THE DENTAL DECISION MAKER June 14 2016, 0 Comments

ELIMINATE FAILED DENTISTRY FOREVER

Every day in your dental office, you tackle a variety of dental challenges that you diagnose and solve for your patients.  Think about the patients you have seen this past week – did you talk to them about periodontal disease, TMJ, broken teeth, root canals, crowns, bridges, dentures, and (maybe) implants?  Of course you did.  These are the most common dental issues that come into the office every day. 

Is that list complete?  What if I were to tell you that this list does not include the most common dental disease that affects a full one third of your patient population?  You never measure it, most of you don’t even see it.  Yet, this dental condition causes countless problems for your patients and often is the main reason for broken teeth, TMJ and orofacial pain, failed dentistry including simple restorations, crowns, bridges, and implants.  

Many of you are probably scratching your heads trying to think of what it could possibly be.  How could you possibly be missing something that occurs in one third of your patients?  The primary reason we don’t think about this disease is because it is so common that we as dental professionals almost accept it as being normal and until now, there has been no way to objectively measure it.  Once we are able to measure this condition, then we can wrap our heads around it, treat it, and then measure it again to make sure our treatment is actually working.  If our treatment is not working, then we can readily adjust the treatment until we reach a satisfactory outcome.

THE DENTAL DISEASE

I hope by now you have figured out that we have been describing bruxism.  Bruxism is the underlying condition that affects every single dental treatment that you provide.  It is also the key factor in determining the long term prognosis and success of the dentistry that you work so hard to place in the patient’s mouth. 

Think about this – what moments in your daily dental practice do you dread the most?  It is when a patient comes in with a crown in their hand that you placed 1 week or 1 month ago.  Your stomach really gets upset when there is tooth structure inside the crown and even worse when there is a post sticking out of it. This is the post you literally just placed after the endo was done (either by you or the endodontist).  Of course you know that this represents a few thousand dollar expense for the patient which you are now going to have to address in terms of retreatment, replacement, or refund.  Are you going to discount or pay for the implant the patient may now need? 

FAILED AT 23

Let me share this case presentation about a patient with a situation that happens routinely in every dental office and show you how new technology to measure bruxism can help you eliminate the dreaded scenario mentioned above.  This will dramatically improve the long term prognosis of every dental treatment that you will provide from now on. In addition, bruxism monitoring will help you decide on the best course of treatment for the patient based on evidence based objective data. 

Let’s introduce you to one of my patients, Liz.  She is a 23 year old female who has suffered from TMJ and orofacial pain in her head and neck since she was 19 years old.  Her medical history is clear other than her history of myofascial pain.  She is in otherwise excellent health and is very active.  Her dental history is another story – especially with the left side of her dentition where she had multiple restorations.  When she was about 19 years old, she began breaking some of the restorations and teeth on the left side of her mouth which required treatment.  Tooth #13, the upper second bicuspid, was particularly problematic as it eventually required endodontic therapy.  The tooth was restored with a resin bonded restoration at the time as the patient could not afford a full coverage crown.  This worked well for about a year when the tooth began chipping again.  Liz then changed dentists and had an initial examination and radiographs, you can see the panorex radiograph in figure 1.  The first question any dental professional should have is why does this patient have more restorations on her left side than her right side.  The second question is why do her teeth keep chipping?  Most of us don’t spend more than a minute (if that) thinking about why this is happening, we just deal with the situation as it is presented to us. 

After a consultation, the patient agreed to have a post, core, and crown on tooth no. 13 at what you can imagine was considerable cost.   The crown was seated and the patient was pleased with the result. 

THE DREADED PHONE CALL

Here comes the dreaded phone call from the patient.  Only 2 months after the crown was placed, Liz comes into the dental office with the crown and post in hand.  Let me ask you this - how do you feel as their treating dentist when you walk into the treatment room this patient is sitting in?  Do you wish you were somewhere else?  We all do. 

Here we are two months after the crown was seated and the tooth is non-restorable requiring an extraction, bone graft, and an implant.  It is a very disappointing visit having to tell the patient this but it is clearly the next step.  Before we send the patient for an implant, should we be thinking about why this happened? Most of us don’t give it a second thought – it must be a material or functional failure.  We tell the patient what the next step is and move on.

It is now a year later and the final implant crown is placed (Emax, Ivoclar Vivadent).  Liz is happy to have a new solid tooth and it looks great too.  She still suffers from TMJ and orofacial pain and a few months after this tooth is placed, Liz is referred to my practice for a TMJ and orofacial pain evaluation. 

Figure 2 shows Liz at her initial examination in our office.  When you are properly trained in orofacial pain therapy, the first thing to do is a complete medical history and then a very good evaluation so you can come up with a diagnosis and treatment plan.  The only addition to her medical history mentioned above is that she has seen her primary care physician and a neurologist for her headaches.  She had tried a variety of medications which did not help manage her pain so right now she is not on anything and has decided to “live with it”. 

WHAT DO YOU SEE?

Let’s evaluate the patient’s head and neck musculature as approximately 85% of TMJ and orofacial pain comes from muscles.  Before I do a complete head and neck trigger point examination, let’s just take a look at her face.  What do you see?  I’ll tell you what I see – her masseter muscles are way too big which gives her a very square appearance to her face.  Take a closer look and you will see that her masseter muscles are asymmetrical with the left masseter being quite larger than the right masseter.  That is very interesting in the fact I mentioned before – most of her dentistry is on her left side.  There is most certainly a connection.

I conduct a cranial nerve, ear, TMJ and dental examination which is within normal limits.  There is one area of concern on her dental examination.  Her left bitewing radiograph in figure 3 shows some osseous cupping around the implant she had placed a year and a half before.  The periapical radiograph in figure 4 suggests deficient trabeculation of the bone on the mesial of the implant.  Indeed, the tooth is slightly loose which we will address later.  I checked the occlusion which seemed to be fine with no centric, lateral or protrusive interferences. 

The trigger point muscle examination revealed trigger points in both trapezius, superficial masseter and deep masseter muscles which cause repeatable moderate to severe radiating pain to the corners of her jaws, both TMJ (left one was worst), front of her head, and behind her eyes.  She says this is exactly the pain she feels chronically which then turns into headaches which occur daily. 

KNOWING THE NUMBERS

There is one more very important piece of diagnostic information that we need to know before we treat this patient.  We need to quantify the patient’s bruxism so that we can know exactly what we are dealing with and then be able to treat this patient and measure again to measure treatment efficacy.  We also need to know if the patient has any sleep disorders that may be contributing to her bruxism. The patient was given a STATDDS home bruxism/sleep monitor (figure 5) to take a home bruxism/sleep test so we can see what her Bruxism Episodes Index (BEI)and Apnea/Hypopnea Index (AHI) numbers are.

Quick introduction to these numbers – the BEI is the number of bruxism episodes the patient has per hour of sleep.  A number above 2.5 suggests significant bruxism which has to be addressed.  If the BEI is above 5, this is very destructive bruxism that can easily break and chip teeth and any dentistry the patient has in their mouth.  If the AHI is above 5, then the patient has obstructive sleep apnea which needs a medical diagnosis by a physician and possibly an oral appliance in conjunction with the physician.  These numbers are so important as they will guide our treatment decision as well as let us know if our treatment is working with post testing.

Figure 6 shows the initial STATDDS bruxism/sleep test with a BEI of 6.8 and an AHI of 3.6.  What does this mean?  Liz has no obstructive sleep apnea but does have very destructive bruxism which is an evidence based number for this patient.   Now that I have the right diagnostic information, I am ready to begin treatment. 

TRIGGER POINTS

Trigger point injections with botulinum toxin (Xeomin, STATDDS) were performed in the affected muscles mentioned above. Xeomin is an alternative to Botox (Allergan) which is equally effective and much less expensive.  10 units of Xeomin were used in each one of the affected muscles except for the left masseter which received an additional 5 Xeomin units due to its larger size.  Xeomin was also delivered into the frontalis, lateral orbicularis oculi, procerus and corrugator muscles bilaterally. 

An amazing thing happened at the treatment appointment – the headache Liz had that day started going away immediately.  The intermittent radiating pain started to resolve.  By the end of the appointment, about 80% of her daily pain was gone.  It takes 2-10 days for the botulinum toxin to take full effect, and indeed, a week later, all of her pain was gone for the first time in years. 

How do we know if our treatment is really effective?  Liz took a posttest with the STATDDS monitor.  Figure 7 shows her post test results which now show a BEI of 2.0 which is now insignificant.  Figure 9 shows the full face photo of Liz in which you can clearly see improved facial esthetics with a more heart shaped face and normal sized masseters.  Figure 8 shows the before and after comparison in a very happy patient.  The patient was given a Custom H/S Bite Splint (Glidewell Labs) to protect her teeth when she feels the bruxism coming back as the botulinum toxin wears off.  Now, what about the upper left bicuspid implant?  If it continues to fail, it will be replaced with a Hahn implant because of its initial stability and a Bruxzir Translucent Crown (Glidewell) for its strength. 

IT WOULD BE NICE TO KNOW

Here is the one question that I have for every single dentist reading this article – wouldn’t it have been nice to know this patient’s bruxism episodes index (BEI) before the endo was done a few years ago?  Look how much this young patient has gone through with dentistry she may not have needed had her bruxism been measured and controlled.  Before you do any restorative case and certainly one that includes crown and bridge, dental implants, or porcelain veneers, you should test your patient for their BEI number so you know exactly how much the patient is bruxing and treat it before you put in a single restoration.  This will make your dentistry last longer or even better, will help the patient preserve their own teeth.  This is exactly why my dear friend and mentor, Dr. Gordon Christensen says, “Bruxism monitoring is one of the most important concepts today!”

TRAINING IS ESSENTIAL

Training is the key in the areas that we call the AAFE Circle of Treatment (figure 10) which includes facial esthetics, facial pain, bruxism and dental sleep medicine as evidenced in this case.  Simply put, you can make your patients look great, feel great, and sleep great!  Successful restorative, esthetics, TMJ/orofacial pain therapeutics and bruxism treatment can now successfully and predictably be treated with botulinum toxin (Botox, Xeomin) and cost effective qualitative objective bruxism testing.  This will guide your treatment decision making giving your patients better therapeutic and esthetic outcomes than ever before.  It is time for you to join the over 9000 AAFE members who already use these concepts in their practices. Get trained today!

Bio

Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author.  Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE).  You can contact him at 800 952-0521 or email drlouis@FacialEsthetics.org.   Go to  www.FacialEsthetics.org where you can find information about live patient Botox and Dermal Filler Training, Frontline TMJ/Orofacial Pain Trigger Point Therapy, Dental Implant Training, Frontline Dental Sleep Medicine, Bruxism Therapy and Medical Insurance, download his resource list, and sign up for a free monthly e-newsletter.

Disclosure: Dr. Louis Malcmacher is a consultant for STATDDS.

Medicare Enforcement Starts Now! June 02 2016, 0 Comments

Medicare Enforcement Starts Now!

 The August 2016 Medicare application deadline date is coming up and your patients will soon be asking you about irritating letters they will be receiving from Medicare that will affect your relationship with these patients. The ADA and CMS have strongly encouraged dentists to enroll with Medicare by August 2016 so as not to disrupt the nearly 50 million Medicare Part D patient’s benefits when the February 1, 2017 kicks in.

 Here is a very quick recap of my previous Medicare articles:  1) You need to get this done now; 2) Each practice needs to decide what is best for their practice; 3) Your Medicare patients will leave you if you do nothing; 4) The right choice will bring many new patients to your office.

 Here is what will happen if you do nothing regarding Medicare. After February 1, 2017, the first time a dentist writes a prescription for a patient with a Medicare part D drug plan, the patient will get a provisional supply of the prescribed drugs and will receive a letter stating that the drug will not be covered again after the first three months because the prescribing dentist is not enrolled. You will receive a letter from Medicare as well since Part D plans are also required to attempt to notify the prescribing dentist. After three months, the patient’s Medicare prescription plan will deny coverage of the prescription.  How happy do you think the patient will be with your office?  I can guarantee they will find another dentist very quickly.

If you opt out of Medicare, you will be excluded from the many Medicare advantage dental plans your office has right now. This will force patients to seek other dental providers. These patients will not receive any dental benefits if you opt out of these plans, so they will come to offices like mine who have enrolled in Medicare. You are locked out of these plans for two years! The chances of you ever seeing these patients again are a big zero.

 Medicare STATistics

 Bottom line is you need to submit your Medicare application immediately!  Here are the latest dental statistics from the STATDDS Medicare enrollment specialists who have helped enroll thousands of dentists over the past two and a half years:

• 97.4% of dentists enrolling in Medicare Part B chose to enroll as an ordering/prescribing provider.
• 1% of dentists chose to opt out of Medicare.
• 1.6% of dentists chose to enroll in Medicare as a billing provider.
• 94% of STATDDS clients who first tried to submit a Medicare application themselves were rejected by Medicare, with the other 6% of this group successfully enrolled into the wrong Medicare choice and now wanted to change enrollment before they lost patients.
• 38% of dentists enrolling with STATDDS in Medicare part B also chose to submit a Medicare DME application at the same time so that they can bill Medicare for oral appliances for dental sleep medicine.

 Medicare Horror Story

 Here are Medicare horror stories I have heard from dentists.  One dentist submitted the wrong enrollment to Medicare resulting in being locked out of their patients for a two-year period of time.  Another dentist submitted an application with the wrong information resulting in months of rejection letters and hours of wasted time.  One dentist reported he could have produced an additional $10,000 in dentistry in the time that it took him to file and try to correct his Medicare application. He finally gave up and asked STATDDS to step in who finished the application in 3 weeks.

STATDDS reports that Medicare is taking approximately 4-6 months to process Medicare Part B applications.  This means if you begin to get your application together now, you will be able to make the August 1, 2016 deadline which will insure your office will be approved by February 1, 2017 enforcement date.  You can then inform all of your Medicare patients that they can tell all of their Medicare friends that your office can take care of all of their dental needs.

This is exactly why I have been recommending from the start to hire Medicare professionals like STATDDS  so they can get it right the first time. There is no dentist that I know that would do their own legal work, office accounting, or file their own taxes. Outsourcing this to professionals will save you time, money, and aggravation.  Get this done today!

Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author.  Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE).  You can contact him at 800 952-0521 or email drlouis@FacialEsthetics.org   Go to  www.FacialEsthetics.org where you can find information about live patient Frontline TMJ/Orofacial Pain, Botox and dermal fillers training, Dental Implant Training, Frontline Bruxism Therapy / Dental Sleep Medicine, Medical Insurance, download his resource list, and sign up for a free monthly e-newsletter.

The Dentists’ Role in Diagnosing Sleep Disorders April 11 2016, 0 Comments

The Dentists’ Role in Diagnosing Sleep Disorders

Advice for Working with Your Patient’s Physician When Developing Treatment

 Sleep disorders affect millions of patients worldwide, many of whom seek treatment in dental offices every day. These disorders can affect the patient’s mood, psychological status, cognitive abilities, and physical reflexes, and are directly related to bruxism, temporomandibular joint (TMJ) disorder, and orofacial pain issues.

 The most common type of sleep disorder is obstructive sleep apnea (OSA). It is important to note that all sleep disorders are medical conditions that require a diagnosis by a physician or nurse practitioner. So, why should dentists care about OSA when it is something that they cannot directly treat or even diagnose without a physician?

 Let’s explore the dental connection to sleep medicine and why every dentist should integrate bruxism, TMJ, and orofacial pain treatment with dental sleep medicine into their practice.

 Dental Sleep Challenges

One method of helping our patients who have sleep disorders is through technology such as oral appliances that can move the jaw forward, thus alleviating the obstructed airway. This will also will reduce or eliminate bruxism, which is one of the most common dental diseases affecting one out of three patients.

 Herein lies the major frustration that dentists keep running into: Dentists cannot legally make an oral appliance for OSA unless the patient has a medical diagnosis; otherwise, they are practicing outside the scope of dental practice. If a dentist administers a home sleep test that only tests for sleep disorders and then sends the patient to his or her physician, the physician does not send this patient back to a dentist because that is not the accepted medical protocol. Instead, the physician will send the patient to a pulmonologist or medical sleep professional. Most physicians simply do not see or understand how a dentist can help this patient who has a medical condition. Most physicians rightfully have a good question: Why is a dentist administering a home sleep test to a patient for a condition the dentist cannot even diagnose?

 The key to a dentist being involved and integrating dental sleep medicine is diagnosing co-morbid bruxism and TMJ issues that are present in most OSA patients.

AAFE Dental Sleep Protocol

One way that dentists can be involved with dental sleep medicine is through the use of home bruxism and sleep monitors that will objectively test the patient for both bruxism and sleep disorders. First, this keeps the dentist within the scope of dental practice with diagnosing a condition that they can legally diagnose. Second, the conversation with the patient’s physician now can go like this: “Dr. Physician, we have a mutual patient whom I have tested and diagnosed with a dental condition (bruxism) of which I am the primary provider. These test results state the patient has OSA of which you their physician is the primary provider. With your permission, I can make them one dental appliance that is considered primary therapy for both bruxism and OSA.” Every physician we have dealt with has agreed to prescribe an oral appliance under those circumstances. Here is why: I have properly tested the patient, stayed within my scope of practice; showed the physician proper documentation; followed a defined, medically acceptable protocol; and have a clear treatment plan that includes follow-up efficacy testing.

 A Call for Treatment Integration

It is time for all dentists to offer appliance treatment, as well as the use of Botox, for bruxism, orofacial pain, and dental sleep medicine in their practices. The method of treatment described above keeps dentists in their scope of practice while directing and ensuring the physician that the patient has been properly diagnosed and treated. General dentists should be integrating bruxism treatment and dental sleep medicine into his or her practice so dentists collectively can start improving patients’ lives while giving them better dental treatment outcomes.

Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author.  Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE).  You can contact him at 800 952-0521 or email drlouis@FacialEsthetics.org   Go to  www.FacialEsthetics.org where you can find information about live patient Frontline TMJ/Orofacial Pain, Botox and dermal fillers training, Dental Implant Training, Frontline Bruxism Therapy / Dental Sleep Medicine, Medical Insurance, download his resource list, and sign up for a free monthly e-newsletter.

IT WOULD BE NICE TO KNOW March 28 2016, 0 Comments

Let me share with you the tale of a young patient who I first met at an American Academy of Facial Esthetics (AAFE) live patient training course who presented for Botox treatment of her masseters. There is a lot to learn from her story as it is very instructive as to a universal challenge that plaques every single dentist on a daily basis. 

 This patient came with the complaint “I grind my teeth and my implant is beginning to get loose”. The interesting thing about this patient was that she is only 22 years old and already has a dental implant.  After a complete dental, head and neck examination I found that many of her teeth have some restorations but she has a very low caries index.  She reports that many of her restorations are a result of teeth that have chipped or broken by themselves and not from “cavities”. 

 She goes on to explain a very common scenario as to why she has this dental implant. Her tooth suffered a fracture when she was about 19 and was restored with a tooth colored filling. A year later, the tooth and filling broke and was restored.  A year later, it broke again and now she needed a root canal, post, core, and full crown.  Three months later, the patient woke up one morning with the crown and post out of her mouth. She took this back to be treating dentist who for the first time mentioned that she must have sleep bruxism. As the tooth was non-restorable, a dental implant was now necessary. The dental implant was placed, she waited 6 months, and a crown was fabricated. Now, after spending thousands of dollars, it felt as if the crown was becoming loose, she sought out another opinion.

 Just looking at this patient, it was obvious she had significant masseter hypertrophy. Using AAFE protocols that we teach, I had her take a STATDDS home bruxism/sleep monitor test and soon found that her bruxism episodes index (BEI) was well over 8.0 which makes her a very significant destructive bruxer. We treated her masseter muscles with 20 units of botulinum toxin (Xeomin, STATDDS).  Two weeks later, she was tested again and had a BEI of only .6 which has resolved her bruxism as long as she maintains this botulinum toxin treatment.

 With this new objective data about this patient's bruxism, I could now properly formulate a treatment plan for this patient that will include restorative materials that are very strong and can withstand very high occlusal forces for when the patient regains full contraction of her masseter muscles until she returns for botulinum toxin treatment.  In this patient's case based on her BEI numbers, for any restorative treatment necessary I would use a fracture resistant universal nano-hybrid composite resin such as Gaenial Sculpt (GC America) or Reflectys (Itena USA). In her case, I had to drill through the crown to unscrew the abutment.  I replaced the implant crown with a full mono zirconia crown (Bruxzir Translucent, Glidewell Lab) cemented with a temporary cement (Dentotemp, Itena).  Should any other full crowns become necessary due to her other large restorations failing, I would use either Bruxzir with conventional cementation or Emax (Ivoclar) with full resin bonding cementation. These restorative choices are the result of the objective bruxism data so now I can insure a good long term prognosis.

 For this first treating dentist, it would have been nice to know an objective bruxism number to guide them in treating this patient, but it wasn’t available then.  With 1 out of 3 patients and now our capability to obtain specific evidence based, objective data on patients that will allow us to properly treatment plan patients, it is no wonder that Dr. Gordon Christensen says, “bruxism monitoring is one of the most important concepts we have today.”

This technology is very cost effective, also tests for sleep disorders, and is easy to administer.  This testing can help you finally measure bruxism so you can formulate a treatment plan with an excellent long term prognosis and not guess if the patient has bruxism.  The AAFE can teach you how to implement this in your office, get trained today! 

Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author.  Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE).  You can contact him at 800 952-0521 or email drlouis@FacialEsthetics.org   Go to  www.FacialEsthetics.org where you can find information about live patient Frontline TMJ/Orofacial Pain, Botox and dermal fillers training, Dental Implant Training, Frontline Bruxism Therapy / Dental Sleep Medicine, Medical Insurance, download his resource list, and sign up for a free monthly e-newsletter.

Disclosure:  Dr. Malcmacher is President of the AAFE and is a consultant for STATDDS.

Are You Super ??? January 21 2016, 0 Comments

I was recently introduced to the term “the Super GP”. The Super GP is a way dental representatives describe a general dentist who is delivering a wide variety of dental services in their practice and also has a depth of knowledge of available dental materials and equipment so that optimal treatment results can be achieved.

 I had never really thought about this until an American Academy of Facial Esthetics (AAFE) member sent me an email describing AAFE members as Super GP’s because of the many different ways these dentists have expanded their office services in the areas of facial esthetics, facial pain, bruxism therapy and dental sleep medicine.  This has greatly benefited their practices and significantly increased their productivity as described in this Dental Economics column in April 2015.

 So what makes a Super GP?  In my opinion, it is first and foremost having the education and knowledge to use the most innovative and effective dental diagnostics for patients. In addition to common diagnostics available, a cone beam (ICat, Carestream CS 9000 and others) when necessary will provide an incredible diagnostic advantage to many cases. Something now standard for most of my patients is the STATDDS home bruxism/sleep monitor which sets a baseline for patient’s bruxism. With bruxism affecting one out of every three patients and much of it coming as a result of obstructive sleep apnea, the bruxism episodes index (BEI) is vital to assessing the long-term prognosis of every single case.

 A Super GP will use super dental materials that are the best choice available for each clinical situation.   For direct restorative materials today, nano-hybrid composite resins have the ultimate blend of strength and esthetics for universal applications.  Some of my favorite nano-hybrid composites include Gaenial Sculpt (GC America) and Reflectys (Itena).  Indirect restorative crown and bridge materials today are indeed super in strength and their esthetics are becoming better than ever. Mono block zirconium such as Bruxzir and Bruxzir Anterior (Glidewell) are the overwhelming favorite of general dentists. 

 In the past, the Super GP was a dentist who incorporated endodontic procedures and cosmetic dentistry into their practice. Now let's take a look at areas today's Super GPs have integrated or are looking to integrate into their practices to expand their service base and be able to deliver better dentistry to their patients:

 Bruxism therapy/dental sleep medicine through the use of oral appliances to manage bruxism and obstructive sleep apnea is the first step in any diagnostic and treatment plan.  Eliminate the sleep bruxism and your dentistry will have a great long term prognosis.  As my good friend and mentor Dr. Gordon Christensen says, “bruxism episodes index (BEI) is highly advantageous to have before treatment.” (Botox and Fillers in Dentistry DVD, PCC-Dental.com).

 Frontline TMJ and oro-facial pain treatment with trigger point therapy has been an absolute lifesaver to so many AAFE member practices because of how frustrating these cases were to treat in the past. Trigger point therapy is accomplished on the muscles that cause oro-facial and TMJ pain.  Super GP’s don’t ignore or run from these patients and now have an evidence based long lasting minimally invasive treatment that has made thousands of patient’s lives so much better.

 Dental implants - I can tell you from many Super GPs who are AAFE members, this is well within the realm of every single general dentist who should follow the path of learning the simple surgical implant cases through a process the AAFE teaches called “brain guided” implant surgery and then systematically work up to more complex cases under the AAFE mentorship program.

 Facial esthetics with botulinum toxin (Botox, Xeomin) and dermal fillers in the oral and maxillofacial areas is an integral part of thousands of dental practices.  Every dentist has the skill and basic knowledge to learn these non-surgical minimally invasive treatments which are part of every esthetic, implant, and restorative case.

 If I have to boil it down to one line, it would be this. The Super GP today can make their patients sleep great, feel great, and look great.  These Super GP’s love to learn and are excited and passionate about dentistry.  Every dentist can and should be a Super GP – the secret is to learn something new and get trained today!

Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author.  Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE).  You can contact him at 800 952-0521 or email drlouis@FacialEsthetics.org   Go to  www.FacialEsthetics.org where you can find information about live patient Frontline TMJ/Orofacial Pain training, Dental Implant Training, Frontline Dental Sleep Medicine, Bruxism Therapy and Medical Insurance, Botox and dermal fillers training, download his resource list, and sign up for a free monthly e-newsletter

Sleep Bruxism – Are Dentists Harming Patients? January 12 2016, 0 Comments

Sleep Bruxism – Are Dentists Harming Patients?  

Vesna S Sutter DDS and Louis Malcmacher DDS MAGD

Abstract:

Sleep bruxism (SB) is a known parasomnia in sleep medicine reported by approximately 8% - 15% of the adult population. It has been recognized for many years that a relationship exists between Nocturnal Bruxism (NB) and Obstructive Sleep Apnea (OSA), but why and how direct is yet unknown.The purpose of the study is to establish if there is a direct link between OSA severity and SB severity, and if yes how strong. Random patients were divided into three categories of OSA, mild, moderate, and severe. Their sleep studies where analyzed for correlations between OSA severity and Sleep Bruxism severity. The results showed that there was no direct linear correlation, but the research did show that close to 80% of the OSA patients had SB. This is a much higher relationship than currently thought.

Method:

1000 subject’s home sleep tests (HST) using the STATDDS Home Bruxism and Sleep Monitor were divided into three categories of sleep. Those with an Apnea/Hypopnea Index (AHI) below 5 episodes per sleep hour were eliminated from the study.  The three groups were: mild, moderate, and severe.  The criteria for the categories was:

1. Mild is AHI of 5 to 15
2. Moderate is 15 to 30
3. Severe is 30 or higher

Then 15 subjects were selected from each category, totaling 45 subjects included in the analysis. Once the subjects were selected the Bruxism Episode Index (BEI)¹ and the Bruxism Burst Index (BBI)¹  were calculated.

 For this study the BEI was used to categorize each group of subjects into 2 sub-categories:

(1) Significant Bruxism having BEI 2.5/hr but < 4/hr

(2).Diagnostic Criteria for Bruxism having  BEI  > 4/hr      

 Results:

The following graph shows the data that was collected and the definitions used to score the bruxism episodes.

 From the graph it can be concluded that bruxism severity and OSA severity are not linearly related. The more severe the OSA is does not mean that the more severe the bruxism episodes will be. However the data does show us that the percentage of OSA patients that also exhibit SB is much higher than expected. In the Mild group of the 15 subjects 86% had a significant BEI; in the same group 8 subjects showed diagnostic BEI greater than 4/hr. In the severe grouping the percentages were very similar to the mild, 86% had a significant BEI. The moderate category in this random selection of subject showed a slightly lower percentage of 66%, but that figure is still higher than currently thought.

  How does this new information affect dentists across the country? Since the presence of OSA is so high in bruxism patients, all patients that are prescribed a night time bruxism appliance should first have a diagnostic sleep study done  to see if  OSA is present. In the United States alone, some 1.6 million splints (AKA nightguards, biteguards, occlusal splints, biteplates, removable appliances, or interocclusal orthopedic appliances) are annually prescribed by dentists in an effort to combat bruxism⁴. According to our study, that would mean that approximately 80% of those patients totallying  1.28 million may also suffer from or have OSA. These patients very well may have a bruxism appliance that may not only be the correct or proper appliance to treat their SB/OSA condition, their bruxism appliance could be very harmful to the patient by blocking their airway and exacerbate their OSA.  The authors combined have 75+ years of experience in dentistry and not once have we ever seen a patient die of bruxism.  Patients do suffer from life threatening OSA or other severe medical conditions that are made worse by OSA.. We as dentists treating bruxism need to see this correlation and accept that we can make a huge impact on patient’s health by working with their physicians in screening for bruxism ad OSA before fabricating a occlusal splint. You can see in the figure below how the AHI and BEI cluster together. Of course not all patients that exhibit clenching and teeth grinding have OSA, but the correlation is high enough that they should be properly evaluated before any kind of treatment.

 What is bruxism and why do people do it? The word bruxism is taken from the Greek word brychein: gnashing of teeth. No standard terminology yet exists. Bruxism can, perhaps, be best defined as the involuntary, unconscious, and excessive grinding or clenching of teeth. When it occurs during sleep, it may be best referred to as sleep bruxism. A few people, on the other hand, brux while they are awake, in which case the condition may be referred to as wakeful bruxism. Awake bruxism is thought to have different causes than sleep bruxism, and is more common in females, whereas males and females are affected in equal proportions by sleep bruxism.⁵

 Sleep Bruxism is a type of sleep-related movement disorder that is characterized by involuntary masticatory muscle contraction resulting in grinding and clenching of the teeth and is typically associated with arousals from sleep.^2,3 According to the International Classification of Sleep Disorders revised edition (ICSD-R), the term "sleep bruxism" is the most appropriate diagnosis code since this type occurs during sleep specifically rather than being associated with a particular time of day, i.e., if a person with sleep bruxism were to sleep during the day and stay awake at night then the condition would not occur during the night but during the day. The ICDS-R defined sleep bruxism as "a stereotyped movement disorder characterized by grinding or clenching of the teeth during sleep",⁶ classifying it as a parasomnia. The second edition (ICSD-2) however reclassified bruxism to a "sleep related movement disorder" rather than a parasomnia.  Jerald H Simmons, MD, recognized the relationship of these conditions, with Ron Prehn, DDS,  they studied more than 700 patients with OSA and came to the conclusion that night time bruxism is an attempt to bring the jaw and tongue forward. Bruxism stops the back of the tongue from blocking the airway and is the brains way of preventing obstruction. This masseter muscle activity can be seen on EMG during a polysomnography.

Figure1: Hypnogram and polysomnographic tracings showing an episode of rhythmic masticatory muscle activity (RMMA) during sleep.

 Figure 2: Four respiratory effort–related arousals (RERAs) are shown. Each RERA is followed by an episode of bruxism as seen in the chin EMG

 Current research being done by the STATDDS clinical support team reveals that an occlusal splint in an OSA patient can worsen the OSA in some case.  For this reason alone, all dentists should be testing their occlusal splint patients for OSA. We need to know what condition we are treating before making an appliance and not put our patient’s health at risk. Of the fourteen patients evaluations post splint therapy, more than 50% of their OSA worsened. Dentists providing occlusal splint therapy to their bruxism patients, who may have undiagnosed OSA, could be seriously harming their patients by closing their airway while trying to improve their bruxism.  Closing the patient’s airway with a bruxism appliance puts the patient and the dental clinician at enormous risk from a health and liability standpoint.

Conclusion:

The etiology of bruxism is controversial and uncertain. ^7,8  At present, the causes are suspected to be many, to overlap each other, and to vary from one patient to another. Some causes include stress, personality types, allergies, nutritional deficiencies, malocclusion, dental manipulations, introduction of foreign substances into the mouth, central nervous system malfunction, drugs, deficient oral proprioception, and genetic factors. Even though the etiology of bruxism is uncertain, it’s correlation to OSA in certain. It is evident that only during a specialized sleep study in which a bruxism EMG sensor is used can we diagnose if the airway is being compromised either as a baseline study or with the patient wearing any kind of dental appliance. Possible airway obstruction during sleep is a highly comorbid condition with bruxism and dentists need to work with physicians to help improve patient health.  This article shows that the wrong bruxism appliance can seriously and negatively affect the patient’s health and it is the dentist’s responsibility to have evaluated the patient’s airway with a home bruxism/sleep monitor (STATDDS) before any appliance or other treatment is rendered.

Reference List:

1. J Dent Res.1996 Jan;75(1):546-52.

Sleep bruxism: validity of clinical research diagnostic criteria in a controlled polysomnographic study.

Lavigne GJ, Rompré PH, Montplaisir JY.

2. Macedo CR, Macedo EC, Torloni MR, Silva AB, Prado GF. Pharmacotherapy for sleep bruxism. Cochrane Database Syst Rev. 2014;10:CD005578.

3. Carra MC, Huynh N, Lavigne G. Sleep bruxism: a comprehensive overview for the dental clinician interested in sleep medicine. Dent Clin North Am. 2012;56(2):387-413

4. Pierce, C. J., & Gale, E. N. (1988). A comparison of different treatments for nocturnal bruxism. Journal of Dental Research, 67, 597-601.
5. Shetty S, Pitti V, Satish Babu CL, Surendra Kumar GP, Deepthi BC (September 2010). "Bruxism: a literature review". Journal of Indian Prosthodontic Society
6. International classification of sleep disorders, revised: Diagnostic and coding manual." (PDF). Chicago, Illinois: American Academy of Sleep Medicine, 2001. Retrieved 16 May 2013.
7. Ellison, J. M., & Stanziani, P. (1993). SSRI-associated nocturnal bruxism in four patients. Journal of Clinical Psychiatry, 54, 432-434.
8. Thompson, B. H., Blount, B. W., & Krumholtz, T. S. (1994). Treatment approaches to bruxism. American Family Physician, 49, 1617-22

To PPO or not to PPO? November 20 2015, 0 Comments

by Dr. Louis Malcmacher

That is the question that dentist have been the debating for the nearly 40 years that I have been in dentistry. I would venture to say that while there has always been an anti-PPO sentiment and, if given the choice, most dentists would love to rid themselves of insurance once and for all, this is not realistic for most dental practices. I can tell you from our own group practice, and on behalf of many American Academy of Facial Esthetics (AAFE) members that I represent, many of us have chosen be in a number of PPO networks.

So if you are like our offices, how can you make the best of the PPO networks that you are a part of? The first thing is to realize that you don’t have to participate in every single PPO in your area. Before you sign up, careful evaluation is critical to see if the proposed fees make sense for your practice. Loss leaders do not work for private dental practices unless you are literally seeing many hundreds of patients from one particular PPO. Even then, it would be rare that this would ever make sense.

Once you have made the decision which PPOs to be involved with, how do you make the most out of this PPO relationship? Most dentists are unaware that they are able to maximize insurance reimbursement even with already negotiated PPO fees. You have already been locked into a PPO fee schedule so every single patient you treat under that fee schedule is going to determine a set procedure production. What if you could increase some or all of the fees in that PPO? That would mean that every single patient you treat would result in a higher reimbursement – meaning more profit for your practice without seeing any increase in patients.

Here is how this can be done – hire someone to negotiate an increase in the PPO schedules. I will tell you the truth we have tried to do this ourselves over the years. We would occasionally call up a PPO and ask for a higher crown fee or molar endo fee. To our surprise, every so often they would actually agree to our request. I know many of you have had the exact same experience and really feel good about yourself thinking that you were a master negotiator. Little did we realize, the PPO manager on the other end of the phone was getting quite a chuckle from our little “negotiation.” Essentially, the PPO manager had just thrown us a bone that, over time, really did not develop into any significant production increase. We did not have the proper information to ask for what would result in significantly more production. Not only that, we never thought to even check whether not that new fee schedule was, in fact, in place by checking monthly EOBs. We just assumed that once we hung up the phone, that was the end

of the matter and we would automatically get the increase. To our dismay, we never really saw any significant income increase.

Thankfully, we did find a professional team at STATDDS that handles PPO optimization management. This is the same company that handles Medicare enrollment for thousands of dental professionals and did a great job for us as well. These are real insurance professionals who understand what information is needed before negotiations with a PPO even take place. They also know what steps need to be taken to implement the new negotiated fee schedules so that we actually start seeing the increased insurance reimbursement. Their team has over 35+ years of industry experience including knowing how to perform demographic studies of patients and dentists in the area, UCR schedules, and knowing which and how many fees have the best potential for maximizing insurance reimbursement.

The negotiation time for the PPOs that we deal with was approximately 4-6 months at which time the STATDDS professionals confirmed that the new fee schedule was in place and that we were actually getting paid on the new fee schedule through their monthly contract monitoring. The best part of the arrangement is that they are paid solely on a successful outcome so if we don’t make more money, they don’t get paid. This insures that they work hard to optimize all of our office PPO schedules on a continual basis. I will take that deal any day as I know many dentists who have spent thousands of dollars with other companies and have nearly no results to show for it.

We dentists think that we know everything and so many times we overreach into areas thinking we are getting the best deal for ourselves. PPO optimization management is crucial to obtaining higher profitability in your office while not having to see one more patient. Outsource this to professionals.

The Medicare application deadline is rapidly approaching. According to the ADA, applications should be submitted by January 1, 2016 or as close to it as possible to allow for enough processing time. You can contact STATDDS at info@ STATDDS.com or 800 693-9076.

Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author. Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE). You can contact him at 800 952-0521 or email drlouis@FacialEsthetics.org. Go to www.FacialEsthetics.org where you can find information about live patient Frontline TMJ/Orofacial Pain training, Dental Implant Training, Frontline Dental Sleep Medicine, Bruxism Therapy and Medical Insurance, Botox and dermal fillers training, download this resource list, and sign up for a free monthly e-newsletter. Mention you are a TPD reader and STATDDS will offer you a special discount of $300 off Medicare enrollment and $200 off the activation fee for PPO Optimization Management. This offer is limited to the first 50 TPD

Don’t Make These Medicare Mistakes Like These Dentists March 02 2015, 0 Comments

(UPDATE: The Medicare Decision has been pushed forward until January 1st, 2106. This is still time sensitive)

The June 1^st Medicare application deadline is almost here and it is incredible that I still meet dentists every day that tell me they don’t even know they have to make a decision.  Most dentists are now waking up and are in panic mode realizing how much they have procrastinated.  Over this past year, in my lectures and live patient training courses to over 10,000 dental professionals, I have heard many of the missteps that have happened to dentists concerning this Medicare decision. 

 First mistake is this – don’t wait any longer to get your application in.  Like simple supply and demand economics, the closer we get to June 1^st, the more this is going to cost you!

SHOULD YOU DO THIS YOURSELF?  NO!

 Ask any of your physician friends if they would attempt to apply to Medicare by themselves, they will look at you like you have lost your mind.

Let me ask you a question – do you prepare your own tax return?  Why not?  The form looks pretty simple, you can look at last year’s return and figure out what your accountant has done and just punch in new numbers.  You can do it, you can find all the information online and get questions answered.  You don’t prepare your own tax return because you would be a fool to do so.  In my opinion, any government application/form preparation including this Medicare application needs to be done by experts.

I will also offer this dental analogy – a patient comes in and asks for whitening.  You quote your fee of a few hundred dollars, take impressions, and the patient leaves the office.  The patient then goes to the drug store and finds out they can do their own whitening at a fraction of the cost, calls your office and is mad at your office for not telling them about the over the counter option and that you are a rip off.  What is your answer?  The same as mine – what we offer in our office is professional whitening, we take responsibility for it, we will do it right, and your chances for success are much higher.  The patient doesn’t listen, tries the OTC whitening, it works a little bit or not at all, and then eventually comes back to your office to get the results they really dreamed of.  The difference is now it cost them time and more money than before. 

The exact same thing is in play with this Medicare application process – some of the Medicare applications look so simple. I get emails and dentists come up to me after courses who have tried to go through the “simple” application process themselves.  

I asked the STATDDS specialists about the Medicare application process and was surprised to learn there is much more to this than just the application (which is why it is called a “process”).  There are letters back and forth from Medicare, there are updates from Medicare, determinations, rejections, corrections, reporting office changes, etc.  There is also a time period where you have to re-apply so that your Medicare status does not get de-activated.    

Nothing with Medicare is simple!

MEDICARE APPLICATION MISTAKES DENTISTS MAKE

Miscues that dentists have reported to me concerning the Medicare decision that has happened to them over the past few months because they did not get professional help:

• Dentists or front office staff try to do the opt in for prescribing application themselves – while it seems to be a short application, it is much more exacting that you know.  It is not just about getting the application right, it is what happens afterwards.  Many dentists have told me they have had this application rejected a couple of times (Medicare does not tell you where the mistake may be), and they have a real mess on their hands after spending countless hours on this. They have gotten Medicare letters they don’t understand, don’t know if and when the application is accepted, have waited months not knowing what to do and calling Medicare is like calling the IRS, good luck getting through and getting an answer.
• Some dental associations have told members to opt out without fully understanding the implications - a number of dentists in a particular state opted out of Medicare and then were locked out of Medicare Advantage dental plans which they previously accepted and were happy with.  These dentists are now locked out of these plans with good reimbursements for two years and will directly lose patients who will not be back once this locked out time is over.
• Some dentists make the erroneous assumption that if they do nothing, their patients won’t care because this is only about the patient’s ability to be reimbursed for Medicare Part D prescriptions which are cheap anyway.  This is a huge mistake.  This affects the patient’s ability to be reimbursed anytime you refer them for a biopsy, imaging or any procedure that Medicare may pay for in addition to their prescriptions.  If you know anything about Medicare geriatric patients, once they are told by a pharmacist that they have to pay even a small fee for a prescription because their dentist messed up, they will leave your office.  For every dentist that tells me they don’t care, I tell them to send the patients to my office.  These Medicare patients are doing more dentistry than ever before and I am happy to welcome them into my office.
• Some dentists have mistakenly opted in for billing Medicare when this is not right for their office.  There are some minimum billing requirements they may not be able to meet at which time Medicare will de-activate their account.
• Many dentists think “opting out” is the same as having nothing to do with Medicare.  They now realize this was a poor decision and have a ton of paperwork added to their daily dental practice which they were not aware of. 
• Some dentists waited to process a separate Medicare DME application which cost them more money than bundling everything together. 

How much is your time worth? How much do you pay your front desk people?  Should a dentist be wasting their time slogging through the application? A few offices have told me they spent collectively about 40 hours on this application process including calling Medicare, trying to find out what is going on with their application, got a few rejections because of tiny mistakes, and they have no idea what to do or how they will know if their application is accepted. In lost production, your valuable time and your staff time which you are paying for, this can cost you $1000-1500, much more than letting professionals handle this for you.

Why did we choose STATDDS?  First, they were hundreds of dollars less expensive than anyone else for both the Medicare Part B applications and especially the DME application.  Second, they have the most experience with dentists and the Medicare choice.  I tried it myself for 2 ½  months and couldn’t get the application done, and my office managers are great at figuring things out. I wasted so much of my valuable time that I wish I could get back! We finally used the professionals at STATDDS to guide us and submit our application, we had our final letter from Medicare in 3 weeks.    

Because we enrolled early, we have already received our determination letters from Medicare and we don’t have to worry about the impending deadline.  We also submitted a Medicare DME application at the same time – this saved us money and more importantly time.  Using the STATDDS home bruxism and sleep monitor, our office has quadrupled the number of bruxism appliances and provides oral appliances for dental sleep medicine at a fee range of $2000-4000. Being a Medicare DME provider will significantly increase the number of these appliances our office will provide. 

STATDDS Statistics

Now that STATDDS has prepared so many dental applications, I asked them for some update statistics as to what dentists are choosing:

1. 97% of their dental clients chose the opting in for enrollment option – this option, also known as enrolling for ordering and referring, is the best choice for most dental practices which is why it is the most popular.  As an ordering and referring provider, dentists will be placed on the Medicare Ordering and Referring Registry and will be able to prescribe medications as well as order and refer patients to Medicare enrolled providers and suppliers (such as blood tests, imaging, and the like) that will be reimbursable because you chose this option.
2. 2% of dental clients chose the opting in for billing – these practices are the ones who provide services that can be billed to Medicare and medical insurance.  These are usually oral surgery practices or hospital based dental practices that treat major trauma and head and neck cancer patients routinely.  These dental practices also had to make choices regarding whether to be a participating provider, accept assignment, and will have to bill patient’s secondary insurance
3. 1% of dental clients chose to opt out of Medicare.  The opt out option has the most continual relationship and paperwork over the long term, interrupts your patient workflow, requires Medicare patients to sign an intimidating document, and requires your office to do a lot of explaining to patients.  These dental practices are opted out for two years and are locked out of Medicare Part C (Medicare Advantage plans) some of which do carry dental benefits.
4. 37% of STATDDS Medicare application dental clients also submitted a Medicare DME application at the same time for time convenience and savings.  Once a dental office is going through the process of Medicare applications, if they either already offer oral appliances for dental sleep medicine or will be in the next 2-5 years, then it makes sense to go through the DME application at the same time.

The bottom line that I tell dentists is this – do you do your own accounting or legal work?  Of course not.  This Medicare application process takes a certain level of professional skill and expertise which I guarantee that you and your front office do not possess.  The choice of which direction, application and provider status to choose requires careful evaluation, education, and professional assistance. 

TIME TO MAKE THE BIG DECISION! February 25 2015, 0 Comments

(UPDATE: The Medicare Decision has been pushed forward until January 1st, 2106. This is still time sensitive)

This article is next in the series of the big decision that dentists have to make concerning Medicare.  To review, dentists must take action by June 1, 2015 and must either opt in or opt out of Medicare. With this deadline, it now becomes a very real decision process that has to be made now.  This is a very important decision as the right decision can really grow your practice and get you many more new patients.  The wrong decision will cost you time, money, prevent many elderly patients from ever considering your office, and will cause these same patients to leave your office right now.  

A decision should not be made on this simple synopsis below, there are serious considerations for each practice.  I have seen other articles by some in dentistry that presents this decision very simply and that is a real mistake.  For more in depth information on any of the options below, I would encourage you to review this column’s articles from the last few month and they can be found on the Dental Economics website at _______________ and to speak to the people at STATDDS who have perhaps the most experience in dental practices and the Medicare decision. 

This decision is very practice specific and if you haven’t already made a decision as to what path you want to take, it is imperative that you now do so.  At this point in time, you may still be able to make the Medicare deadline of June 1, 2015, so that there will be no interruption for your Medicare eligible patients regarding being reimbursed for their Medicare Part D prescriptions. 

Here are the options in quick synopsis form:

1. Do nothing: If you do nothing, then nothing changes in your office workflow.  The only major change is any patient that has Medicare (which is most patients over 65 years of age) will not be reimbursed for any prescriptions that you write for them.  If you know anything about geriatric patients, they will not look kindly on your office once they are surprised at the pharmacy.  Even more so, with the incredible rise of dentists referring patients for diagnostic imaging, that too will not be reimbursable to the patient because you chose to do nothing.  Imagine the surprise on your patient’s face when they see they are not getting reimbursed because your office chose to do nothing.
2. Opt out of Medicare: As described in previous articles, this is not the same as doing nothing.  Most dentists make the mistake thinking that opting out means you have no relationship with Medicare and don’t have to do anything.  Nothing could be further from the truth.  The opt out option has the most continual relationship and paperwork over the long term, interrupts your patient workflow, requires Medicare patients to sign an intimidating document, and requires your office to do a lot of explaining to patients.  You also must opt out again after a two year period of time.
3. Opting In for Billing: This option is for dental practices that would like to bill Medicare for Part B services.  There are very few dental services that fall under Medicare Part B so this option may not be best for dental practices unless they treat a number of oncology patients or perform a lot of surgery.  Other choices that must be made with this option is whether to be a participating provider, accept assignment, and accept Medicare approved payment in full.  Because many Medicare patients also have secondary insurance, that must be billed as well.
4. Opting In for Prescribing: Also known as enrolling for ordering and referring, this option is a good choice for many general dental practices.  As an ordering and referring provider, dentists will be placed on the Medicare Ordering and Referring Registry and will be able to prescribe medications as well as order and refer patients to Medicare enrolled providers and suppliers (such as blood tests, imaging, and the like) that will be reimbursable because you chose this option. 

Remember that these choices only relate to Medicare Part B.  This has nothing to do with Medicare DME (durable medical equipment) which relates to oral appliances for dental sleep medicine.  Dental sleep medicine only when coupled with bruxism therapy is an area every dental office should seriously look into and integrate into their practice.  This is an area that Medicare and medical insurances will reimburse and the reimbursements are well worth your time and effort and patients get the treatment they need for obstructive sleep apnea which is what causes patient’s bruxism.  Once dentists make the application for one of the options above, it is a great time to apply for Medicare DME which will save you both time and money as each application is tedious and can be confusing.  This is why it is very important to have experts help you make this decision and complete and follow your applications.

Being that the application process no matter what you decide will take 2-6 months and if the application is not correct the first time, it will be delayed even more.   You can see that June 1, 2015 will be here very quickly.    You better make the decision a good one.  There is no question that most dental practices should not go this alone.  The choice of which direction, application and provider status to choose requires careful evaluation, education, and professional assistance.  For my own practice, we used the professionals at STATDDS to guide us and submit our application now to make sure we don’t lose our patients who are 65 years and over.

For those of you who are wondering, after consulting with the STATDDS Medicare specialists, the option I chose for my own practice was number 4 above.  Because we enrolled early, we have already received our determination letters from Medicare and we don’t have to worry about the impending deadline.

As you can see, this is a career decision, a business decision, and also largely a very important practice and patient management decision.  The right decision here can also be a very powerful marketing tool, increase your productivity, and help you retain and recruit many new patients to your practice.

Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author.  Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE).  You can contact him at 800 952-0521 or email drlouis@FacialEsthetics.com   Go to  www.FacialEsthetics.org where you can find information about live patient Frontline TMJ/Orofacial Pain training, Frontline Dental Sleep Medicine, Bruxism Therapy and Medical Insurance, Botox and dermal fillers training, download his resource list, and sign up for a free monthly e-newsletter.

Medicare and Dentistry October 29 2014, 0 Comments

(UPDATE: The Medicare Decision has been pushed forward until January 1st, 2016. This is still time sensitive)

The Big Decision

Medicare and medical insurance in dentistry for the last few years until now was an optional decision.  Did you know that The Centers for Medicare and Medicaid Services published a final rule in May that requires all physicians and eligible professionals—including dentists—who prescribe Part D covered drugs to be enrolled in Medicare or opt out for those prescriptions to be covered under Part D?  What this means is that any dentist who treats Medicare beneficiaries (which is any patient 65 years and older) must either enroll in the program or opt out in order for these patients to be reimbursed for their prescriptions that you write for them with Part D drug plans. 

Dentists must take action by June 1, 2015 and must either opt in or opt out of Medicare. With this deadline, it now becomes a very real decision process that has to be made now.  This is a very important decision as the right decision can really grow your practice and get you many more new patients.  The wrong decision will cost you time, money, prevent many elderly patients from ever considering your office, and will cause these same patients to leave your office right now.  

There are many common mistakes and misconceptions about Medicare by dental professionals because we have never had to deal with it.  First of all, Medicare is not a welfare program like Medicaid.  Medicare is a health insurance that is offered by the government to those 65 years and older.  Do a search using your practice management system to see how many patients you have right now that are in this demographic.  They will all tell you that they have Medicare.

Yes, I know that there are dentists that tell me that they will never be part of Medicare.  I tell them that it is too late - Medicare already knows about you as a dental professional.  How is that, you ask?  Do you have an NPI number?  That is the National Provider Identifier (NPI) number that dentists and all healthcare providers are required to have under the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA.  All this information is coordinated with CMS – the Centers for Medicare and Medicaid Services. 

Dentists need to make some decisions now on Medicare that will affect the future of your practice - whether to do nothing, opt in or opt out.  You also need to understand the definitions and ramifications of what each one of those terms mean because each has specific requirements in terms of applications, affidavits, and patient forms that may need to be filled out and submitted.    The worst decision you can make is no decision because you will then be in no-man’s land.

The choice of whether to opt in or opt out is very practice specific and then there are different applications and provider status to choose from.  The consequences of opting in to Medicare vary depending on which way you opt in and can include accepting a Medicare fee schedule.  There are very limited dental procedures that Medicare covers so this hardly affects most dental offices.  The consequences of opting out include initially much more in-office paperwork with Medicare patients.  Either way, this does require having a well trained team to handle these requirements.  Education and training is the key to making the right decision and implementing it.

Depending on what you decide, there is an application process which is tedious and confusing.  Being that the application process no matter what you decide will take 2-6 months and if the application is not correct the first time, it will be delayed even more.  You can see that June 1, 2015 will be here very quickly.  One more reason why the right decision is so important – whatever you decide will either lock you in or lock you out for two years.  You better make the decision a good one.  There is no question that most dental practices should not go this alone.  The choice of which direction, application and provider status to choose requires careful evaluation, education, and professional assistance.  For my own practice, we used the professionals at STATDDS to guide us and submit our application now to make sure we don’t lose our patients who are 65 years and over.

As you can see, this is a career decision, a business decision, and also largely a very important practice and patient management decision.  The right decision here can also be a very powerful marketing tool and help you retain and recruit many new patients to your practice.

Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author.  Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE).  You can contact him at 800 952-0521 or email drlouis@FacialEsthetics.com   Go to  www.FacialEsthetics.org where you can find information about live patient Frontline Myofascial Pain training, Frontline Dental Sleep Medicine, Bruxism and Medical Insurance, Botox and dermal fillers training, download his resource list, and sign up for a free monthly e-newsletter.