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.