I am not a jogger. I DESPISE jogging. I have a 0.0 sticker on my car. That’s funny because most triathletes and marathoners like to brag about their mileage. Me? I like to brag about the fact that I do NOT jog. So why is it that I love Dental Sleep Medicine? DSM is kind of like a marathon. You must be patient, you have to build endurance and you must train your “body,” or team. Once you have a patient sitting in your hygiene chair you discuss dentistry and restorative needs, then introduce an entirely new concept – sleep. You finally get them to have an awareness and maybe admit a problem, then a consult, then a sleep study, then possibly a trial of CPAP, then medical insurance financials, then records, then lab time, then FINALLY a delivery. Phew… are you tired yet?
Delivery is my favorite appointment for two reasons. One is that the patient can finally get treatment and two is that we can finally bill it out. Many dentists new to sleep apnea ask me how to do a delivery. Honestly? I don’t know. My awesome team handles that. We never pre-appoint deliveries because we don’t want to disappoint them. We do a great job of creating urgency and then, suddenly, we tell the patient to wait for three weeks! Once we get the appliance in our hot little hands we call the patient right away. We have appointments reserved for immediate delivery. It’s for this reason I am going to hand over this article to Brianne Bove, my DSM Champion for our office. This is exactly what I do in real life too… hand everything over to Bri.
Hello, everyone, this is Bri. The first thing I do once I receive the case from UPS or FedEx (our delivery men love us by the way because we are always so happy to see them and there is always a fishing or hunting story to share) is to check the ledger to make sure the pre-auth is back, the referral is back and that financial arrangements have been discussed and are in order. I call the patient and schedule the appointment as soon as possible. We used to pre-appoint about 3 weeks after we send out impressions however there were too many disappointments and unmet expectations at no fault to the lab or us. It’s fun making these calls because I feel like Santa Claus. The patients are pumped. I’m careful to make a note in our software to make sure we keep records of everything.
Prior to the patient even coming in, I set out a nosecone with acrylic or stone burs depending on the type of appliance being delivered. If it’s an acrylic based appliance, I pre-soak the appliance in an alcohol-free based mouthwash to remove the nail salon smell. You don’t want your first impression to leave a bad taste in the patient’s mouth. Pun intended.
At the impression appointment, my patient signed the financial arrangements, the CPAP waiver, and the informed consent. I review these and make sure I have them. I begin with the warranty. The appliances and labs we use offer a 3-year warranty; however, I stress to the patient that negligence such as dog chews and loss or major changes in dental work are not covered. I then discuss how to store and clean the appliance. Knowing that people only retain 30% of what is discussed or taught, I stress that the patient should go home and read the instructions that the manufacturer provides. Prior to even trying in the appliance I discuss how to advance. First I demonstrate to them on one side how to advance and then I make the patient show me they can do it on their own on the other side. Depending on the appliance I have them advance every night or every third night as comfort allows and as symptoms dissipate. There are times I can tell that the patient is overwhelmed, so I wait until our first follow up appointment to show them that. Our goal in the first couple of weeks is to have them get used to the appliance and to have them attempt to wear it every night and all night. I stress that it is not failure to have to take it out. I also set up their expectations. I remind them that this is just a very good guesstimate on their starting position because we don’t want them advanced too much where their jaw hurts. We are easing them into treatment. I warn them that they may still snore, they may still be tired or even more tired because they are finally catching up on lost sleep. Their body is finally resting. Most of the time they notice improvement and have their Eureka moment from night one. We just don’t want them to expect it.
Next I have the patient try in the appliance. I have the patient insert it and have a mirror available if needed. I am there to help direct and guide the patient if needed. I let the patient know it will feel snug but should become more comfortable as the appliance warms up to body temperature. I like the analogy that it’s like a new pair of hunting boots (in my world). The more you wear it the more comfortable it will get. I let them know that if they feel excessive pressure on one tooth or on the gums that we can easily resolve that with some adjusting. I explain that it is normal to have excessive salivation for the first week or two. If, on the contrary, they have dry mouth we have solutions to resolve that too. We have a stock of GC Dry Mouth Gel and XyliMelt tabs. I have them sit for 5 minutes to make sure it is still comfortable and that they are hitting evenly with occlusion. With the labs we use there is barely any adjusting most of the time. I can deliver from across the room. We remove the appliance and I review once again how to store and clean the appliance.
From there I go into their morning exercises. I warn them that their bite is going to feel different in the morning as their muscles have been postured forward at night. There may possibly be some muscle soreness but I reassure them that it’s like going back to the gym. That they can push past it. Their bite might be off for 5 minutes and resolved by chewing gum or it may take a couple of hours. I provide them with a list of exercises that Braebon has provided for me and a “chew toy” as we like to call it. They don’t forget that name! We warm up and have the patient bite into the mouthguard material that we get from the lab or we make an AM aligner. We also have them massage in the shower as that provides moist heat that the muscles appreciate. While I am getting the hot water needed to soften the chew toy, I have the patient sign the “Proof of Delivery” paperwork. Medicare requires this. Anything that Medicare requires, we apply as standard protocol for all insurances. Dr. Elliott always is part of the delivery, although I take care of most of the work so she can be in another room being productive.
I make sure all questions are answered but most importantly I provide them with my business card and email. Email is always the best way to get a hold of me and ask any follow up questions. Sticky notes and phone tag are avoided. As the patient walks out the door they have the following: their appliance, their instructions, their models and impressions (I don’t want to be responsible for them), a case for travel, advancing tools, a toothbrush and a sample of Polident for Partials if there are metal components, and my business card. They always always ALWAYS leave with a 2 week follow up.
I love my job. I love that Dr. Elliott has afforded me the opportunity to move from changing people’s lives due to their smile and their teeth to their sleep and their lives. I love the challenge of making medical insurance pay, and I love taking a patient from having no idea that snoring is an issue to awareness, urgency and gratitude. If there is any way I can help you please let me know: firstname.lastname@example.org
Dr. Elliott: As you can see I appointed the right person as my DSM champion! In fact, most people ask for her before they do for me (it might be the hunting and fishing conversations). Just remember that delivery is our finish line. Have the endurance and the patience to see it through until you get your medal at the end. You have won. You deserve more than a 0.0 bumper sticker at this point.