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Three Questions December 25 2017

Three Questions

I have two quick questions for you to consider. The number one question is, are you busy? The second question is - are you able to handle more capacity in your office? Capacity means the capability to see more patients with the office structure that you have right now in place.

Dentists tell me all the time that they are just not busy enough. They say they have a full-time practice and there are still significant holes in their schedule. They have the capacity to see a lot more patients but just can't seem to get their treatment chairs filled. On top of this, these dentists complain, they are incredibly bored with dentistry.

The first thing I ask these dentists is what services they are offering to patients. The answer I typically get is “everything”.

Now the fun begins – I question these these dentists what services they actually provide in their office. Do you do crown/bridge and restorative dentistry? “Of course”. Do you do endodontics? “No, I never really liked endo.” Do you do orthodontics? “No, couldn’t figure out the wire bending or aligners.” How about cosmetic dentistry? “Sure, I do that, I do a couple of veneer cases a year.” Do you place implants? “No, surgery always scared me but I restore them sometimes.” What about Botox and dermal fillers, do you offer those? “No, I know my patients want Botox and my team is making me crazy to learn but I just haven't gotten around to it yet.”

Of course these dentists are having trouble filling their schedule – they are not offering a wide array of modern dentistry and they are certainly not offering procedures that patients want! And most certainly these dentists are bored, they have barely learned anything new since dental school.

With the majority of dentistry performed today being elective dentistry (1), if you want to fill those holes in your schedule, you should be offering the most popular types of services patients want and right now are getting elsewhere. If you're still providing the same services that you've always been providing and can't fill up your schedule, then you have got to do something different – you must learn new skills to provide the elective treatment patients want now.

Botox and dermal fillers are now the #1 and #2 most popular esthetic and therapeutic procedures in dentistry today, nothing else comes close. While many dentists are still scratching your heads wondering if they should add it to their practice, the over 13000 dental professionals that the American Academy of Facial Esthetics (AAFE) have already trained have rapidly expanded their dental practices by incorporating Botox and dermal fillers with everyday dental treatment plans. AAFE member practices who are giving patients what they want and average an additional $32,500 of monthly production with these procedures. What would your practice look like with that added production?

Botox and dermal fillers also have many therapeutic and esthetic uses in dentistry, including the treatment of TMJ/orofacial pain, restorative dentistry, establishing lip lines/smile lines, endodontics, gummy smile, orthodontic relapse, denture retention, eliminating black triangles, and a myriad of other uses (figure 1). From California to New York and from Washington State to Florida, dentists are allowed to use Botox and dermal fillers for dental esthetic and therapeutic uses in the oral and maxillofacial areas which are the areas that you treat on a daily basis and are well within the scope of dental practice. All you have to learn is a new skill to provide Botox and dermal filler services. It is certainly time to take “Yes” for an answer and learn how to use Botox and dermal fillers for dental esthetics and dental therapeutics that can really help your patients (figure 2).


I do have a third question for you – how long are you going to wait to fill your empty office capacity? Botox and dermal fillers should be on the menu of services you offer patients. If your patients are not ordering what is on the dental service menu in your office and you have empty holes in your schedule, you need to change the services you are providing and give people what they want and are paying for at other offices. Stop complaining and being bored, get trained, fill those chairs and get busy!

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 Fillers training, Solid Filler PDO Threadlifts, Frontline TMJ/Orofacial Pain training, Dental Sleep Medicine, Bruxism Therapy and Medical Insurance, and sign up for a free monthly e-newsletter.


1. J Am Dent Assoc. 2000 Oct;131(10):1496-8.Elective vs. Mandatory dentistry. Christensen GJ. The reader can imagine if this was true in the year 2000 how much more so it is today.

Figure 1. Botox and dermal fillers before and after for facial volumization and gummy smile treatment as an alternative to surgical procedures.
Figure 2. AAFE member dentists learning new skills to grow their practices.



Bruxism, Botox, and Dental Implants May 01 2017

Bruxism, Botox, and Dental Implants

 

Louis Malcmacher DDS, MAGD

Timothy Kosinski, DDS, MAGD

 

Patients presenting with functional and esthetic concerns can be restored a number of ways. Conventional treatment includes crown and bridgework, root canal therapy, core buildups and removable partial dentures.  With the advancement in implant dentistry, and the access to dental education for our patients through the internet, dental implants have become an excellent alternative to our conventional procedures.

 

We all want the dentistry that we deliver to have an excellent long term prognosis especially with costly treatment plans.  If a patient is investing thousands of dollars for an esthetic and functional smile, neither patient nor dentist is pleased when things go wrong in a short period of time.  This usually means that you will be “married” to this patient for a long time re-doing complicated dentistry resulting in an unhappy patient and an even unhappier dentist.  Before embarking on the dental implant journey with patients, it is important for every dental clinician to accomplish proper examinations and diagnostics to insure the highest rate of treatment success for a good long term prognosis. 

 

One of the most important areas where clinicians fail to do a proper evaluation is in the area of bruxism.  With 1 out of 3 patients having some level of bruxism, it is vitally important to get this under control with proper recognition and bruxism treatment before placing any dental implants or for that matter any dentistry.

 

There are two ways to evaluate a patient for destructive bruxism.  One way is the physical examination of the patient.  Most dentists are well trained to detect teeth wear which is a symptom of bruxism.  What I would like to focus on is what the American Academy of Facial Esthetics (AAFE) refers to as “reading faces” for bruxism and occlusal disease.  You are probably wondering what a patient’s face has to do with bruxism in the mouth.  In the experience of thousands of AAFE members who are dental professionals, we would all tell you that “reading faces” is much more important than seeing what is happening in the mouth.

 

Let’s look at some faces together and it will be clear as to what I am talking about.  Figure 1 shows a patient at rest.  What do you see?  If you learn to read her face, you will see very big masseter muscles with her left masseter being significantly larger than her right masseter.  At rest, these muscles are unusually large which means they are getting quite the workout to achieve that size. Indeed, they are the same as any other muscle in the body, the more you work it, the larger it gets.  Would it surprise you that this patient has significant destructive bruxism?  I don’t even have to look in her mouth to know it.  She didn’t even have to tell me about the 8 bruxism appliances she has had over the last few years which she chewed through and didn’t help her at all.  Most certainly, before we perform any restorative dentistry in her mouth, we will need to address these masseter muscles which provide all the power to her bruxism.  This is what we refer to as “reading faces”.

 

If we want to confirm objectively how much bruxism this patient has, we can have her take an overnight bruxism/sleep monitor test (STATDDS).  We in fact did administer this test and found that her bruxism episodes index (BEI) was 6.2 which now gives us a baseline of the destructive bruxism that she has (a BEI over 5 is clinically destructive bruxism).   It is foolish to attempt any restorative dentistry, especially implant dentistry, without addressing her bruxism issues concretely.  It is for this reason that Dr. Gordon Christensen has said, “Bruxism monitoring is one of the most important concepts in dentistry today”.

 

Botulinum toxin (Botox, Allergan or Xeomin, STATDDS) is an excellent treatment for bruxism.  What botulinum toxin will accomplish is reduce the intensity of contraction of the muscle through its mechanism of action of interrupting the neurotransmission of acetylcholine to the muscle.  With proper training in the anatomy, physiology, pharmacology, and botulinum toxin delivery, a simple injection in each masseter will eliminate her bruxism and give her face a more esthetic appearance.  This is confirmed by a post test with the STATDDS bruxism/sleep monitor which now shows her BEI to be 0.6, effectively eliminating her bruxism.  Even more so, by reading her face in the post operative photo (figure 2), you can see for yourself that her bruxism is eliminated even without testing.

 

The advantages of using botulinum toxin for bruxism over any kind of appliance are no compliance issues to deal with and it is safe and effective.  In this patient’s case, none of the bruxism appliances she had made were successful (she reported how each successive dentist told her the previous appliance wasn’t going to work but the one the new dentist made would definitely work).  Her bruxism and 12 year history of orofacial pain was completely resolved with a treatment plan consisting of botulinum toxin injections and trigger point therapy.  It is important to let patients know that it takes botulinum toxin 2-10 days to begin to work after treatment and will last for 3 months at which time the patient will need re-treatment.

 

Once a patient’s bruxism is under control, now it is time to go inside the mouth and implant treatment can begin with the clinician can feel confident of the long-term prognosis.  Another way to deal with the results of bruxism is to use high strength restorative materials which can withstand the impact of excessive bruxism.

 

MAKE HEADERS IN THIS ARTICLE

 

Our patient is a 43 year old female who presents to our practice with a chief complaint of missing maxillary right and mandibular left dentition, broken down bicuspid teeth and unesthetic, worn down maxillary anterior teeth (Figures 3-5).  She is treated for Crohn’s disease with Asacol and was diagnosed with micoadenoma pituitary gland. 

 

When patients present with missing posterior occlusal stops, function then rests on the anterior teeth. This may result in excessive wear and un-esthetic flattening of incisal edges as a result of her occlusion and her bruxism. 

 

Here our patient had several concerns including pain in the upper right quadrant, fractured teeth and loss of occlusion due to the missing maxillary right teeth and mandibular left teeth.  It was determined that her mandibular teeth were in good repair and maintained esthetic contours.

 

She presented with a fractured maxillary right first bicuspid and a painful second bicuspid (Figure 6). She is unhappy with her smile.  We discussed the possibility of retaining teeth #4 and 5 and consulted with an endondontist who found tooth #4 unrestorable. A conventional post and core and crown was completed on tooth #5.

 

The decision was made to restore the maxillary arch with dental implants and strong esthetic crowns. This would increase the vertical dimension of occlusion, improve the length of the teeth to a younger appearance and provide stability to the occlusion due to restoration of the posterior regions.

 

For this case, the Hahn Tapered dental Implant system (Glidewell Direct, Irvine , CA) was used due to it’s innovative design and initial stability following surgical placement.  The system allows for the practitioner to angle and position the implant into available bone due to the pronounced threads that bore firmly to maximize bone adaptation.  There is a buttress thread pattern that allows this stability and reduces bone resorption at the crest, which is often seen with other implant systems.  Corornal microthreads help to preserve the crestal bone.  The Hahn implant is processed with a resorbable blast media which promotes osseointegration. (1,2) There is also an intentional machined collar on the implant which helps with soft tissue health.  The internal design of the implant is a conical hex connection. This connection insures a firm and proper prosthetic seal. Note that the prosthetic design is one of platform switching, with all abutment connection on the inside of the body of the implant.

 

The surgical protocol for the Hahn implant system is precise.  First a 2.2mm diameter pilot drill is used to create the initial osteotomy. This establishes proper depth around any vital anatomy and the mesial-distal angulation of the implant. I prefer to parallel multiple implants to the natural tooth roots. Proper depth is determined radiographically.  Next 3.5mm and 4.3mm diameter osteotomy burs of established depth are used to create the final osteotomy.  The Hahn implant is threaded into the prepared site and torque is established. Here 40Ncm of torque was achieved upon initial placement.  Cover screws are inserted into the implants. The beveled surface of the implant is positioned slightly subcrestal in the immediate extraction socket, but at the crestal ridge of the edentulous molar site.

 

Using CAD/CAM designed and milled custom abutments allow for proper emergence profile and smile design. The margins are created at or just slightly subgingival to maintain tissue health and eliminate the possibility of cement staying in the gingival sulcus.  Screw retained crowns are used when the vertical occlusal space is compromised or where milled abutments would be too short to maintain a cement on crown.  Here Bruxzir anterior esthetic crowns were used. These are of a monolithic zirconia material formulated to maximize esthetics and strength in the esthetic zone of the anterior regions of the mouth.  This all ceramic material is designed for long term strength and durability and some natural translucency.  The implant retained crowns are virtually designed and milled using the most innovative CAD/CAM technology. 

 

The plan was for dental implants to be strategically placed in the maxillary right second bicuspid and first molar area, following atraumatic extraction of the non restorable bicuspid tooth.  The maxillary right first bicuspid was treated with a post and core assembly and a new functional crown. 

 

Tooth #4 was atraumatically removed and the site grafted with Cerasorb Tri-Calcium Phosphate 250-1000 microns (Curasan Corp.) and a 4.3mm X 13 mm Hahn dental implant immediately inserted and torqued to 40Ncm (Glidewell Dental). A second 4.3mm X 8 mm Hahn implant was also placed in the edentulous maxillary right first molar site using a flapless technique.  The implant engaged bone anterior to the maxillary sinus (Figure 7).  The implant placement was prepared and then verified for proper orientation and position with CBCT images (Vatech) in figures 8 and 9. Note that the immediate implant placement is about 1mm subcrestal allowing for proper physiologic reorganization of the bone.

 

The implants were allowed to integrate for approximately 4 months prior to impression techniques and fabrication of a custom abutment and implant retained cement on Bruxzir crown on the #4 implant and a screw retained implant crown in the #3 implant (figures 10 and 11). 

 

The dental laboratory (Glidewell Lab) fabricated a custom abutment for the maxillary right first bicusipid implant. Note that the margins are prepared at or just slightly subgingival to insure that cement removal is simple and complete.  The maxillary molar implant is restored with a screw retained Bruxzir crown. The access opening is easily concealed with a composite resin (figures 12 and 13).

 

 

The mandibular left posterior site was also restored with Hahn dental implants. The plane of occlusion was established using the mandibular arch, which was in better repair.

 

Due to the excessive wear and flattening of the maxillary anterior teeth due to bruxism, Bruxzir anterior esthetic crowns were planned for teeth #6-12.  These would establish not only esthetics, but the increased incisal opening would improve function and facial esthetics (figure 14).

 

Advanced dental implant designs and surgical protocol enable the practitioner to routinely treat patients with missing teeth.  The implant integrate in a relatively short amount of time, and are restored with high quality, functional and esthetic implant retained crowns. The innovative Bruxzir anterior restorations provide for great strength, durability, translucency and attractive smile design for all cases and especially for those that suffer with bruxism.

 

The dental clinician now has a number of different options to deal with bruxism which must be addressed before restorative dentistry.  The days are gone where a dentist just gives a patient a bruxism appliance with the thought that the bruxism is under control before restorative and implant treatment.  This article has presented the concepts and case presentations using bruxism monitoring, botulinum toxin (Botox) for bruxism, and high primary stability implants, and strong restorative materials.  Every dentist needs to get trained in these areas which will help achieve best therapeutic patient outcomes possible.  Both of the authors are heavily involved with training general dentists in these areas and every general dentist is capable of placing implants and using botulinum toxin treatment for bruxism.  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 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.

 

 

Dr. Kosinski is an Affiliate Adjunct Clinical Professor at the University of Detroit Mercy School of Dentistry and is in private practice in Bingham Farms, MI. He is currently the Associate Editor of the AGD journals. He is a Diplomate of the American board of Oral Implanvology/Implant Dentistry and the ICOI, and is a Fellow of the AAID, the ACD and ICD and the ADI. He can be reached at drkosin@aol.com .

 

 

References:

 

  1. Piattelli M, Scarano, A. Paolantonio, M et al. “Bone Response to Machined and Restorable Blast Material Titanium Implants.” An Experimental Study in Rabbits.”  Orla Implantol. 2002: 28 (1): 2-8.

 

  1. Nishimoto SK, Nishimoto, M, Park SW et al. “The Effect of Titanium Surface Roughening on Protein Absorption, Cell Attachment, and Cell Spreading.” Int. J. Oral Maxillofac Implants. 2008 Jul-Aug: 23(4): 675-80

 

 

Legends

 

Figure 1.  Reading this patient’s face tells you she has destructive bruxism and TMJ/orofacial pain.

 

Figure 2.  Post treatment with Botox resolves her bruxism issues and allows restorative treatment to begin.

 

Figure 3.  This patient is a bruxer who has worn down her maxillary teeth significantly and is missing some posterior teeth.

 

Figure 4.  Digital periapical radiographs illustrate large broken restorations and caries present.

 

Figure 5.  Radiograph shows more of the same including a significant loss of tooth structure on the cuspid due to bruxism.

 

Figure 6. Tooth #4 was deemed non-restorable and endodontic therapy treatment on #5.

 

Figure 7. Post operative radiograph of Hahn implants ideally placed.

 

Figure 8.   Post operative CBCT images (Vatech America) of implant #3 in proper orientation

 

Figure 9.  Post operative CBCT images (Vatech America) of implant #4 in proper orientation

 

Figure 10.  After 4 months of integration, impression copings are placed into the internal design of the Hahn implants.

 

Figure 11.  A radiograph is made to insure a complete seat of the impression copings.

 

Figure 12.  A custom abutment is fabricated on #4 and a screw retained one piece Bruxzir crown and abutment is made for #3.

 

Figure 13. Occlusal view of the two implant crown in positon.

 

Figure 14.  The final esthetic result is achieved by reducing excessive wear and using high strength restoratives.

 

 


The August 1st Keep Your Patients Deadline June 22 2016

The August 1st Keep Your Patients Deadline

The August 1st Medicare application deadline is 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.   You can still get this done even if you are reading this article after August 1st but you need to have it done in the next 60 days.  Most dentists are now waking up and are in panic mode realizing how much they have procrastinated. 

 

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 August 1st or once you are past August 1st, the more this is going to cost you in money and lost patients!

 

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.  You need an expert because nothing with Medicare is simple!

 

MEDICARE APPLICATION MISTAKES DENTISTS MAKE

 

The most common problems dentists have made because they did not get professional help:

 

  • Trying to prepare the application themselves – while it seems to be a short application, it is much more exacting than you know. One dentist received a 7 page rejection letter because of the mistakes he made on a “simple” application.

 

  • 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 for two years! Say goodbye to these patients forever!

 

  • 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. 
  • 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.

 

 

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 up to $10,000 of lost dental production, much more than letting professionals handle this for you.

 

STATistics On Medicare Choices

 

I asked STATDDS for their most updated statistics as to what the thousands of STATDDS dentists have chosen the past 2 1/2 years:

 

  • 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.
  • 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.

 


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 so we could bill Medicare for oral sleep appliances at a patient fee of $2000+ (time for you to learn dental sleep medicine and make oral sleep appliances – the AAFE can train you today!).  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 acceptance letter from Medicare in 3 weeks.   

 

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.  Get it done today!

 

Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known educator.  Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE) and is a consultant for STATDDS.  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/Headaches/Orofacial Pain live patient training, Botox and Dermal Fillers live patient training, Bruxism Therapy and Frontline Dental Sleep Medicine, Medicare/Medical Insurance, dental implant training, download his resource list, and sign up for a free monthly e-newsletter.

 

 

 


Does Your Team Know What You Do? November 20 2015

 

– ARTICLE by Louis Malcmacher, DDS, MAGD

Oftentimes we as treating clinicians can suffer from a little bit of tunnel vision. A patient may come in for elective esthetic treatment, and we get so focused on that, we fail to see the broader picture. It is important to remember that every dental case has both esthetic and therapeutic components that must be blended together. This is especially true of facial esthetic treatment cases, as they relate directly to patients’ orofacial and TMJ conditions.

 

Here is a case report from one of our American Academy of Facial Esthetics (AAFE) faculty members, Dr. Elizabeth Slocum, who is an outstanding dental clinician and educator with a practice in Cartersville, Georgia. This case is a prime example of blending the best esthetic and therapeutic outcomes possible for our patients. The other lesson to be learned from this case presentation is to ensure that your team knows all of the treatments that you, the dentist, are competent in and able to deliver to patients.

 

I present Dr. Slocum in her own words:

 

Andrea has worked with us for eight years now. She is as beautiful on the inside as she is on the outside. She was excited when I decided to take a course on BOTOX® (Allergan, Inc.; Irvine, Calif.) and dermal fillers with the AAFE. Since completing the course, I have treated her for dentofacial esthetics, and she loves the results.


Through a series of events involving Andrea, I learned a valuable lesson about why it is important to make known all of the techniques and treatments that I’ve been trained to provide; a lesson that is doubly important in light of all that I’ve learned from the AAFE, as my employees, like yours, might not realize that dentists are capable of treating patients for facial esthetics, temporomandibular joint (TMJ) pain, orofacial and myofascial pain, and headaches and migraines.


Andrea went home from work early one day not feeling well. She missed the next day as well. She came back to work the third day still not feeling well. As we spoke, I realized that she had been absent due to a migraine. I was a little shocked that she hadn’t thought of having me treat her migraine in conjunction with the facial esthetics treatment I had already been providing her. She agreed to treatment, and I made some adjustments that would account for her migraine. I treated her glabellar area, frontalis, and crow’s feet areas, as well as her masseter and temporalis muscles. I used Xeomin® (Merz Pharma – available  from STATDDS for dentists) a botulinum toxin just like and as effective as BOTOX that is more cost-effective and has been reported to have a faster treatment response. She never looked back. In fact, we still treat her for both facial esthetics and her migraines (which are now under control) on a regular schedule.

 

Figures 1 through 4 show the before and after of the procedure.

 

Figure 1: Patient before treatment. Notice the facial wrinkles, which are a result of the muscles causing her migraines and orofacial pain.

 

 

Figure 2: Patient after treatment, a blend of facial esthetics and elimination of her migraines and orofacial pain. Notice the reduction in masseter size, resulting in a more esthetic jawline.

 

 

Figure 3: Patient before treatment showing muscle contraction that contributes to her migraine and orofacial pain.

 

Figure 4: Patient after treatment showing elimination of dynamic wrinkles as a result of frontalis muscle relaxation and pain relief.

 

Again, the lesson here is to share all of the procedures that you do with all of your employees. Every time you learn new material, share it with your entire team. I thought I had shared most of what I had learned, but I had really only talked with them about facial esthetics and TMJ pain — not nearly as much about headaches or migraines. We started doing ‘lunch and learns’ by watching some of the video series available from the AAFE. The staff enjoys them, and it opens the door for them to ask questions about any of the procedures that we offer. They really want to know what we do and how to share the information when speaking to patients.


Everything we learn and bring back to the office is basically an unknown to our team members, unless they go to the training with you — which is now something I do routinely. Think back to the first AAFE BOTOX, fillers, TMJ/orofacial pain, or trigger-point therapy live-patient training course you attended or video you watched — or any dental continuing education course for that matter. There’s so much information out there that clinicians can learn. We bring back new and exciting procedures and have all of that information in our heads or on a handout, but your team members will only learn what you share with them.

 

Today, the AAFE uses the STATDDS® Bruxism and Sleep Monitor (STATDDS; Cleveland, Ohio) to establish a baseline bruxism-episodes index number as part of the patient’s initial diagnostics in order to better evaluate and treatment plan bruxism, TMJ pain, and orofacial pain cases (Fig. 5). This monitor will also tell us whether or not the patient will have sleep disorders that might be a co-morbid condition or can be the cause of TMJ and orofacial pain.

 

Figure 5: The STATDDS Bruxism and Sleep Monitor is the only medical-grade bruxism/sleep device that objectively measures bruxism along with providing sleep data

 

The results of the STATDDS Bruxism and Sleep Monitor will directly guide the dental clinician as to which bruxism appliance or oral appliance for dental sleep medicine is the best choice for each individual patient (Figs. 6–11).

 

Figure 6: This STATDDS report shows an orofacial pain patient who does not have a sleep disorder but does have very significant destructive bruxism. Note the Bruxism Episodes Index (BEI) is well above 2.5.

 

Figure 7: Treatment consisted of a Comfort H/S Hard Soft Bite Splint and botulinum toxin (BOTOX) to reduce masseter muscle contraction intensity and eliminate the patient’s orofacial pain.

 

Figure 8: Post-treatment patient test without appliance showing BEI reduction and bruxism elimination as a result of treatment described in Figure 7.

 

Figure 9: The STATDDS report shows this patient has moderate obstructive sleep apnea (AHI of 19.7) and very intense and destructive bruxism (BEI of 21.2), indicating the patient needs an oral sleep appliance and botulinum toxin.

 

 

Figure 10: Botulinum toxin (Xeomin) and an EMA® oral appliance (Frantz Design Inc.; Austin, Texas) were the treatment of choice based on the STATDDS report.

 

Figure 11: Follow-up STATDDS report with the patient wearing the appliance shows the elimination of bruxism (BEI of 1.1) and obstructive sleep apnea (AHI of 2.2).

 

This article’s two main points are these: First, make sure your team knows all of the services that you are trained to provide. It is time for every dental practitioner to take his or her team along to continuing education, especially when introducing new services to the practice. Second, let’s start obtaining objective data on bruxism, which affects one out of every three patients. I will measure most patients first with a STATDDS Bruxism and Sleep Monitor test and then let the data drive the treatment plan. This is especially helpful in choosing appliances and deciding the correct muscle treatment.

 

Education especially live-patient training is absolutely essential in the areas of bruxism, restorative dentistry, orofacial pain, dental and facial esthetics, dental sleep medicine, and oral appliances. The continued education of clinicians is important so we can ensure favorable long-term restorative prognoses for patients across the span of our careers. Successful restorative, bruxism, and orofacial pain treatment has now entered a new era with the use of cost-effective qualitative objective testing, botulinum toxin, and the known relationship of bruxism and OSA. The AAFE (FacialEsthetics.org) offers the most comprehensive live-patient training in the areas of botulinum toxin, dermal fillers frontline TMJ/orofacial pain, dental implants, and bruxism/sleep therapy. Get trained today!  CM

 

Dr. Malcmacher is a practicing general dentist and an internationally known lecturer and author. He can be reached at 800-952-0521 or via email at drlouis@facialesthetics.org.

 

Disclosure: Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE) and is a consultant for STATDDS.

 

Visit www.facialesthetics.org for information about live-patient frontline TMJ/orofacial pain training, dental implant training, frontline dental sleep medicine, bruxism therapy and medical insurance, and BOTOX and dermal fillers live-patient training. You can also download Dr. Malcmacher’s resource list and sign up for a free monthly e-newsletter at the site.


The Medicare Decision Dentists Have To Make Now January 19 2015

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

The Medicare Decision Dentists Have To Make Now

As has been widely reported in dentistry, Medicare is requiring dentists to take action by June 1, 2015 to 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.  With nearly 50 million people in the United States with Medicare, dentists should take a real look at their practice to make it appealing to this huge and growing patient population. How fast is it growing?  Baby boomers are turning 65 years of age at a rate of 8000 people a day.

Do you want these geriatric patients in your practice?  I sure do.  Why?  Because today’s geriatric patient demographic owns 70% of the wealth in the US, has an average income of approximately $74,000, and does the most implant, restorative, and esthetic dentistry of any other patient demographic.  The reason is they have the time, money and the teeth to work on, more than ever before.  You can now see how this becomes 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.  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, imaging, biopsies, or other services that a dentist may prescribe for patients. 

Here are the options in quick synopsis form:

  1. Do nothing: If you do nothing, you may think this decision will not affect your practice and you couldn’t be more wrong.  The 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 nor will they be reimbursed for any biopsy you may send them for.  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.  I am sure you will hear from these irate patients who then will leave your office in a hurry.
  2. Opt out of Medicare: This option 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 is a good option 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.

The application process 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.    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 enrollment 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.