The heavy lifting is done. You’ve brought awareness to the patient, the patient admitted they had a problem, you helped them get diagnosed properly by a sleep physician with the use of a sleep study where they REALLY owned that they had a problem, got them to see the value and pay for treatment with or without the help of medical insurance, took records and now today is the day. The day of excitement, of anticipation, the day of delivery.
In our office we do not schedule the delivery until we have the appliance delivered to the office. At this point, there is no FDA approved in office 3D printed appliance so we work with labs and rely on delivery services. We always get excited when we see those boxes arrive because not only can we finally bill the appliance but we can get the patient the much anticipated rest they need. As a side note, we also just love seeing our delivery people because they are just great people. There are a few hard and fast rules when it comes to appliances and waiting until delivery to bill is one of them.
We leave room in our schedule for deliveries so we can get the sleepy patients in almost immediately. Prior to calling them we make sure all of the appropriate paperwork is in place including a pre-authorization and GAP (if appropriate) and the referral. We used to pre-appoint delivery appointments at the records appointment but due to delays from medical insurance and/or lab delays we don’t want to have to call and reschedule disappointed patients.
At the records appointment, the patient signed the financial arrangements, the CPAP waiver, and the informed consent. We review these and make sure we have them. When the patient is seated, we begin with discussing the warranty. The appliances we use all offer a 3-year warranty; however, we stress to the patient that negligence such as dog chews and loss or major changes in dental work are not covered. We then discuss how to store and clean the appliance. Knowing that people only retain 30% of what is discussed or taught, we stress that the patient should go home and read the instructions that the manufacturer provides.
After reviewing the above, we try in the appliance. After all, that is the main event. We warn the patient that it may feel tight at first and will begin to feel more comfortable as the saliva warms up the appliance. There are times that we pre-adjust the appliance before the patient even tries it in if there is a fragile tooth we are worried about, an implant, or a bridge. The most common place of adjustment if the patient complains it is tight, is in the anterior crowded areas. As the appliance is not usually getting its retention from those areas anyway, we tend to be generous with the adjustments. We have them wear it for a few minutes and reiterate that it can feel snug but should start to feel more comfortable as the appliance catches up to mouth temperature. If there is one or two teeth that have excess pressure we adjust it by using Hydent Pressure Indicator Paste Spray. It is the best and cleans up easier than Occlude. We have a mirror available so that the patient can practice putting it in and taking it out with ease. We also discuss that the initial position was a good “guesstimate” on the starting position. We want them to advance as they can comfortably towards a position that their subjective symptoms are better. It may not be the initial position as we might have started at a lower % protrusion for comfort. Depending on the appliance we have them adjust the appliance forward a little each night or 1mm every 3-4 nights. We show them how to advance on one side and then have the patient do it on the other. Every appliance we use has elastics to help promote mouth seal. We review the use of them, the application on one side and have the patient do the other side.
From there we go into the morning exercises. We review the discussion we had at the informed consent and reiterate that their bite might feel different in the morning as the muscles have relaxed. Their bite might be different for 5 minutes and be resolved with chewing gum or it might take longer and then they will need to utilize the custom thermoplastic “chew toy” or morning repositioner that will be created. We heat up a white thermoplastic wafer until it is clear and then have the patient bite into their normal MIP and let it cool. Now they have a chairside custom bite plate that allows them to massage their jaws and slowly move their jaw back into it’s original position. It is important they do this to help maintain their bite and mitigate side effects.
And most importantly, we have the patient sign a “Proof of Delivery” form that medical insurance requires. As stated before, we cannot bill until delivery and medical insurance definitely follows up on this.
If we adjusted a lot or the patient seemed overwhelmed we will bring the patient back in one week. We usually reschedule for two weeks if all goes well. The patient ALWAYS always always leaves with another appointment. When they leave we make sure to give them an email address so if they have any questions along the way we can avoid phone tag and make sure their questions get answered. Lastly we collect any remaining balance but most importantly we send them home with the box with the appliance, a travel case, the instructions, the morning repositioner, advancing tools if applicable, and of course a business card with our email address!
As you can see, this appointment is very exciting because all of the legwork we did up until this point has been worth it. The patient has been expectantly waiting as well. This is our chance to give them a better night’s sleep! It may seem like a long, convoluted road but it is worth it. It is worth it to help patients that have been searching for a solution for a long time or the patient that you discovered in hygiene that didn’t even know their fatigue and insomnia was anything a dentist could help with. It is worth it! With many patients suffering and with dentists being on the front lines it is time to get your team trained and start screening and treating. It may just bring some professional satisfaction you need.
