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.
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