not covered. I then discuss how to store and clean the appliance. Knowing that people only retain 30% of what is discussed or taught, I stress that the patient should go home and read the instructions that the manufacturer provides. Prior to even trying in the appliance I discuss how to advance. First I demonstrate to them on one side how to advance and then I make the patient show me they can do it on their own on the other side. Depending on the appliance I have them advance every night or every third night as comfort allows and as symptoms dissipate. There are times I can tell that the patient is overwhelmed, so I wait until our first follow up appointment to show them that. Our goal in the first couple of weeks is to have them get used to the appliance and to have them attempt to wear it every night and all night. I stress that it is not failure to have to take it out. I also set up their expectations. I remind them that this is just a very good guesstimate on their starting position because we don’t want them advanced too much where their jaw hurts. We are easing them into treatment. I warn them that they may still snore, they may still be tired or even more tired because they are finally catching up on lost sleep. Their body is finally resting. Most of the time they notice improvement and have their Eureka moment from night one. We just don’t want them to expect it. Next I have the patient try in the appliance. I have the patient insert it and have a mirror available if needed. I am there to help direct and guide the patient if needed. I let the patient know it will feel snug but should become more comfortable as the appliance warms up to body temperature. I like the analogy that it’s like a new pair of hunting boots (in my world). The more you wear it the more comfortable it will get. I let them know that if they feel excessive pressure on one tooth or on the gums that we can easily resolve that with some adjusting. I explain that it is normal to have excessive salivation for

APPLIANCEdelivery the first week or two. If, on the contrary, they have dry mouth we have solutions to resolve that too. We have a stock of GC Dry Mouth Gel and XyliMelt tabs. I have them sit for 5 minutes to make sure it is still comfortable and that they are hitting evenly with occlusion. With the labs we use there is barely any adjusting most of the time. I can deliver from across the room. We remove the appliance and I review once again how to store and clean the appliance. From there I go into their morning exercises. I warn them that their bite is going to feel different in the morning as their muscles have been postured forward at night. There may possibly be some muscle soreness but I reassure them that it’s like going back to the gym. That they can push past it. Their bite might be off for 5 minutes and resolved by chewing gum or it may take a couple of hours. I provide them with a list of exercises that Braebon has provided for me and a “chew toy” as we like to call it. They don’t forget that name! We warm up and have the patient bite into the mouthguard material that we get from the lab or we make an AM aligner. We also have them massage in the shower as that provides moist heat that the muscles appreciate. While I am getting the hot water needed to soften the chew toy, I have the patient sign the “Proof of Delivery” paperwork. Medicare requires this. Anything that Medicare requires, we apply as standard protocol for all insurances. Dr. Elliott always is part of the delivery, although I take care of most of the work so she can be in another room being productive. I make sure all questions are answered but most importantly I provide them with my business card and email. Email is always the best way to get a hold of me and ask any follow up questions. Sticky notes and phone tag are avoided. As the patient walks out the door they have the following: their appliance, their instructions, their models and impressions (I don’t want to be responsible for them), a case for travel, advancing tools, a toothbrush and a sample of Polident for Partials if there are metal components, and my business card. They always always ALWAYS leave with a 2 week follow up. I love my job. I love that Dr. Elliott has afforded me the opportunity to move from changing people’s lives due to their smile

and their teeth to their sleep and their lives. I love the challenge of making medical insurance pay, and I love taking a patient from having no idea that snoring is an issue to awareness, urgency and gratitude. If there is any way I can help you please let me know: Dr. Elliott: As you can see I appointed the right person as my DSM champion! In fact, most people ask for her before they do for me (it might be the hunting and fishing conversations). Just remember that delivery is our finish line. Have the endurance and the patience to see it through until you get your medal at the end. You have won. You deserve more than a 0.0 bumper sticker at this point.


CONTINUING education

Punishment for “Needing” a MAD: Condemned to Suboptimal Treatment? by Kevin Kwiecien, DMD, MS


perfect, unobstructed, smooth-flowing, and properly functioning airway would be my wish for everyone. My second wish would be to treat the “root cause” of the compromised airflow, whether it be orthodontic expansion, surgically facilitated orthodontic treatment (SFOT), mandibular advancement surgery, rhinoplasty and sinus reconstruction, or maybe just eliminating allergens and learning to breathe through the nose again, or any combination thereof. But what about the patient for whom a mandibular advancement device is the appropriate treatment for better sleep and airway? (Figures 1-2) Whether temporary or long-term, there are patients who need an appliance to “help them get worse at the slowest possible rate,” as Bob Barkley so eloquently stated. The patient understands that they are compromised and could do more about their problem. Yet they don’t. But they might still need dentistry. Yet they are having their mandible pulled forward every night. And teeth might move. And skeletal structures might change. Why would we do more than “repair” them, addressing issues only as they arise? Why would we want to even discuss optimal treatment? Every patient is entitled to know what optimal is, the benefit, the likely consequences of suboptimal, and the compromises of anything less. The process for the dentist can still be systematic, interdisciplinary Figures 1-2 in nature, and somewhat predictable.

32 DSP | Summer 2017

Educational aims

Taking the whole stomatognathic system into account is the goal of every patient-dentist relationship. When considering dental health, from stability to consideration of the need for restorations or esthetic enhancement, one must consider the airway as well.

Expected outcomes

Dental Sleep Practice subscribers can answer the CE questions on page 36 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • See how airway management can be considered along with restorative goals. • Realize applying known parameters and techniques to achieve dental health outcomes does not need to be compromised when helping patients breathe well at night. • Communicate a whole-person approach that allows the dentist and the patient to collaborate on what is to be achieved.

CONTINUING education The Dilemma

Perfected occlusion, as Dawson describes it is “…simultaneous equal intensity contacts on all teeth when the condyle-disc assemblies are completely seated in their respective sockets,” and “the disclusion of all posterior teeth the moment the mandible moves from centric relation.”1 This sounds somewhat counterintuitive since pulling the mandible forward every night has long been known, and currently confirmed in the literature, to cause unpredictable changes, while opening the airway. (Figures 3-4) One 11-year study showed that, “clinically significant changes  in occlusion were observed and were progressive in nature. Rather than reaching a discernible end-point, the dental side effects of MAS therapy continue with ongoing MAS use.”2 Maybe slightly less discouraging, yet an undeniable consequence that we have all seen to some extent, that is also in current literature, is that, “The use of MADs may lead to the development of TMD in a small number of patients. Nevertheless, these signs are most likely transient. Patients with pre-existing signs and symptoms of TMD do not experience significant exacerbation of those signs and symptoms with MAD use. Furthermore, these may actually decrease over time. POB (posterior open bite) was found to develop in 17.9 % of patients; however, only 28.6 % of these patients were aware of any  bite  changes.”3 So, how does one even begin to treatment plan possible treatment in such an unpredictable environment?

point. If we don’t begin with the optimal end in mind, how can we ever know what is possible and how any compromise might affect the otherwise optimal treatment? A systematic approach helps shed light beyond the confusing starting point. You might be refer to it as Global Diagnosis, Diagnostically Driven Treatment Planning, or Facially Generated Treatment Planning, to name a few. The name is less important than the process for treatment

Systematic Approach to Visualize Optimal Esthetics and Function Understanding the current condition of the entire stomatognathic system and visualizing the ideal end result must always be a starting

Figures 3-4

As a member of the resident faculty at Spear Education, Dr. Kevin Kwiecien teaches hands-on workshops and is a member of the faculty dental practice. He also creates and manages content for Spear Online. Before joining Spear Education full-time, Dr. Kwiecien served as assistant professor of restorative dentistry at Oregon Health and Sciences University School of Dentistry where his roles included director of the university’s faculty dental practice, director of patient admissions, and director of the urgent care clinic, as well as course director of pre-clinical fixed prosthodontics and co-course director of advanced restorative concepts for thirdand fourth-year students. Dr. Kwiecien is a past-president of the Oregon Academy of General Dentistry. He also maintains memberships in the American Dental Association, Academy of Operative Dentistry, American Academy of Cosmetic Dentistry, American Equilibration Society, American Academy of Craniofacial Pain, and the American Academy of Dental Sleep Medicine. He is a fellow in the Academy General Dentistry and also holds a Masters degree in Healthcare Administration.


CONTINUING education

When the dentist has a clear vision and holds what is possible for the patient as a legitimate option, conversations change and treatment becomes more predictable.

planning, ranging from simple to complex. When working from the face or from the outside in, “the outcome of the esthetic treatment plan will be enhanced without sacrificing the structural, functional and biological aspects of the patient’s dentition.”4 (Figure 5) A recent article describes a case study restoring a 29-year-old woman with a history of stomach-acid-related reflux and extensive loss of tooth structure, similar to what we see in many patients with airway or sleep issues. The author noted that the goal was to, “improve the prognosis in each of the four dental  categories-periodontal, biomechanical, functional, and dentofacial, and that, “the treatment plan utilized a systematic approach to sequentially restore and protect the young woman’s dentition.”5 The verbiage is less important than the process. However, what might be more important when restoring a patient whose mandible is being held forward on a nightly basis is understanding

and visualizing a stable physiologic position which will be challenged by the appliance. A fully-seated condylar position has been shown to be an optimal, albeit controversial in some circles, position at which to restore a patient when the joint space and disc are healthy. Several recent studies demonstrate that, “the condylar position is an important concern in maintaining or restoring temporomandibular harmony with the dentition and the position of the condyle in the glenoid fossa plays an important role in the stability of occlusion,”6 and that it, “contributes not only as a reference position to build optimal  occlusion  in artificial dentition, but is also related to sound periodontal health and stomatognathic function.”7 Visualizing the ideal function can be done using models to better understand the structure necessary to achieve the function and the likely compromises to suboptimal. (Figures 6-7) Once the ideal esthetics and function have been visualized, a key to restoring most patients, but especially patients wearing a MAD, is to involve the interdisciplinary team when discussing the ideal structure and supporting biology, to better understand the possible shortcomings due to the compromise of wearing the appliance, and maybe more important, options for carefully and predictably phasing the treatment. (Figure 8)

Interdisciplinary Communication

Figure 5

Figures 6-7

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Teeth may drift, treatment might need to be phased, or the occlusion might be compromised, all of which and more would benefit from intentional interaction with our specialists. A recent article says it well: “The physiologic tooth position is determined by interactions between the periodontal tissue and occlusal, tongue, and lip forces,” which seems suspiciously familiar to conditions related to airway. It continues to illustrate that often a force or condition (like wearing an appliance that pulls the mandible forward

Figure 8

CONTINUING education every night), “disturbs the equilibrium of these interactive balances, leading to pathologic tooth migration, often requiring multidisciplinary treatment approaches,” and reinforces the benefit of, “a systematic periodontal-orthodontic-prosthetic treatment for achieving the optimal  structural, functional, and esthetic outcomes.”8 A recent case study involving a patient with severe attrition, again like what we see in patients with airway and sleep issues, reinforces, “how a stable occlusion can be obtained inexpensively. The result of segmented treatment remained  optimal  and esthetic,”9 demonstrating once more the benefit of not only visualizing the optimal final result, but also including specialists in the process, creating an option for the patient to be ideally restored, regardless of time, money, or dental compromises.

Figures 9-10

Figures 11-12

Appropriate Treatment

When the dentist has a clear vision and holds what is possible for the patient as a legitimate option, conversations change and treatment becomes more predictable, fun, and appropriate. The esthetic outcome is visualized, the functional outcome is founded on sound principles, the structure (restorative material, including enamel) is clear, especially with respect to longevity and phasing, and the biology to support the structure, including possible compromises, is clear. Finally, the condition and treatment of the airway is understood, also including any compromises it will have on any of or all four other categories. A recent article describes how, “Direct resin composite restorations made with the stamp technique are a valuable treatment option for restoring erosively worn dentitions,”10 illustrating that a systematic approach, involving the interdisciplinary team, allows the dentist to better identify what material makes most sense to restore patients, even patients who are wearing mandibular advancement devices. A patient wearing a MAD can certainly be restored to an optimal esthetic and functional stomatognathic environment. (Figure 9-10) Moreover, understanding the compromise that the appliance brings to the system and the ideal restorative plan, steps can be taken to maintain, as much as possible, the appropriate result, with respect to the esthetics, function, structure and biology for that patient. The best and most appropriate way

to “help our patient get worse at the slowest possible rate,” while supporting the “restored” patient, as opposed to the “repair as things break down” mentality might be as simple as a morning deprogramming appliance to remind the body where to go and reinforce a more physiologic and stable environment. (Figures 11-12) Even a patient who is sending the entire stomatognathic system into a frenzy every night by wearing a MAD deserves the option to be optimally restored in a predictable manner, while all parties involved understand the compromises until the root cause is addressed and corrected. 1. 2.


4. 5. 6. 7.

8. 9. 10. 11. 12.

Dawson, P. Functional Occlusion: From TMJ to Smile Design, 2007, Mosby, Inc., p.32 J Clin Sleep Med. 2014 Dec 15;10(12):1285-91. doi: 10.5664/jcsm.4278. Obstructive sleep apnea and mandibular advancement splints: occlusal effects and progression of changes associated with a decade of treatment. Pliska BT1, Nam H1, Chen H1, Lowe AA1, Almeida FR1. Sleep Breath. 2013 Mar;17(1):323-32. doi: 10.1007/s11325-012-0695-1. Epub 2012 Apr 4.The incidence and prevalence of temporomandibular disorders and posterior open bite in patients receiving mandibular advancement device therapy for obstructive sleep apnea. J Am Dent Assoc.  2006 Feb;137(2):160-9. Interdisciplinary management of anterior  dental  esthetics. Spear FM1, Kokich VG, Mathews DP. Perez CV1, de Leeuw R, Okeson JP, Carlson CR, Li HF, Bush HM, Falace DA. Compend Contin Educ Dent. 2012 Sep;33(8):606, 608, 610 passim. A systematic approach to recreate a patient’s former smile. Afshar A. J Contemp Dent Pract. 2016 Aug 1;17(8):679-86.Improved Visualization and Assessment of Condylar Position in the Glenoid Fossa for Different Occlusions: A CBCT Study. Kaur A1,  Natt AS2,  Mehra SK3,  Maheshwari K4, Singh G2, Kaur A2. Minerva Stomatol.  2011 Oct;60(10):543-9.The controversial issue of centric relation: a historical and current dental perspective?Chhabra A1, Chhabra N, Makkar S, Sharma A. Int J Periodontics Restorative Dent. 2012 Apr;32(2):225-30.A multidisciplinary approach for the management of pathologic tooth migration in a patient with moderately advanced periodontal disease. Kim YI1, Kim MJ, Choi JI, Park SB. Compend Contin Educ Dent. 2016 Jun;37(6):390-4. Segmenting Full-Mouth Reconstruction to Enable Financial Feasibility. Duffield LD1. J Adhes Dent. 2015 Jun;17(3):283-9. doi: 10.3290/j.jad.a34135. Posterior Vertical Bite Reconstructions of Erosively Worn Dentitions and the “Stamp Technique” - A Case Series with a Mean Observation Time of 40 Months. Ramseyer ST, Helbling C, Lussi A.


CONTINUING education

Continuing Education Test


Certificate Details

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 1/1/2016 to 12/31/2017 Provider ID# 356023

REF: DSP Summer 2017

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Punishment for “Needing” a MAD Kevin Kwiecien, DMD, MS 1. Treatment of the compromised airway is commonly labeled: ___________ a. first step prosthetics b. upselling the treatment plan c. addressing the ‘root cause’ d. pathway to adequate results 2. Means of managing the sources of airway problems include all the treatments listed EXCEPT: ___________ a. eliminating allergens b. sinus surgery c. mandibular advancement devices d. surgically facilitated orthodontic treatment 3. Every patient is entitled to know __________ a. optimal treatment option b. likely consequences of no treatment c. benefits and expectations associated with treatment choices d. all of the above 4. Pulling the mandible forward every night has been confirmed in the literature to: ___________ a. reliably reposition the epiglottis b. allow nasal breathing to resolve obstructive sleep apnea c. cause unpredictable changes to the stomatognathic system d. relax tense muscles of mastication

36 DSP | Summer 2017

5. Patients with pre-existing signs and symptoms of TMD ___________ a. do not experience significant exacerbation of these symptoms with MAD use b. should not be treated with oral appliance therapy c. can expect to need anti-inflammatory medications for extended time d. must sign a different informed consent than most patients 6. A fully-seated condylar position _________ a. is unimportant, as MAD therapy automatically unseats the condyle b. can never be used as a reference point, because it is unrepeatable c. is pathologic, as the true functional position is with the condyle down and forward d. is related to sound biological and structural health and stomatognathic function 7. Appropriate treatment always involves these factors: ___________ a. esthetics, function, cost, and structure b. biology, airway, structure, esthetic and functional outcome c. longevity, comfort, esthetics and functional outcome d. airway, age, structure and esthetics

8. Improving the prognosis of a severely dentally-damaged patient involves ___________ a. building expectations that the result will never be fully reliable b. visualizing stable physiologic position c. presenting all treatment as temporary when MAD is in use d. managing the airway with CPAP or other external devices 9. Airway and comprehensive dental therapy have in common ___________ a. treatment plans that involve significant expense b. the need to involve at least two dentists and three physicians c. interactions between the periodontal tissue and occlusal, tongue and lip forces d. both disturb the equilibrium of the head, with vertigo a common complication 10. Managing a compromised airway with a mandibular advancement device is said to a. be the best long-term solution for the majority of our patients b. result in improved social skills and driving ability c. aid in acceptance of comprehensive restorative dentistry d. help our patients get worse at the slowest possible rate

Discover the Possibilities With

Airway Prosthodontics

Learn new ways to manage airway issues from Spear Education and Dr. Jeff Rouse

What is Airway Prosthodontics? Airway Prosthodontics is the study of aberrant or irregular breathing — when awake and asleep — and its impact on the development and health of the stomatognathic system. This specialty moves beyond sleep appliances and their impact on the airway during sleep.

Dental Sleep Practice readers save $200!

Leading the discussion on airway and sleep complications is Jeff Rouse, D.D.S., a seasoned prosthodontist who is at the forefront of this incredibly important topic in dentistry. As a member of Spear Education’s Resident Faculty, Dr. Rouse has helped to develop a comprehensive course with Spear Education on how dentists can better treat their patients with airway-related issues. In this Airway Prosthodontics seminar, Dr. Rouse helps dentists realize that airway issues can be addressed in a variety of ways other than simply making a repositioning appliance. Dentists will learn a systematic approach to controlling and resolving sleep-induced airway issues with a six-step protocol.

AIRWAY PROSTHODONTICS — TAKING DENTISTRY BEYOND SLEEP APNEA AND ADVANCEMENT APPLIANCES CE CREDITS 14 CE Credits | 2 days | Lecture/Seminar LOCATION The Spear Campus, Scottsdale, Ariz. SCHEDULE August 18-19, 2017 | December 15-16, 2017 TUITION $1,495 (Regularly $1,695) Please reference Promo Code: DSPM200 to Save $200 To register now, call 866.781.0072 or email a Spear Education Advisor at For more information about this seminar, visit

© Copyright 2017 Spear Education. All rights reserved.


AADSMpreview Apex Dental Sleep Lab

Apex Dental Sleep Lab fabricates and develops quality, customized dental sleep appliances. We help dentists give their patients quality sleep with simple solutions. We are proud licensed partners of SomnoMed®, Panthera Dental, MicrO2, EMA®, OASYS Oral/Nasal Airway System™, OravanOSA, Luco Hybrid OSA, TAP® and KAVA. Each case is thoughtfully cared for by a family owned and operated team of professionals. Our 30 years of experience is united by one goal – to help our clients improve quality of life for their patients through better sleep. Our mission – develop new products, and find effective solutions for clients to offer. Our vision – help every patient suffering from the symptoms of apnea, bruxism, and TMD/ TMJ gain access to the industry’s leading solutions for improving sleep.

The DS3 Experience

The DS3 Experience is your comprehensive solution for your Dental Sleep Medicine success. We offer the Four Paths: Education, Coaching, Software and Support. To the Four Pillars of DSM Success: Screening, Testing, Treating and Billing. Stop by booth 310 for a free consultation of your dental sleep practice and get on the path to Dental Sleep Medicine success. You can also call our office for a demo of the DS3 Experience. Reach out to us today at 877.95.SNORE or visit us online at

Visit Apex Dental Sleep Lab at Booth No. 620


Kettenbach: What do you like about the Panasil Putty and Panasil Initial Contact Regular Combination for taking impression of your sleep apnea patients? Dr. Nicole Chenet: Essentially when treating obstructive sleep apnea we see a lot of irregularities in the mouth. Often we see excessive wear patterns, narrow maxilla Dr. Nicole Chenet palates, and significant undercuts. Pittsburgh, PA This leads to challenging situations for capturing the perfect impression, but we want to capture those important details and we have found the Kettenbach Panasil Putty and Panasil Initial Contact Regular Light Body offers us those details consistently. Many patients coming in are nervous about getting the impressions and by using the Panasil Putty and thicker wash combination it has significantly decreased the amount of 2nd impressions due to inaccuracies. Simply, my goal is delivering an oral appliance that is critically accurate on the first try, and it is essential that the impression is accurate if the fit of the appliance will be perfect. I truly believe that you get back what you give, so we only give the best for our patients. Visit Kettenbach at Booth No. 531

38 DSP | Summer 2017

Visit DS3 at Booth No. 310

MediByte® Lite Kit from Great Lakes

The MediByte® Lite Kit is a first-line home screening device that provides comprehensive oral appliance monitoring for sleep-disordered breathing. This 12-channel, level 3 screener is the only device that has a cannula that captures both oral and nasal breathing. MediByte® Lite also records snore decibels with audio, in addition to oral facial movement. The device is easily configured to accommodate both adult and pediatric breathing parameters. A HIPPA compliant web portal is available for convenient co-management of your patient with a sleep physician. Simple and comfortable to wear. Great Lakes also offers the 6-channel MediByte® Junior. For more information, call 1.800.828.7626 or visit

Visit Great Lakes Orthodontics at Booth No. 618

AADSMpreview ResMed

ResMed changes lives by developing medical equipment for treating and managing sleep-disordered breathing and respiratory disorders. Through 25 years of innovation, we have pioneered solutions to improve the health of those suffering from these conditions while raising awareness about the consequences of untreated sleep-disordered breathing. For more information, visit us at AADSM’s 26th Annual Meeting, booth #306, or visit

ProSomnus® Sleep Technologies is the Only OAT Manufacturer That is 100% Committed to Your Success! • 7-Day Production Turnaround • Find a Dentist Website for Patients • Customized Digital Designs • Precision Dental Sleep Medicine Visit the ProSomnus Booth #302 at the AADSM Annual Meeting in Boston, MA June 2-4, 2017. 844 537 5337 • Visit ProSomnus Sleep Technologies at Booth No. 302

Visit ResMed at Booth No. 306

Tufts University School of Dental Medicine


Visit SomnoMed at Booth No. 517


SomnoMed, the global leader in COAT™ (Continuous Open Airway Therapy) has successfully treated over 300,000 patients world-wide, and we are proud to exhibit at AADSM 2017. Visit us at booth 517 and learn more our quality oral devices for the treatment of obstructive sleep apnea, including the SomnoDent Fusion™ and SomnoDent Herbst Advance®, our EO486 Medicare verified device. For more value added resources, visit www.somadvantage. com to register for SomAdvantage, our premier Member Appreciation Program and download customizable marketing materials and product offers. At SomnoMed, we place quality first in everything we do. Our commitment to you is to continually improve our processes to develop, produce and market products & services that exceed your expectations. Visit us online at

Tufts University School of Dental Medicine is proud to provide the latest in Temporomandibular Disorders (TMD) and Dental Sleep Medicine (DSM) Education with 3 exciting programs: Dental Sleep Medicine: A Comprehensive Introduction, Temporomandibular Disorders Mini-Residency, and Dental Sleep Medicine Mini-Residency! Additionally, we are pleased to announce that both Dental Sleep Medicine programs are CE-eligible for the AADSM Qualified Dentist Designation. Created and directed by Drs. Noshir Mehta and Leopoldo Correa, these courses are perfect for anyone with an interest in DSM and TMD. Please visit for course details.

Visit Tufts University at Booth No. 735


AADSMpreview The GEM Pro was designed to assist the dentist in managing patients with complaints of snoring and who show signs of damaged teeth as a result of clenching and grinding during sleep. This home sleep study emails a detailed report automatically to the dentist when patient finishes night study, enabling multi-night screening without bringing the device back to the dentists office. • Bruxism – Measures the type, frequency, strength and total masseter energy expenditure • Audio – Record snoring and tooth sounds from clenching and grinding • Heart Rate – Documents changes in heart rate during sleep, including Brady and Tachycardia • Oxygen Destaturation – Proprietary oxygen analysis provides essential information about breathing while asleep • Body Position – Provides information on the impact of body position on the quality of sleep Whip Mix Corp. • Visit Whip Mix Corp. at Booth No. 734

Oventus Medical are proud Gold Sponsors of the AADSM 26th Annual Meeting. Our customized oral appliances offer a treatment platform that is changing the paradigm of care for sufferers of snoring and Obstructive Sleep Apnea (OSA). Our O2Vent™ appliances stabilize jaw position and bring the tongue forward to reduce airway collapse, similar to other models. What makes Oventus appliances unique is the incorporation of Oventus Airway Technology – a unique internal airway built into its patented design, allowing for breathing through the appliance via a low resistance airway, to bypass nasal resistance and obstruction of the velopharynx which can contribute to snoring and sleep apnea. Come and visit us at booth #533 to explore new OSA treatment alternatives for your patients. Or call us today on 844-780-5957 Visit Oventus at Booth No. 533

Visit Dental Sleep Practice at Booth No. 623 to sign up for a discounted subscription, order additional DSP Patient Education Guides and enter to win a BrainTap for your practice!


Celebrating its 60th year of service to the dental community, SML (Space Maintainers Laboratories) continues to provide practice-building solutions for more than 150,000 dentists and orthodontists worldwide. Our dental/orthodontic specialties include appliance design and manufacture – sleep, fixed, functional, removable, pediatric, orthodontic, orthopedic, TMJ; 3D digital imaging and records storage; diagnostic consultation; ADA CERPrecognized continuing education; and products and supplies for the dental practitioner and laboratory. For nearly 30 of our in-operation years, we have led the way in dental sleep appliances – the widest range in the industry – and results-driven sleep education. We know sleep… and we know how to make it work for our clients and yours. 1-800-423-3270 • Visit Space Maintainers Laboratories at Booth No. 309

40 DSP | Summer 2017


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Visit Dental Sleep Practice at Booth No. 623


Sleep Disordered Breathing in the Pediatric Population is a Silent Epidemic


out of 10 children exhibit at least one symptom! The goal is for dental and medical professionals to evaluate airway and breathing issues in every patient. This type of evaluation can occur by providing a Healthy Start sleep questionnaire to every patient. Many states require a school physical and a dental exam prior to the beginning of school. This is a perfect time to include the Healthy Start sleep questionnaire in the examination paperwork. A suggested treatment and evaluation regimen:

Treatment Protocol

Grayson with her Healthy Start™ Habit-Corrector

42 DSP | Summer 2017

• Sleep Questionnaire • Sleep study (clinical or home sleep study test) • Evaluation of tonsils and adenoids • Assessment of Growth and Development • Airway analysis • Correction of poor Oral Habits • Expanding narrow dental arches • Training away from mouth breathing

Expectations with treatment • • • • •

Permanent results with early treatment Expanded dental arches Less crowding of teeth Proper tongue position habits Development of proper swallowing habits • Correcting improper skeletal jaw relation • Promote proper airway growth • Dental and Medical Insurance coverage Register to join a FREE Healthy Start Medical Webinar to earn CE credits and learn from one of our premier Dental and Orthodontist Providers who are experts in their field. Find out why the Health Start System is one of the fastest growing, life-changing orthodontic/orthopedic treatments, helping families worldwide! June 8, 2017 – “The Dental Connection to Children affected by Sleep Disordered Breathing” Dr. Anthony Marino, DDS, MS, an expert in Orthodontics. July 13, 2017 – “What do ADD/ADHD, Bed-Wetting, Mouth Breathing and Crooked / Crowded Teeth have in common?” Premier Healthy Start Provider Dr. Diana Batoon, DMD. To see a full list and register for any of our upcoming webinars, please visit http://www. For more information, call 844-KIDHEALTHY, email, or visit


“SELL” is a 4 Letter Word

by Chris Bez, opportunity engineer


ow great would it be to have patients coming through your door, unsolicited, ready to move forward with treatment? What if it happened with virtually no expense to you and resulted in a robust and continuously expanding patient base? As a coach and marketer for Sleep Medicine Dentists, one of the biggest objections I get to promotional discussions is, “I’m not a salesperson – I can’t sell – I don’t want to sell – I hate the idea of selling!” No kidding? You mean you went to college for dentistry, graduated, pursued additional education, grew your practice and didn’t find time to moonlight as a salesperson? Well, you’re not alone. Selling isn’t all about used cars, unsolicited product demos or any of the other stereotypical images most of us carry. In today’s world, information is the new “pitch”– and offering information can be as easy as having a discussion. If you have added Sleep Dentistry to your practice and still treat other patients, screening each patient with an Epworth Scale or Stop Bang form is a great start. BUT, without a relevant follow-up discussion as to ‘why?’ the new form, or a conversation regarding the implications of untreated sleep apnea, the form is a missed opportunity to engage and share information. And that missed opportunity to inform becomes a missed opportunity for your patients to start conversations with their friends and family about the benefits of sleep dentistry – (for those of you playing along at home, this is how you create unsolicited patients actively seeking your services and products!) Conversations can start by patients filling out a survey on your website, with your staff during a phone call, or while the patient is standing at your reception desk. They can happen in a hygiene chair or during a chart review. Sales, marketing and the development of the enhanced communication skills that support both of those efforts, has been the focus of Chris Bez’s career since inception. From a start as a Sales Manager for a national manufacturing company, she became an award-winning Marketing and Advertising Executive, a Professional Executive and Team Coach and a national speaker on marketing and promotions. Today she focuses her attention on niche marketing for Dentists – specifically for those practices that have incorporated Dental Sleep Medicine into their patient offering. She writes and advocates on the imperative of consulting versus selling, and the development of individuals and teams. For more information, contact Chris at

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Being aware of patient appearance, mood, complaints or other audible or visible signs of sleep debt is another opportunity for you and your staff to inquire about how patients are doing. In-office signage that informs about the link between chronic disease and inadequate or interrupted sleep can even prompt a patient to start a conversation. A patient in conversation can be heard. They can be given information so they can make an informed decision about getting a diagnosis for themselves or for a family member. At that point, they no longer need to be sold your services or products, they are empowered to make informed choices based on their own insight. Bottom line, all this discussion starts with a solid education about snoring, sleep apnea, the importance of sleep, and treatment options. You, your staff and your patients, together in this discussion, fosters trust and builds long term relationships. Training yourself and your staff to discuss sleep apnea treatment matters to patients; it means better health, feeling and looking youthful, improved functionality, a return to “the big bed.” Everyone in your office the opportunity and responsibility to be part of the patient care team. Give away information freely. Have information readily available for your staff to give away. Patients not only walk through the door of an office where they trust the provider – they also refer their family and friends, and that is invaluable!

Introducing Chris Bez – she calls herself an ‘opportunity engineer’ because she’s experienced in helping dental offices, specifically dental sleep practices, find opportunities to build their practices. This essay, from her blog, marks the first of DSP’s latest quarterly column, Practice Growth. Chris will be engineering exciting opportunities for every issue!


Marketing to MDs Building Strategic Alliances to Treat More Airway Patients by Rob Suter


hysicians recently surpassed Dentists with the highest suicide rate among all professions. Why? Many MDs are burnt out, have marriages on the rocks, and have incredible college debts looming over them. With hospital mergers, consolidations, and CMS cutbacks, they are losing control and feeling the reimbursement squeeze like never before. They are forced to pick up shifts on the weekends, at Urgent Cares, and a lot of times work depressed as they try to live the Hippocratic oath. MDs are literally under the gun. They have more on their minds than “how to pick a Dentist to work with.” The Dentist making Sleep appliances who is perplexed when a Physician doesn’t send any CPAP intolerant referrals after that one marketing visit to their office is missing the big picture. Did they not understand the referral form I left? Surely they read every line of 10 clinical papers that outlined Oral Appliance efficacy? Why aren’t they referring to me? Over the last two decades I have spent a lot of time training companies and Dentists on the answers to these questions. I have lectured all over North America on how to market to Physicians. When I worked for ResMed we had a training program that trained DME representatives on how to market to MD’s. These DME companies dispense CPAPs…

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a lot of them. The training was all day and taught reps how generate more referrals. Companies like Apria have small armies of reps calling on the same MDs that RX all the CPAPs, showering attention on the coveted local Sleep MD. They may see this Sleep MD weekly, buying lunches, leaving chocolates, building strong relationships with the entire office, thus galvanizing their CPAP habits. This makes it tricky for a Dentist who tries 1-2 times to get past the gatekeeper, never sees the big MD, gets frustrated, and gives up. In one year, I trained more DMEs in the Chicago market than anyone in the company and became the #1 global territory manager for CPAP sales. Hence marketing to MDs works, but it takes strategy and persistence. I firmly believe that Dentists who want to market to MDs can use similar tactics to build referral alliances, and enjoy similar success, with four basic strategies. These strategies are: 1. Solve problems 2. Make an MD’s life easier 3. Speak their language and use SOAP notes 4. Come bearing gifts

Solve problems

I led a DDS-MD summit in Dallas, Texas with some of the top players in that market. They all came together to try to figure


Pound for pound, an ENT can send more Sleep patients to a DDS than anyone else in town.

out how to treat more patients and automate CPAP intolerance to Oral Appliances. One Sleep MD, Dr. Raj Kakar, mentioned that he was using a certain Dentist because they solved a problem for him. The Dentist was using 3D Airway images to warm the patient up and propel them to his lab. Dr. Kakar went on to say that these same patients were more compliant to show up for sleep studies and go on therapy, most likely because they understood they were breathing through a constricted Airway. Dr. Kakar and I feel having 3D is a distinct advantage Dentists should leverage a lot more. Less than 1% of MD’s have CBCT and many know nothing about it. Yet 5-15% of DDS have 3D and that percentage is growing rapidly. Dentists with CBCT should always send an Airway scan, along with the referral, to the MD. Why? An Airway scan illustrates the problem. That scan is the ‘best case scenario’ for the Airway, as good as the Airway will ever look. 3D scans should lead to more patients getting diagnosed and treated. For example, if you are doing an implant and the patient has scalloped tongue, worn down incisors, and masseters the size of Alaska, expand the FOV and trace their Airway. My bet is this implant patient has a bad Airway. Researchers in Spain showed that ‘81% of patients with OSA experienced complications with their implant prostheses.’ (Sleep Review 2017). Recently, I helped a Dentist and a Sleep MD form a relationship. I told the Dentist to show 3D scans to this Sleep MD who RXs over 100 CPAPs per month. The MD was so impressed he wanted to get scanned himself. This organically opened up an opportunity for the Dentist to explain how 3D will lower TMJ and bite change adverse events – two very common complaints MDs use to justify not referring for appliances. Tip: Be ready to discuss these issues with an MD because side effects slow their practice down and

Rob Suter has worked in the Respiratory, Sleep, and Dental industry for over 15 years. He resides in North Carolina and has a lovely wife and three children. He is the District Sales Manager for Vatech Imaging in the Carolinas. Prior to Vatech, he managed the North American CADCAM unit for ResMed and was recently the VP of Sales at OSA University. Rob is available at

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create unhappy patients. Solving problems, not creating them, is a good way to increase referrals. Everyone agrees that marketing to MDs can be a challenge – why do you think Pharma companies have billion-dollar ad budgets? I have found most Dentists go after the biggest fish in town. They go for the big Pulmonologist (or Pulm) who owns the lab AND the DME and wonder why they fail. They make the referrals and lose their patients to CPAP. Here’s why – Pulm’s are trained to ventilate first and ask questions later. Strike 1. They like data and can bill for office visits reviewing CPAP data. Strike 2. Appliances don’t really provide data and they don’t understand the process. Strikes 3 and 4. Lastly, many Pulms own the DME so they see appliances as direct competition for their bread and butter. Strike 5. That’s a lot of strikes! So who should a Dentist target to grow their practice? If I was going to put medical clinicians in the order of ease of access and ROI I would say: 1. ENTs 2. Neurologists 3. Physician Assistants and Advanced Registered Nurse Practitioners (PAs and ARNPs) Pound for pound, an ENT can send more Sleep patients to a DDS than anyone else in town. I know a big ENT that RX’s 70 appliances a month to three Dentists. That’s not a typo. Tip: If you haven’t connected with all your local ENTs, start doing so. Dentists doing any Appliance volume at all generally have a solid relationship with one or more Otolaryngologists.

Make an MD’s life easier

Dentists, you don’t need to get in front of that big Pulm or even the big Sleep MD a lot of times. Tip: Sleep MDs read studies at labs after hours and this is a better place to catch them than in their clinics. Most MDs rely on their PA/ARNP heavily, and these clinicians have a lot of referring power and are easier to access. Every time a CPAP patient turns into a non-compliant ‘pumpkin’ at day 91 of their cpap trial, someone in the office gets ‘the fax’ stating the DME is pulling the patient’s CPAP. Tip: Dentists, ask who gets these faxes and who determines what 2nd line therapy will be for the patient. This person more than

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MARKETING likely is the PA/ARNP and not the MD. Focus your energy on the decision makers, not someone who doesn’t have the time to see you. If you can provide an easy way for struggling patients to get from CPAP to appliances you are solving a problem, and making the MD’s life easier, and you did it by showing the ARNP a viable solution. But what if they don’t know much about the process or appliances in general? Just keep reading.

Speak their language, use SOAP notes

I was invited to speak at SPEAR Education to teach Dentists the Medical/CPAP side of Sleep. Dentists need to know the ‘lingo’ of Medical Sleep. So I taught Dentists how MD’s communicate: what a CPAP setup was, how a pillows mask differs from full face, and how an Auto Bi-level works. This knowledge is power for a DDS: just knowing their preferred terminology can help you engage

more DME’s, MD’s, and Sleep Labs. For more on this click on this link: Other best practices on communication include one from Dr. John Tucker who always uses SOAP notes to communicate appliance efficacy and tolerability to MDs. He always asks the patient permission to send info to ALL the MDs they see on a regular basis. If you have a cone beam, I would advise you to do the same thing with your airway scans. The Vatech Green CT with a Ceph is ideal for sleep and it creates a nice report in a couple clicks. The report vividly shows the airway and gives you room to write out your Subjective, Objective, Assessment, and Plan, exactly what MDs want to see from their Dental colleagues. Study the medical notes you get from the MDs and copy their style – when your notes feel ‘familiar,’ the MDs will be more comfortable referring to a colleague.

Come bearing ‘gifts’

Dr. Richard Drake taught me a valuable lesson years ago. He said, ‘Rob whenever I meet with a sleep lab manager, I always have a couple patients’ charts that need sleep studies with me.’ Tip: Follow Dr. Drake’s advice. Ask yourself: “How many referrals do you send the ENT for nasal patency issues, or the Neuro for migraines, or the Sleep MD for CPAPs, etc.” If the answer is ‘umm, umm, well none” my point is made. You have to give before you get. My friend Dr. Daniel Klauer has built a Sleep and TMD juggernaut in the Midwest at a very young age. How? He has a marketing strategy that employs unique techniques that set his practice apart. He creatively uses audio visual resources to get past the gatekeepers. He also tracks how many referrals he sends out and receives. He uses these metrics in business reviews as leverage. Recently, while I was in his office he said he was on the verge of putting an MD in the penalty box because the MD wasn’t referring back as much as he was referring to him! Track your numbers. To the Dentists reading this article, the best pearl I can give you is this: Do what you do best, be a Dentist. Tip: Offer to make an ARNP an appliance. Get them away from their grind and over to your office, take digital impressions and 3D scans on them. Your technology

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MARKETING will impress them, trust me. Then make them a CADCAM appliance and give them the same device on models when you deliver theirs so they can show potential patients. That will be the best money you ever spent. That ARNP will know exactly where to send the patient who says “I can’t do one of those masks on my face.” The beauty of making an appliance for that ARNP is now they can articulate the whole process from digital scans, to insertion, to titration. When ’the fax’arrives from the DME, they educate and show the patient 2nd line therapy with personal testimony. A Dentist’s close rate in this scenario will be much higher because the patient is warmed up and educated by the ARNP. Tip: Always communicate where the patient is in the appliance process and refer the patient back to the ARNP with SOAP notes to close the loop. This is critical. I once knew a Dentist who lost a massive VA account because she didn’t use SOAP notes correctly. In conclusion, the Dentist that wants to work with MDs should target the correct

players and employ these tactics, along with a persistent and creative approach. Dentists should try to empathize with an MD’s challenges and solve their problems, which in turn makes the MD’s life easier and builds local alliances. It’s imperative to learn their language – it’s their turf, so speak their lingo. Lastly, Dentists who make MDs an appliance or come bearing referrals tend to receive more referrals themselves. The ROI on making an MD an appliance is astronomical and a great way to give before you get. Airway is about life and death, stroke or no stroke. This isn’t a game we can give up on. MDs are not sitting around, wondering how to move beyond CPAP. It’s up to Dentists to reach out to them to make a difference for the CPAP intolerant patients and the 85% of apnea patients who remain dangerously undiagnosed. Finding a way to help these patients also helps their harried Physicians— which many will be grateful for—and in turn, helps you, too. Good luck and don’t give up! Lives are depending on you!

Dentists, Physicians, Physical Therapists, Nutritionists, Speech and Myofunctional Therapists, and Team members will come together for the

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Uncovering the Why Behind OSA Treatment Acceptance by Steven Wick


he average dental practice in 2017 is full of undiagnosed and untreated Obstructive Sleep Apnea (OSA) sufferers. The first challenge is uncovering your undiagnosed patients. This can easily be done using readily available questionnaires and doing comprehensive oral exams. Once identified, the process becomes harder. Convincing patients to undergo a sleep study is the first step. Agreeing to treatment is the second step. People make decisions everyday based on their understanding of the problem and their individual needs and wants. Behind every good decision there’s usually an educated patient and a compelling why that’s been uncovered and addressed. Educating patients on traditional dental procedures is often second nature. The “why” may be pain that leads a patient to the endodontist, or lack of self-esteem that finally gets them to the see the Orthodontist. Educating your patients on OSA and then identifying and addressing the “why” is often more difficult. OSA education isn’t straight forward and quick. It takes time and contemplation. The “why” can be just as challenging. Why does my dentist need to know if my OSA/Snoring is causing marital strain? Why does he/she care if my daytime sleepiness is causing problems at work? Why would my untreated OSA contribute to additional health issues? These are hard conversations to have with your patients, and you still might not uncover an appropriate “why”.

Steve Wick has spent the past six years identifying pain points for dentists who treat OSA, and crafting solutions to minimze the obstacles. Steve currently oversees the development of Oventus Medicals North American business unit. He can be reached by email at stevemwick@gmail. com or by phone at 425-681-1894.

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My “why” was Restless Leg Syndrome (RLS.) Wanting treatment for my RLS, I went to my physician and underwent a sleep study which revealed my severe OSA. I went home with medication for RLS and a CPAP for my newly diagnosed condition. My “why” had been my restless legs, not OSA. I took the medication and put the CPAP in the closet. My second “why” came a year later when I couldn’t get life insurance due to my untreated OSA. This second “why” led me to the dentist where I had an oral appliance fitted, which I wear every night without fail. My experience was like that of many others. I didn’t know or care that I had a problem until a compelling “why” was put in front of me. Once confronted with my “why” I chose treatment. I then discovered another “why” and wrote a book about my experience: “Kicking the Bear out of the Bedroom” Snoring and Sleep Apnea the not-so-silent Killers. My new “why” that the book addressed was the realization that Dentists needed a tool that would educate their patients on the seriousness of OSA and help them identify their own “why” and accept treatment. The book is an easy, quick read available on Amazon. For more information on how to incorporate it into your Dental Sleep Medicine practice, please contact me directly and I’ll share with you how offices around the world have used it effectively to get patients to agree to treatment.


Education in Sleep Medicine by Michael Simmons, DMD, MSc


ow does the dentist with a deep interest in becoming expert in providing sleep disorder care stay on the right path? The simple answer is to learn from true sleep medicine experts and study the topic as if it is a passion. It takes time, exposure and serious commitment. Like all hard-earned expertise, it is not as easy as you may first be led to believe. In recent years, I have been impressed by dentists’ foray into providing care for sleep disorders. This editorial expresses my view of the ethical representations of one’s training in sleep medicine to patients, to colleagues and to oneself. It touches on how much training is enough and speaks to ways to stay on track if you have a sincere interest in the field of somnology. Choosing significant, lifelong, education is quite different than settling for the superficial training often found as part of developing easy income streams. The first order of business is to share an aspect of what dentists providing sleep disorder care is all about. Sleep disorder care is not about providing a product as a lab person or dental assistant without ownership of the health care outcome. Delivering oral appliance therapy (OAT) for sleep related breathing disorders (SRBD) is provision of professional, doctor level care, which includes ensuring the correct diagnosis, delivering appropriate treat-

ment and following up with extended care of a chronic disorder. Even provision of clinically validated surgical interventions for SRBD conditions using MMA or other approaches needs extended follow-up to ensure the outcome is successful over many years. Dentists providing sleep disorder care take on an ethical obligation to have adequate understanding of related sleep and medical disorders. Sleep disorders care is a health care discipline which is comparable in knowledge base to the discipline of dentistry. The “Sleep Bible” contains the best collection of how much baseline sleep information is known. This Bible, aka “Principles and Practice of Sleep Medicine”, 6th edition, was released in 2017. It includes 1730 pages (not including the thousands of support references that are only available online) and is far larger than any dental text I have seen; 171 chapters, 317 contributors/authors – the majority are MDs and PhDs and a good number with both degrees, 16 dentist contributors world-wide (11 of which also have PhDs), 3 dentist contributors from the U.S. and only one dentist world-wide as a Section/Deputy Editor – Gilles Lavigne DMD, FRCDC, PhD. Most dentists realize their doctorate included ~4 years-worth of training and enormous study and financial commitment. Dentists would have a hard time accepting a


EDUCATIONspotlight dental assistant with 25 hours of training in dentistry be considered qualified to provide unsupervised dental care. What if it was a family practice physician with the same 25 hours of dental education? Understandably there is a difference between assistants and doctors, but most dentists would likely opine that 25 hours is enormously insufficient to claim qualification to provide unsupervised dentistry. It’s reasonable, then for authentically credentialed sleep experts to have a similar view that 25 hours of education in sleep medicine does not provide sufficient training to “qualify” dentists in sleep medicine. So, when a sleep academy offers to sell such a “qualified” credential, or give Dentists providing sleep it away with a paid membership with same 25 hours of education, it is disorder care take on the ethically dubious at best and appears an ethical obligation to to overstate qualifications. Why even credentialing to a dentist achave adequate under- provide knowledging education to the level standing of related sleep of a supervised assistant or lab techMarginalizing a typically unand medical disorders. nician. supervised dentist in this manner is a difficult pill to swallow and confuses the public who are not exposed to the limits of this “qualification”. Moreover it is insulting to the truly qualified sleep expert that committed to hundreds of hours of specialized study and passed rigorous independent testing. It leads us to important and meaningful questions such as (1) How many educational hours does it take to become truly qualified or expert in sleep disorders? (2) What testing is required to authenticate qualification? (3) Who qualifies / credentials experts? These questions deserve considered answers as more dentists seek to become involved in providing sleep disorder care.

Michael Simmons, DMD, MSc (in sleep medicine) is a diplomate ABDSM and ABOP, fellow in pain management UCLA school of medicine, director of two accredited dental sleep medicine facilities, well respected lecturer and leading teacher of sleep medicine to dental students. He is part time faculty at both UCLA and USC, has more than a few published articles in peer reviewed journals, continues to engage in research and serves in multiple leadership positions in dentistry and sleep medicine. Dr. Simmons is a strong proponent in engaging more dentists to provide quality sleep medicine care.

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Currently there are about a dozen Council on Dental Accreditation (CODA) approved U.S. dental schools with post-doctoral M.S. training programs in orofacial pain and at least one university offers a primarily online program. These programs for the most part have added training in sleep disorders without specific and consistent published educational requirements. Although still in their infancy, these dental school “sleep education” programs are among the best options for the serious student in sleep medicine. They have proven themselves with CODA accreditation focusing on the “Orofacial Pain” component of the training and simply piggyback the sleep disorder training. Other disciplines such as prosthodontics and oral surgery also have components of sleep disorder training in their CODA requirements although less well-described. The problem here is the assumption that these training programs are all adequate and similar enough in scope to qualify the post-doctoral students in “sleep disorders”. While some of the dental school educators are true sleep disorders pioneers or experts, it is risky to assume that all educators teaching about sleep disorders in these programs are “qualified” themselves to teach this topic. So, allow me to elaborate on what I perceive the sleep disorders education pyramid is about and where dentistry will evolve. The top tier of the educational pyramid for dentists would require two components. First, it would require attendance at a university-based medical school interdisciplinary sleep program. These programs have been limited to physicians but are starting to train dentists. Some leading multidisciplinary sleep centers that educate doctors in somnology include Stanford, Oxford, and the Universities of Pennsylvania and Sydney. Training programs may include PhD’s, MS or PGDip (postgraduate diploma) programs in sleep. Entering into a program of this level requires perseverance and may be available to dentists on a case by case basis. The second component to top-tier education would require passing an independent and validated exam. Such examination is available through the independent American Board of Medical Specialties and is administered by various medical disciplines such as pulmonology, otolaryngology and internal medicine, but not open to dentists. While the Ameri-

EDUCATIONspotlight can Board of Dental Specialties (ABDS) is well on its way to becoming a qualification board, independent to the ADA’s recognized specialties, the ABDS has yet to authenticate such testing. The next level of expertise in the educational pyramid is through training, experience and testing from the various university based specialty dental programs which include rotations through medical sleep centers. This next level of expertise would have testing process available to dentists through the best current testing process: that offered through the American Board of Dental Sleep Medicine (ABDSM). ABDSM qualification is recognized by the leading international sleep medicine group, the American Academy of Sleep Medicine (AASM). Other dental, oro/ cranio facial pain and sleep groups, with no

AASM recognition, have recently developed copycat Diplomate awards, without apparent validation by independent parties. Some of these alternative awards in sleep medicine unfortunately appear little more than bought certificates, with no significant sleep disorder training pre-requisites to sit for their exam. The net result is to bring the whole authenticating process down by lowering the quality control aspect. A robust education and testing is necessary to qualify expertise, as anything less opens dentistry up to attack on credibility from other sleep experts. This type of qualification commitment is a very different message than the easy education/easy income approach increasingly used as a carrot to entice dentists to provide sleep disorder care. The lowest training and education level of dentists in sleep medicine is provided by

How to increase your level of sleep training

Pyramid of Education

Addition of independent credential testing at all levels improves educational status and authenticity Intra-program testing/grading of learned material improves educational program

Most Qualified

University Medical School interdisciplinary sleep disorder training program. Includes significant research experience/ publication of original research

University Medical School interdisciplinary PhD, M.S. PGdip sleep disorder training program University Dental School Post Doctorate PhD, M.S. PGdip training program with extensive sleep education by sleep experts in medical and dental disciplines (+ research/publication is better) University GPR/Fellowship program with rotations in various medical sleep specialty disciplines >250 hours education Documented hours in sleep medicine attendance in unbiased educational settings. Hands on experience and feedback mechanism. Min hours 250 Mini residency in sleep disorders with hands on component (>100 hours with more hours better given same educator expertise) Documented attendance at unbiased sleep educational programs such as non-profit sleep academies Min >100 hours. Additional time with hands on experience would be considered beneficial. (More documented hours is better) Biased education which often includes “profit centered” program/sleep academies, industry sponsored sleep education events and dentists selling products in an educational program.

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Least Qualified

Only 15% of airway/ sleep disorders are diagnosed. Help address this major unrecognized public healthcare crisis


by joining thought leaders, academies, organizations and corporations to bring a unified message of awareness to the public.

• Attend Foundation Events - White Flag Event II @ the AAPMD Conference September 13-17, 2017 in San Juan, Puerto Rico - Airway Summit @ The Greater New York Dental Meeting November 25, 2017 in New York, NY

• Complete the Foundation for Airway Health Pledge (below) and be listed as a resource for those seeking care for airway/sleep problems.

For more information, visit Foundation for Airway Health Pledge We want to fill our pledge rolls with practitioners of any modality that believe in the importance and priority of airway. Those interested can use this form or visit the Foundation website and find the pledge under the Healthcare Professionals tab. Thank for your support and partnership in our airway mission.


I am committed to championing the recognition, diagnosis and treatment of airway disorders through collaboration, awareness, research and education, and access to care. I pledge all patients seen in my office will be screened for airway/sleep problems and will be provided resources for diagnosis, treatment and referral.


I wish to be listed on the Foundation for Airway Health website as a referral resource for those seeking care for airway/sleep problems. Airway is a priority.

Name ____________________________________________________ Email ____________________________________________________________ Send to Foundation for Airway Health, 355 Lexington Ave., 5th Floor, New York, NY 10017 or

EDUCATIONspotlight the entrepreneurial and most often self-proclaimed dentist experts, typically introduced or supported by industry. These educational venues and programs often feature products that are sold to dentists. Avoiding these programs is important, as it is hard to unlearn bad information and a false sense of empowerment is a dangerous thing. Some of these educational programs were sold to dentists for tens of thousands of dollars and often by opportunistic dentists or companies There is simply no offering get rich quick schemes. There simply no substitute for hours of substitute for hours of isstudy and commitment to the topic. Fortunately for our patients there study and commitment a mid-level sleep medicine educato the topic. istion. A “weekend warrior� education in sleep medicine, and even a year long, 3-5 weekend, mini-residency university based education is no substitute for formal training, but it is significantly better than industry sponsored education. The reason being that university based mini residency programs are more likely associated with true sleep experts providing unbiased education. Unfortunately, these mini residency programs still lack quality control in accepting students, lack oversight and are devoid of formal testing. On the bright side the mini residencies have continuity, options for individualized attention and often exposure to a wide range of sleep related information. These programs also allow for development of contacts with other like-minded dentists with opportunities to learn from each other. In between the industry and university based education are the non-profit sleep academy programs. These are fabulous venues to meet many sleep medicine enthusiasts and experts, Five steps in determining if the CE course is worth attending 1. Review the background of each speaker to see their past research and publications 2. Confirm speaker(s) credentials are authentic and significant to the topic presented 3. Ask if the group / academy / society / lecturers presenting the course have a history of past unbiased helpful information or were programs anecdotal, profit or politically based course agendas. 4. Determine if there are product or further CE sales involved, who is sponsoring the course/ speakers and how that impacts the information presented. 5. Assess whether the course promises get rich quick approaches or does it promote best care patient centered principles. Assure yourself that the topics covered are relevant to contemporary practice.

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connect with researchers to discuss their scientific abstracts, as well as experience what industry is offering in their sales booths. Their programs often include a number of sponsorships and the academy itself may have a political agenda that dictates the information they present. However, there should be a requirement for annual or biannual attendance of 25 hours at this minimal level of education when providing sleep medicine care, much as any discipline requires ongoing continuing education. Not to be forgotten are local study clubs devoted to sleep disorders care; the range of help in these venues is totally undefined and depends entirely on the makeup and programming of the group. So how does the dentist with a deep interest in becoming expert in providing sleep disorder care stay on the right path? The answer is to learn from true experts and study the topic whenever possible in a formal university based interdisciplinary sleep program. This is not to dissuade the average dentist from practicing sleep medicine but rather encourage them to grow out of the supervised role as a technician and assistant and into an equal partnership position with other sleep experts. We are fortunate now to have a number of true dentist experts in sleep medicine scattered around the globe from whom to learn. To determine an expert, look at their training background, their degrees, credentials and qualifications, what have they published in peer reviewed journals and if they previously presented unbiased information. This is in comparison to typically biased information provided by speakers with industry backing, speakers politically motivated to promulgate their societies self-survival agenda or speakers benefiting from sales of their own related products, support systems or future CE sales. Above are 5 questions you should ask when signing up to sleep education programs, or for that matter, any program geared towards your education. Finally, I leave you with one recommendation: Every day you practice sleep medicine you should open up the Sleep Bible and learn something new. This study ethic is sure to keep you humble, grounded and appreciative of all the work that pioneers did to enable you. This is part of a commitment you have as the perpetual student and healthcare provider, to your patient who is entrusting their life to you.

Are you free?

Actually free? Or are you chained to another CE course chair? Are you chained to traveling around the country looking for that one program that’s finally going to give you the missing pieces of the puzzle? Chained to a company that promises to “do everything for you,” while things still don’t seem to be progressing the way you envisioned? Chained to the fear of not knowing what to do to help that patient with the TMJ problem? Or chained to a schedule and agenda you didn’t create? Are you missing that special family event? Postponing that celebration? Is that what you really want? Is that where you really want to be? Here’s the deal. There’s no easy button. But, you CAN be FREE. Free to have access to the education, mentoring and documentation YOU WANT. WHENEVER you want it. WHEREVER you want it. HOWEVER you want it.

Spencer Study Club was built from the ground up with the focus of providing dentists AND THEIR TEAMS with ALL the education, mentoring and tools to GIVE YOU THE CONFIDENCE you need to help as many patients as you can with their Sleep and TMD problems. 45+ hours of content. Video, Audio and Written formats. How to videos. ALL the documentation. Live mentoring. Hands on opportunities. You name it. Nothing held back. For less than the cost of a single weekend program for you and your team. Over 150 of your colleagues are waiting for you to join…and we only launched a few months ago! No risk. No limits. No gimmicks. No more BS (BS = “buying stuff” by the way ;-D).

If you’re ready to be free…Welcome to the Club! and enter code “Freedom” or call 208.949.7007 to claim your freedom today.

And don’t forget to download your FREE DSM Billing Book at That’s right…FREE!!! Who Loves Ya Baby?!




by Ken Berley, DDS, JD, DABDSM and Courtney Snow, Medical Insurance Consultant


n this edition, I continue our journey into the tangled maze of Medicare. In our last article, Courtney and I looked at the Medicare regulations associated with opting out, in this article we will explore the use of Advance Beneficiary Notices (ABN’s) and Dental Sleep Medicine (DSM) practitioner’s enrollment in Medicare Part B. Again, I want to thank Courtney for her amazing help in writing this series of articles. Medicare…for some, the word can make you cringe! I get questions about it all the time, and I cringe. It’s not that I mind the questions, the problem is that I don’t have solid answers to many of them. This is made more frustrating by government Medicare bureaucracy. When you ask Medicare questions directly, you can receive a multitude

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of different answers…..or no answer at all! For the readers who are relatively new to the practice of DSM, let me take a minute to explain why we are in such a difficult position when providing Oral Appliance Therapy (OAT) for Obstructive Sleep Apnea (OSA) to a Medicare patient. The first issue is that when we provide OAT to a Medicare patient, we are classified as a Durable Medical Equipment (DME) supplier. We are not classified as a physician/ dentist. As a DME supplier, we (the dentist) receive a detailed written order (DWO) (a.k.a. prescription) from a physician for a piece of equipment which, in our case, is a custom made oral appliance [a.k.a. mandibular advancement device (MAD)]. Once we receive the DWO, we are then allowed

LEGALledger to fabricate the appliance and deliver it to the patient, and Medicare has a set allowed amount which is payable for this piece of equipment (custom made oral appliance). In my humble opinion, OAT as a whole SHOULD NOT be classified as DME! The custom made oral appliance itself certainly meets the definition of DME, but what about all of the professional services and doctor level decisions that are made in order to fabricate a custom made oral appliance? The procedures and protocols that dentists employ to effectively treat a patient with OSA do not fit within the traditional DME model. Dentists treating OSA should be treated as physicians.

The first problem

The DME model assumes that all intake examinations, radiographs, monitoring, evaluation of effectiveness and “doctor level decisions” will be provided by the prescribing or ordering physician. In Dental Sleep Medicine, this is not the case. Before OAT can be provided, dentists practicing DSM must complete an extensive oral & airway examination to determine whether the referred patient is a proper candidate for OAT. This intake examination generally involves doctor level decisions regarding the oral health of the patient. Before a decision is made to fabricate a custom made oral appliance, the patient must be evaluated for a number of items such as: the status of the patient’s teeth, gums, Temporomandibular Joints (TMJ’s), bruxism/ clenching, number of teeth, oral cancer sta-

tus, crowding/occlusion, amount of available protrusion, deviations and deflections on opening…and the list goes on. Additionally, I personally order current radiographs of the teeth and the TMJ’s before I determine if the patient is a proper candidate for OAT. So the question is: “What do you do if the patient is NOT a candidate for OAT after you spent an hour of time doing the examination & x-rays?” Can you charge Medicare for your time and effort spent to determine that the patient was NOT a candidate for OAT? My answer to come shortly!

The second problem

Medicare assumes that Oral Appliance Therapy will take no longer than 90 days and the patient will never be seen again. In DSM, this is not the case. Medicare regulations state: “Items that require repeated adjustments and modification beyond the initial 90-day fitting and adjustment period in order to maintain fit and/or effectiveness are not eligible for classification as DME. These items are considered as dental therapies, which are not eligible for reimbursement, by Medicare under the DME benefit. They must not be coded using E0486.” In DSM dentists are providing therapy for a disease that in the majority of cases must be monitored and controlled for the rest of the patient’s life. When a dentist fabricates a custom made MAD – HCPCS code E0486 – and submits a claim to Medicare for reimbursement, Medicare’s assumption is that the payment provided will cover the entire cost for the appliance including any

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.

As Director of Training and DentalWriter™ Software Implementation at Nierman Practice Management, Courtney Snow is well known in the Dental Sleep Medicine industry for her work with medical insurance reimbursement for Oral Appliance Therapy for Obstructive Sleep Apnea. She is also an excellent resource for medical billing for Temporomandibular Disorders (TMD), oral surgery services, and other medically necessary services performed in the dental practice setting. Courtney can be reached at 1-800-879-6468 and through


LEGALledger adjustments and follow-ups. Medicare DME has no provisions for on-going recall and evaluation of the patient by the DME supplier (which, of course in this case, is the dentist). This statement is easier to understand if you envision that you are providing a wheelchair for the patient instead of a therapy to treat a potentially deadly disease. Items are generally considered DME when they: can withstand repeated use, are used to serve a medical purpose, are generally not useful to an individual in the absence of an illness or injury, and are appropriate for use in the home. In a Medicare article titled “Correct Coding of Oral Appliances”, it is stated: “An oral device is considered durable medical equipment (DME) which: • Can withstand repeated use • Is primarily and customarily used to serve a medical purpose • Is generally not useful to a person in the absence of an illness or injury • Is appropriate for use in the home”

Medicare DME has no provisions for on-going recall and evaluation of the patient by the DME supplier.

Therefore, in the current landscape of OAT, you need to think of yourself as a wheelchair salesman! When a patient is provided a wheelchair under DME, the patient receives a prescription from his or her physician, and that prescription is presented to a DME supplier. The DME supplier determines the size wheelchair that the patient needs and adjusts the wheelchair for the patient’s comfort. The DME provider has the patient complete the appropriate paperwork including the proof of delivery. After delivery the DME supplier can bill Medicare. The DME supplier is obligated under policy to make any necessary adjustments the wheelchair for 90 days. However, after 90 days from delivery, no other payments are available for the wheelchair. The proceeding wheelchair example is how OAT is set up under Medicare. Medicare has no provisions or payment arrangements for dentists practicing DSM to perform intake examinations, radiographs, or recall of our patients. Those procedures are assumed

62 DSP | Summer 2017

to be done by the sleep physician who ordered/prescribed the MAD. We are all aware that complications secondary to MAD therapy are possible, therefore, it is impossible to provide OAT with any level of competence without an extensive intake examination and regular recall examinations. So the question becomes – how do we provide the optimum level of care to our Medicare patients without losing money on the therapy? So, we are left holding the short straw. To make matters worse, if the calibration of a MAD takes more than 90 days for any Medicare patient, no Medicare benefits are available. Yes, I know that some of you are filing these visits under Medicare Part B, however, I have personally had communication with 14 different Medicare Medical Directors and all of these physicians agree that filing these appointments and procedures under Part B is a misuse of those E & M Codes. When questioned as to why some dentists are being reimbursed under Part B, the collective answer was that the payments were not appropriate because Medicare does not have “Dental” benefits. What does all this mean to us as Medicare DME suppliers? Sadly, I think each practitioner must determine the level of risk that you are comfortable with. Personally, I have struggled with this conundrum. I want to operate within the letter of the law, but I hate placing my practice at a competitive disadvantage. However, I have made the decision to forego enrolling as a Medicare Part B provider. When I receive a Medicare referral, Patty (Wife/Office Manager/DSM Coordinator/Goddess) calls the patient and asks a series of questions in an attempt to eliminate those referrals who may not be proper candidates for OAT. The questions asked pertain to the typical issues that might disqualify the patient as a candidate for OAT. These questions include: date of last dental visit, date of last dental cleaning, diagnosis of gum disease, any dental work needed, number of teeth on each arch, diagnosis of migraines, ringing in the ears (tinnitus), and current adult orthodontics. Upon completion of this questionnaire, Patty makes a decision whether there is a likelihood that this patient will be a proper candidate for OAT. This screening process has greatly reduced the number of Medicare patients who are appointed that ultimately are disqualified as candidates for

LEGALledger OAT. Therefore, I do not worry about filing Medicare Part B for the initial examination and radiographs, and I rarely perform an intake on a Medicare patient that is not a proper candidate for OAT. Regarding recalls, I use ABN’s and my patients pay for those visits. Once the MAD is delivered and the initial 90 days have expired, my patients are financially responsible for all subsequent appointments. They are informed of this fact prior to beginning therapy in our patient financial contract. When they present for the recall appointment day 91 or after, the patient is presented with an ABN which informs the patient that they will be financially responsible for the amount of the visit and that Medicare is NOT expected to pay. In our office these Medicare patients are only charged a nominal fee, but I do not file these services to Medicare Part B. Here is the RUB! The American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) protocols indicate regular recall of all our patients after the patient’s MAD has been calibrated to the appropriate position to reach maximum medical improvement. Medicare has not created provisions for DME suppliers (dentists in this case) to be reimbursed for these appointments. However, there are lecturers and billing companies galore who are encouraging the use of Medicare Part B for reimbursement of these services, and some dentists have been successful in receiving payment for recall appointments under Medicare Part B. However, I again want to reiterate, my many sources at Medicare consistently state that this approach is a misuse of Medicare Part B, making the practitioner subject to audit. Medicare regulations require that we maintain all records for a period of 7 years. Therefore, any Medicare audit could easily include inappropriate (Medicare Part B) payments for a period of 7 years, plus penalties and interest. Now for the GOOD news! The directors at Medicare are well aware that OAT as a whole should not be a part of DME. I have had numerous discussions regarding the inequity of payment provisions. Surprisingly, numerous directors at Medicare are in agreement. They are aware that we provide a therapy/treatment for OSA, not simply dispense a piece of DME like a wheelchair. It is my understanding from the Medical Directors at

Medicare that DSM was placed under DME upon request from directors of the AASM/ AADSM and therefore, Medicare is unwilling to revisit this issue without the cooperation of the leadership of the AASM/AADSM. Therefore, the only solution to this dilemma is to have the leadership of the AASM/ AADSM approach Medicare and request that OAT be removed from DME.

In Conclusion

I call on the leadership of the AASM/ AADSM to launch a committee to approach Medicare and petition that OAT be removed from DME or as an alternative, petition that Medicare Part B reimbursement be allowed for intake examinations, radiographs and recall examinations. These actions would resolve much of the confusion that exists pertaining to Medicare, but for now, Be Careful!

Watch for It


















64 DSP | Summer 2017

































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Dental Sleep Practice 2017 Summer Edition  
Dental Sleep Practice 2017 Summer Edition