I. SESSION I: Introduction / Getting Started
a. Watch Video
i. “Fundamentals of Dental Sleep Medicine”
ii. Log in – Dashboard - Education - Watch Videos, click the play button on the Fundamentals video, hit the expand button to watch in full screen
b. OPTIONAL: Fundamentals of sleep webinar on you tube
i. Search “Dental sleep solutions webinar #1 fundamentals”
c. Watch the “DS3 Overview Video”
i. NOT SURE where to find this
d. DENTIST to review Dental Sleep Medicine Manual Overview. View this on the big screen and walk through each section, with the idea being to educate your staff about sleep in general: Why we sleep, REM and non REM, Dreaming. Don’t spend more than a few minutes on this. This will be good practice for the dentist to give public talks later. You find it by:
i. Dashboard - Education – Dental Sleep Medicine Manual – Overview
e. Homework for staff:
i. Read Procedures Manual first two chapters
1. Overview
2. Screen, Test, & Treat
ii. Review Forms
iii. Make sure staff knows how to log in and get to the Procedures Manual and the Forms
f. Sleep Action Checklist Module One
i. Review the entire Sleep Practice Checklist (to begin digesting the scope of what you are undertaking)
ii. Assign a staff member and due date for each step in Modules 1-4
iii. Create additional staff log ins for DS3
iv. Buy 3 each of either the TAP gauge or George gauge
v. Purchase tablet with Wi-Fi capabilities
g. Administer Review Test 1
i. Utilize Review Test 1 PPT AFTER test done
II. SESSION 2: Treatment Options
a. Watch video
i. “Treatment Options for SDB”
b. Watch Webinar
i. Insurance Billing Strategies (NEED to create this and link)
c. OPTIONAL: Watch DSS Webinar #2 through you tube on Treatment options for sleep disordered breathing
d. DENTIST to review Dental Sleep Medicine Training Manual
i. Review of Treatment Options (again, show this on large screen and talk about it as you go through it)
e. Homework for staff:
i. Read Procedures Manual
1. Insurance
f. Sleep Action Checklist Module Two
i. Contact Malpractice insurer and inform them of your intent to treat sleep disordered breathing patients
ii. Develop insurance strategy (in house Vs. 3rd party biller)
iii. Establish Medicare status and begin process (Complete 855S via PECOS system for those who do not opt out)
iv. Assign sleep practice marketing to staff member (bus cards, brochures, posters, web content)
v. Enter 50 most popular med docs AND local sleep labs into DS3 contacts
vi. Call local sleep lab(s) and ask for their referral form & send your dental business cards
vii. Establish system for referring patients for getting patients tested (HST & PSG/private and Medicare)
viii. Begin to treat family, friends and staff
g. Administer Review Test 2
i. Open and utilize Review Test 2 PPT AFTER test
III. SESSION 3: Screening
a. Watch Video
i. “Screening”
b. Watch Webinar
i. “Sleep Testing Protocols” NEED LINK
c. Watch Videos: Tablet Screener and New Patients/Web Portal (May NOT need/have)
d. DENTIST to review DSM Training Manual
i. “Identifying SDB patients in your practice”
ii. “Patient Protocols”
iii. “Patient Classifications”
iv. “AASM Guidelines”
e. Homework for Staff:
i. Read Procedures Manual on
1. “Screening”
f. Sleep Action Checklist: Module 3
i. Have each staff member show ability to:
1. Turn on Tablet / connect to Wi-Fi
2. Log in to DS3 / Screener
3. Screen a patient
4. Review Results of screener
5. Discuss next steps: talk to doctor, set up sleep test, consult
ii. Discuss and decide how you will implement screening into your practice
iii. Discuss and decide on insurance billing strategy (in house Vs. Third Party)
iv. Discuss marketing options for cards / brochures / posters
v. Discuss and decide on who will add dental sleep medicine marketing to your website and current practice marketing materials
g. Administer Review Test 3
i. Open and utilize Review Test 3 PPT AFTER test
IV. SESSION 4: Pre Consult & Insurance
a. Watch Video
i. Consultation (first half only)
b. Watch Webinar
i. Marketing & Insurance Reimbursement on you tube (Search for Dental Sleep Solutions webinar #6 marketing and insurance reimbursement)
ii. Interpretation of Sleep Studies (NEED LINK, this is DSS webinar)
c. DENTIST or Office Manager to lead discussion about
i. Billing strategies
ii. In house Vs third party (decide and begin implementation)
iii. VOBs / Determining patients’ out of pocket estimate
1. Need: Copy of baseline sleep test, insurance info, clinical notes
iv. GAP exceptions
v. Pre Authorizations
vi. Claim filing
1. Need: Copy of baseline sleep test, ins. Info, Rx and LOMN, clinical notes, CPAP intolerance affidavit (sometimes)
d. DENTIST to review DSM Manual
i. Medical Insurance Reimbursement
e. Sleep action checklist
i. Review Sleep Action Checklist and assign staff and due dates for Modules 5-10
ii. Review Screening Report for last week: how many screened, patients identified, how the process is going, how to improve
1. Dashboard – Reports – Pt Screener
iii. Discuss and decide on sleep marketing materials for cards / brochures / posters
iv. Discuss and decide on who will be closing the treatment case
1. Particular staff member who will review VOB, patients estimate portion, treatment device,
v. Review Q and A from Review Tests 1-3
f. Administer Review Test 4
i. Open and utilize Review Test 4 PPT AFTER test
I. SESSION 5: Consultation
a. Watch Video
i. Consultation (last half)
b. OPTIONAL: DSS webinar #4 on you tube, Patient Protocols
c. DENTIST to review DSM Manual
i. Case Acceptance Training
ii. Pt Screening, consultation, Evaluation, Charting
1. Consultation
2. Patient Evaluation
d. Homework for Staff:
i. Read Procedures Manual
1. Initial Consultation
e. Sleep Action Checklist: Module 5
i. Order at least three dental device samples
ii. Create Rx/Ref/LOMN pads for local sleep docs and high potential referrers
iii. Sleep marketing material printed (Cards, posters, brochures)
f. Administer Review Test 5
i. Open and utilize Review Test 5 PPT AFTER test
II. SESSION 6: Comprehensive Exam & Impressions
a. Watch Video
i. Comprehensive Exam & Impressions
b. OPTIONAL: DSS webinar #3 on you tube, Patient Evaluation & Consultation
c. DENTIST to review DSM Manual
i. Patient Evaluation to Device Delivery
d. Homework for Staff:
i. Procedures Manual
1. Comprehensive Exam & Impressions
e. Software Videos (NEED)
f. Sleep Action Checklist: Module 6
i. Print and deliver Ref/Rx/LOMN pads to high potential referrers
ii. Add sleep content to your website
g. Administer Review Test 6
i. Open and utilize Review Test 6 PPT AFTER test
III. SESSION 7: Device Delivery
a. Watch Video
i. Device Delivery (20 minutes)
b. OPTIONAL: DSS Webinar #5 on you tube Device Delivery and Titration
c. DENTIST to review DSM Manual
i. Device Delivery and Impressions to Managing Side Effects
d. Homework for staff:
i. Procedures Manual
1. Device Delivery
ii. DSM Manual
1. Dental Device Delivery
2. Titration of Dental Device
e. Software Videos (NEED)
f. Sleep Action Checklist: Module 7
i. Deliver Marketing Materials and Ref/Rx/LOMN pads to high potential referrers
ii. Add sleep content to your website
g. Administer Review Test 7
i. Open and utilize Review Test 7 PPT AFTER test
REVIEW TEST 7 (UTILIZE POWER POINT HERE on big screen)
· First goal of device delivery?
o Get the device to fit properly and be comfortable; the patient won’t wear it if it’s not
· What verbiage should you use to give the patient “realistic” expectations about their new experience?
o You may make it through the night and wake up feeling great tomorrow, or you may wake up at 2 AM and have to take it out because your teeth or jaw is hurting; those are the bookends. You will be somewhere between those two. Our goal is to make the device comfortable and get you to wear it through the night. Normal for all of the teeth, especially from canine to canine, to feel a little funny, and for the jaw to be a little sore.
· When would you start to titrate or calibrate the dental device forward?
o Clinical judgment is key. As a general rule, if the patient can wear it through the night with NO pain, OK to titrate forward, smaller increments better. TAP, for example, 1-2 half turns. Dorsal 2-3 clicks.
· Should you allow the patient to titrate the device himself? Or should only the dentist do it?
o Usually we allow and encourage the patient to do it himself. Creates “ownership” of the device and the disease process. Some patients simply don’t have the dexterity to do it themselves. Don’t ask a patient to titrate the device if he can’t physically do it; this will only discourage him. Again, use clinical judgment.
· BEFORE the patient leaves the office, he should
o Have signed an Informed Consent
o Shown proficiency in inserting and removing his dental device
o Shown proficiency in how to adjust the device
o Shown proficiency in how to clean the device
o Understand how often / when to adjust his device
o Understand importance to document his adjustments
· What two devices are most commonly used to help recapture bites?
o AM Aligner and Morning Repositioner
IV. SESSION 8: Managing Side Effects (Dentist and Assistants only)
a. Watch Video
i. Managing Side Effects (30 minutes)
b. Homework for staff
i. Procedures Manual
1. Managing Side Effects
c. Sleep Action Checklist: Module 8 (Entire staff)
i. Review entire sleep action checklist / update / reinforce completion
ii. Commit to delivering marketing material to at least two potential referring docs per week (100 offices a year later!)
d. Administer Review Test 8
i. Open and utilize Review Test 8 PPT AFTER test
REVIEW TEST 8 (UTILIZE POWER POINT HERE on big screen)
· BEST ways to handle side effects?
o Give the patient realistic expectations about what to expect BEFORE you start
o Review the Informed Consent and tell the patient these are very real possibilities
· What two devices are most commonly used to help recapture bites?
o AM Aligner and Morning Repositioner
· What other ways do we have to help recapture the bite?
o Tongue retruding exercises
o Chin push
· Posterior open bite is BEST managed by:
o Aggressively recapturing the bite EVERY morning. Can also take time off from wearing device, 6 out of 7 nights is still pretty good and less likely to have bite changes. Can also alternate with PAP therapy.
· Once a patient has an open bite, can it ever go back to normal?
o Yes. Quit wearing device. Utilize morning repositioner, tongue back, chin push
· Which teeth are most likely to be sore from dental device therapy?
o Anterior teeth, especially maxillary teeth that are more facial and lower teeth that are more lingual
· Manage teeth hurting by
o Adjusting device; make sure that it is not due to the device moving the teeth and then the way the teeth come together
· Bilateral joint pain managed by:
o Back up and slow down, discontinue wearing for a time, moist heat, NSAIDs, muscle relaxants, decreasing vertical height, tripod device
o Remember that it can simply be sore muscles, too, not joint pain
· Unilateral joint pain managed by:
o Side that’s hurting is the side that’s hitting
o Ensure both sides adjusted the same from an up and down and front to back standpoint
· Too tight or too loose
o Tight: adjust
o Loose: Add acrylic, heat device and pinch together, Hillyard plier
· Muscle pain managed by
o Back up, slow down; moist heat; muscle relaxers, NSAIDs, physical therapy
· Saliva
o Too much: self-limiting usually
o Too little: Water, biotene, salivart
· Crowns / Fillings coming out
o Informed consent, adjust around suspiciously short crowns / implants
· Long term effects on tooth movement
o Retroinclination of maxillary anteriors; proinclination of lower anteriors; decreases overbite and overjet; increases lower face height; posterior open bite
· Increased tooth mobility
o Use your brain; adjust appropriately
· Allergic reactions
o Get buttons of material from lab; tape under arm; test for allergic reaction; some of screw devices contain nickel so be careful
V. SESSION 9: F/U, Titration HST, Tx Complete, Annual Recall
a. Watch Video
i. Follow Up and Home Sleep Testing (35 min)
ii. Treatment Complete / Annual Recall (7 min)
b. Procedures Manual
i. First Evaluation / Follow Up
ii. Device Evaluation / Follow Up appointments
iii. Titration Sleep Test appointment
iv. Yearly Evaluation
v. Thirty month evaluation
c. Sleep Action Checklist:
i. Review entire sleep action checklist / update / reinforce completion
d. Administer Review Test 9
i. Open and utilize Review Test 9 PPT AFTER test
REVIEW TEST 9 (UTILIZE POWER POINT HERE on big screen)
· Goals of f/u appointments
o Listen to and encourage the patient; address and manage side effects; evaluate integrity of device; record and evaluate subjective tests; confirm pt is adjusting properly; plan for titration going forward; confirm recapturing the bite every morning
· How do you decide if you should continue to move the device forward?
o Ask and record subjective tests at EACH f/u appointment; use professional judgment based upon ALL of your information and clinical skills and experience
· When would you schedule a patient for a Titration home sleep test?
o When subjective tests have improved, when patient feels like they have the device dialed in
· What is the best way to do a titration home sleep test?
o One night, one position (determined as above, usually about 75% of max protrusive)
o One night, two positions (best guess, plus one more mm)
o Two nights, two positions
· Can you refer to local sleep lab to do titration sleep test?
o Yes. Include orders: “Titration sleep study with dental device in place. Start test at present position of device: if AHI greater than 10, wake patient and have the patient adjust the device (four turns, change bands, etc.); continue adjustment as needed up to five hours; if still not successful, remove dental device and titrate patient with PAP therapy”
· How do we define success?
o AASM: Reduce by one half, get to below 10 for AHI and below 15 for RDI AND improvement of subjective symptoms
· Can the DDS decide if treatment is successful?
o No. Involve MD. Do HST and get MD to do interpretation. Refer back to MD and write letter!
VI. SESSION 10: Review / Growing your sleep practice
a. Watch webinar:
i. Growing your sleep practice (DO NOT HAVE presently; could use DSS webinar #6 from Keller that is on you tube)
b. Sleep Action Checklist
i. Review entire sleep action checklist / update / reinforce completion
c. Questions and Answers