Instructor Spotlight: Dr. John Carollo

How I started in Dental Sleep Medicine and how it changed me, and my Dental Practice.

Dental Sleep Medicine is very dear and close to me. In 1992 I was diagnosed with Mild to Moderate Obstructive Sleep Apnea. Back then the Pulmonologist sent me to an Ear, Nose & Throat (ENT) physician for UPPP Surgery. UPPP, (or UP3 as physicians refer to it now), is Uvulopalatopharyngoplasty. This is a procedure where the uvula is removed, (Figure 1). It was very painful, it was like having the worst pizza burn ever and the pain lasted 3-4 weeks. The UPPP was successful for six months- my snoring decreased but then my soft palate and tissue became loose again, and again I started snoring and feeling tired during the day.  So the pulmonologist started me on CPAP therapy.  I stayed on CPAP therapy for years and had no major issues, but I knew there were alternatives to CPAP Therapy. I made myself an oral appliance and alternated between the oral appliance and CPAP.

Around the same time, I started to ask my patients if snoring was an issue for them or for their significant other.  I started to make snore appliances for my patients.  I did not know about AHI, RDI, SpO2 and all the other sleep parameters that are important for an effective dental sleep medicine protocol.  I used a few different appliances and settled on the SUAD oral appliance at that time.  I used a typical protrusive bite, sometimes a George GaugeTM for my bite registration.  There was no medicine or science involved with these snore appliances or my protocol at that time.

Around 2010 I started taking Dental Sleep Medicine courses and really started learning what Dental Sleep Medicine really is.  There were some good programs, most of them were half day and evening programs that provided basic information without any hands-on.  I was only making a handful of oral appliances yearly.  In 2013 I took my first two day program with Sleep Group Solutions (SGS) that changed what I now know about Dental Sleep Medicine.  More importantly, it changed how I treat patients medically for Obstructive Sleep Apnea, (OSA), and how it changed my dental practice for the better.

Dr. George Jones, was the instructor along with John Nadeau and Ben Scarborough from SGS, it was a great two days. I learned how we as dentists along with the medical community can effectively treat OSA with Oral Appliance Therapy, (OAT).  I learned about the different oral appliances to treat OSA, but the most important factor was understanding the airway and its stability at given vertical and horizontal positions. It was the hands-on demonstration with the Eccovision® Acoustic Pharyngometer, (Figure 2) that made me fully understand and see the airway and how it responds to mandibular advancement both vertically and horizontally.

 

I purchased the Eccovision® Acoustic Pharyngometer & Rhinometer and started screening all my existing dental patients and followed the protocol I learned from SGS.

Sleep On It!

A Sleep Group Solutions powered Dental Sleep Medicine newsletter

Instructor Spotlight:

Dr. George Jones

How I successfully market Sleep Disordered Breathing in my practice

It seems that many dentists fall into the trap of thinking that marketing is in poor taste, or something sleazy. They feel that to market a procedure or service means to stoop to the level of used car salesman using “hard sell” techniques. Thus they never maximize their true office potential for that service.

THE PSYCHOLOGY OF MARKETING

For me marketing is simply a way to bring awareness to our services and to ultimately start a conversation. When I began treating Sleep Disordered Breathing in my office the first thing I did was to create a word document using information I had culled from my Sleep Group Solutions seminar notes. I included information on the risk factors, signs and symptoms, comorbidities, and what we at Sunset Dental were doing about it. I added a couple of pictures and then I took this document to a local printer and had it printed into a poster.

SILENT MOTIVATORS: OFFICE POSTERS

We framed it and hung it in our lobby so our patients would read it and begin asking the staff questions (Marketing). Questions frequently asked by my patients: “What can a dentist do to treat Snoring and Sleep Apnea?”, “Does the oral appliance replace a CPAP?”, “My husband has many of these symptoms! How would we know if he has sleep apnea?”

It is important to note that for this to be effective my staff had to be trained to properly answer these questions. This poster, a subtle silent educator was wildly effective in bringing an entry level of awareness to our patients because we had begun screening all patients as they presented for their hygiene appointments. I think the total cost of my poster was less than $120 and it hangs there in my lobby today. My poster is certainly a more effective promotion than a pretty art poster.

ENGAGING HEALTHCARE PROFESSIONALS TO “MARKET” FOR ME.

I made a simple excel spreadsheet, using my patients, showing the Before and After results- tracking such things as AHI, Oxygen Saturation Nadirs, Time spent below 90% SaO2, etc. I then met with the local Primary Care Physicians whenever we had a mutual patient that was either recently diagnosed or demonstrated that they were high risk. My approach was simple: call them on the phone and ask if we could arrange a 5-10 minute meeting regarding a mutual patient. How could they refuse that? Most were very accommodating. I typically would ask to come by at lunch or on my day off- promising this would be to the point and beneficial to the patient.

During the meeting I would take great care to explain that we were interested in the overall health and wellness of our patients. That we were not trying to talk patients into switching from their CPAP over to oral appliances.

But with every meeting I had 3 things I wanted to emphasize:

1. I made a point to show them my documentation, as many PCPs were not aware how effective appliance therapy could be.
2. I asked them to consider using my office and Appliance Therapy for any CPAP noncompliant patient they saw.
3. I would treat them, their spouse or any staff member in their office free, so they could “experience” our process, and the benefits of Appliance Therapy. With or without insurance I would do the whole case as a professional courtesy for them to see how professionally and effectively we would treat any referred patient.

Points 1 and 2 cost me only a little of my free time and an occasional lunch. Point 3 had the potential to cost me about $300-500 per “free patient”. But I felt I would gain a potential referral source or just to build some general “good will” in the local medical community. And it certainly did that. Most were shocked at the gracious offer! Do you care to guess how many have actually taken me up on my offer? In over 4 years only 1 doctor has taken me up on my offer. He and his partners are one of my best referral sources now. From a total cost about $500 the ROI was 300% after his first referred patient! He’s since sent me dozens of them!

Lastly, consider taking some pictures and thoroughly documenting one of your successful cases. Use the documentation to present a “case study” to the local medical community. Present them with the following information:
Pretreatment AHI, SpO2 spent below 90%, SpO2 nadir, mean heart rate, maximum heart rate.

Then show them the post treatment values of the variables mentioned above. Take the time to explain the method for finding the appropriate bite that maximizes the airway opening (pharyngometer), the appliance you chose and any other information that makes the case interesting. Be sure to provide your practice contact information, have the case printed in color and simply mail to the local medical community.

PRESENT AN IN-OFFICE SEMINAR TO THE MEDICAL COMMUNITY

Invite key members of the medical community for a DSM presentation after hours in your office. ALSO invite city officials and the public. Let them all know who they will meet at this educational networking event. The town mayor, chiefs of police and fire departments will see the meeting as beneficial to their public standing and some health care professionals will see it as an opportunity to raise their image (and maybe learn something). You will be recognized as a “thought leader” and a caring public servant.

These ideas are a little time consuming to put together but cost very little. So it doesn’t take much to see a very significant ROI with this marketing plan.

 

A Unique Application of a Mandibular Repositioning Device to Manage Both Temporomandibular Joint Dysfunction and Sleep-Related Breathing Disorders when Co-existing in the Same Patient.

By: Daniel E. Taché, DMD, DABDSM

In an editorial piece which appeared in The Journal of the Craniomandibular Practice and Sleep 2013, Dr. Shapira reminded those of us who treat patients with orofacial pain and temporomandibular joint disorders (TMD) that oftentimes, these patients present to our office with a laundry list of symptoms which are seemingly unrelated to “the jaws and teeth” but often improve from our treatment, most notably symptoms such as:

• Fibromyalgia
• Chronic fatigue syndrome
• Migraine/tension headache syndrome

• Irritable bowel syndrome
• Mitral valve prolapse syndrome

Our understanding of how such conditions might be related has until more recently been poorly understood, (i.e. a medical mystery perhaps). TM disorders have largely been viewed as psycho/social disorders best treated by “psychological therapy and drugs.” These medically unexplained symptoms, are now most often referred to as the Functional Somatic Syndromes.

Because our medical doctors view our treatment of TMD patients as solely orthopedic in nature, there has been a disconnect between medical science and the almost miraculous improvement in the health

of many of our patients. TM disorders have for many years been referred to as The Great Imposter and our treatment protocols were thought of as almost voodoo in nature.

As Dr. Shapira went on to explain, “Sleep is the magic ingredient that explains many of the amazing improvements seen in treated TMD patients.” Undetected and unmanaged sleep disturbances associated with TMJ disorders will often compromise treatment outcomes and reduce the effectiveness of our treatment to reduce these associated symptoms in TMD patients. Sleep disorders

increase systemic inflammation which in turn can adversely affect the cardiovascular system because of the constant cardiac activation occurring during sleep microarousals; these microarousals lead to increased sympathetic dominance of sleep which also been implicated in diabetes and high blood pressure. Newer concepts and techniques for diagnoses and analyses are changing the very nature of how we practice dentistry, which enable us to more fully evaluate and manage our patients. Availing ourselves of current technology and incorporating it into every day protocols of patient assessment will greatly enhance the ability of all dentists to identify patients at risk for sleep-related breathing disorders (SRBD) in our every day practice of Dentistry and because available technology can be delegated to support staff, we can conceivably extend this optimum level of care to every patient we see. Temporomandibular disorders have been linked to sleep disturbances: chief complaints of a majority of TMD patients are unrefreshing sleep

and pain and residual fatigue upon awakening. In several studies, a majority of TMD patients have reported unrefreshing sleep and furthermore that poor sleep quality and symptoms associated with TMD have a bidirectional relationship. Pain-related awakenings from sleep have been shown to have a profound negative effect upon the intensity and severity of masticatory myofascial pain and pain threshold.

A polysomnographic study shows the prevalence of sleep disorders in TMD patients revealed that 45% of the population of patients studied were diagnosed with one sleep disorder and 26% with two sleep disorders.

FULL case review on TheSleepMagazine.com