Terri Lively

Dental manufacturers and suppliers have been incorporating bioactive and antimicrobial agents in their materials. The proposed benefits sound great and may resolve some issues with recurrent decay with specific patient populations. We take a closer look at both types of materials and how they might benefit some of your restorative cases.

Peter Auster, DMD, a private-practice clinician in Pomona, New York, and frequent lecturer for the dental industry says bioactive and antimicrobial materials are trending. Dr Auster says that in 2 years, almost every company is going to have a bioactive product, “for better or worse.”

“Dental manufacturers tend to play follow the leader,” Dr Auster says.

The official definition of the word bioactive is that it is a material “

,” however there is not an “official” definition for bioactive dental restorative materials. The idea behind bioactive restorative dental materials is to switch dentists’ restorative mindset from reparative to a preventative one.

Bioactive dental restorative materials are different than other materials based on what they do after they are placed. Bioactive materials share the physical and mechanical properties of other dental composites, but they also release minerals—such as calcium, phosphate, and fluoride—into the tooth to strengthen and heal tooth structures and prevent future decay.

To read more about How Bioactive Materials Are Changing Restorative Dentistry, 

However, not all bioactive restorative dental materials are the same or serve the same function. The 

American Dental Association’s ACE Panel Report from 2018

, listed the “Most Commonly Used Bioactive Products,” which included:

Ceramir Crown and Bridge QuickCap (Doxa Dental)

BioCem Universal BioActive Cement (NuSmile)

Dycal Calcium Hydroxide Liner (Dentsply Sirona)/Life Pulp-Capping Material (Kerr)

MTA-Angelus (Angelus)/ProRoot MTA Root Repair Material (Dentsply Sirona)

In that 2018 ACE Panel Report, there is the beginning of a definition of what bioactive dental materials are. The ACE Panel defined dental biomaterials as those that can form surface apatite-containing material (ACM), which include hydroxyapatite in a simulated body fluid. The ACE panel also suggested that with these properties, they could be used at an open margin, at the interface of restorative materials and the tooth, or liners that contact with pulp. In these situations, the ACE Panel said that the bioactive materials will interact with pulpal tissue or preserve pulp vitality.

Dr Auster says that although some bioactive products have been available for upwards of 10 years, more research is warranted to determine their long-term results. Some of the proposed benefits about bioactive materials are more theory than practice, but the concept of continued nourishment and hydroxyapatite formation are proven and that is certainly a win-win for dentists and patients.

The concept that bioactive materials are products that “don’t die” is a great one, Dr Auster says. He explains that a conventional cement in a crown is passive, meaning it doesn’t do anything else once you place it.

However, Dr Auster continues, a bioactive material is active the entire life of the restoration. Bioactive products form a layer between the tooth and the material that is a hydroxyapatite layer, which is a natural, moisture-friendly bond that occurs in other parts of the body as well. The moisture friendly bond is key, he says, as the exchange of water going back and forth between the tooth and the material is also transporting minerals, calcium and phosphate into the tooth and recharging the tooth structure.

Bioactive materials are growing in popularity with many dental professionals. These restoratives support dental practice’s current environment that emphasizes infection control even more than usual and the patient populations’ growing awareness that a healthy oral cavity is an integral part of a patients’ overall health. Dr Auster says that the coronavirus disease 2019 (COVID-19) pandemic has brought these themes to the fore, making bioactive dental restorative materials an area to which many dental practices will pay attention. 

“Good dental health and healthy internal organs go hand in hand,” Dr Auster says of today’s dental practice philosophy. “People with compromised organs are in more danger during a pandemic. It’s so important to everyone at this point in time. Anything that reduces microbial damage is a good thing.”

Dr Auster has been using bioactive products for quite some time, beginning with Pulpdent’s ACTIVA™ and Doxa Dental’s Ceramir Crown and Bridge QuickCap. Describing them as interesting products, he uses them a lot with immunocompromised patients, children, people with issues with bacteria or seniors who have problems with home care because of disabilities or other reasons. He recommends using bioactive products with a proven track record like the Pulpdent’s ACTIVA line over products that are brand new to the market.

“You are trying to stop biofilms from forming and causing recurrent decay,” Dr Auster says.

However, there are situations where he would reach for a conventional dental restorative over a bioactive one. Dr Auster’s personal preference is to avoid using bioactive products in highly esthetic areas because some bioactive cements are more opaque and he gets better results with conventional composites. He also avoids using them in heavy occlusion areas because the mechanical properties are not quite as strong as conventional composites. Also, there can be more staining around the edges when using bioactive materials. Dr Auster warns patients who are smokers or heavy red wine drinkers that he will have to polish the restoration occasionally if he chooses to use a bioactive restorative material for their treatment.

Despite these drawbacks to the materials, Dr Auster says as the bioactive materials improve in their physical and mechanical properties, he would consider using them in more cases. For example, he likes TheraCem® from BISCO, which he describes as a conventional self-adhesive cement with bioactive properties and TheraCal PT® and LC®

“It does have a fair amount more strength, so that's a very interesting product that I've been using,” he says.

Bioactive materials feel different in your hands than composite, per Dr Auster. He recommends getting more comfortable with bioactive restorative materials through a test run on your countertop or in a Dentiform tooth before you try it in the mouth.

“Once you figure out the feel, it’s very simple,” Dr Auster says. “But it just takes a little while to get used to it.”

Antimicrobial materials are designed to prevent bacteria adhering to the tooth and biofilm formation. Per the 

, antimicrobial dental materials usually work by releasing an agent, killing upon contact, and “multifunctional strategies” to prevent initial bacterial attachment and biofilm formation after completing the restoration.

There are a few different antimicrobial restorative materials. The first antimicrobials that were release-based were made of silver compounds in the 20th century and have evolved to include the nanotechnology of the 21st century. The nanotechnology behind antimicrobials either improves the antimicrobial qualities of existing materials or make new antimicrobial dental restorative materials.

If you want to know more about the details of antimicrobial restorative materials described in the 

When it comes to antimicrobials, Dr Auster says there are very few patients he wouldn’t use them on. For many years, he says, dental professionals have used glutaraldehyde and there are a lot of excellent glutaraldehyde products available from the different manufacturers, like GLUMA® from Kulzer, and Telio CS Desensitizer from Ivoclar Vivadent, to name a couple. GLUMA is antibacterial and blocks the dentin tubules so the fluid can’t leak out, which stops the decay and desensitizes the tooth.

Another popular antimicrobial agent is chlorhexidine. Chlorhexidine is a bactericidal agent that also prevents the formation of bacteria where it is used. Chlorhexidine destroys bacteria by binding to its cell wall and interfering with the membrane transport systems, which causes the protein to deposit out of the cytoplasm.3 While it is used in all kinds of products outside of dental practices, for the oral cavity it comes in many forms, including mouth rinses, gels, root canal irrigants, varnishes and more. Dr Auster uses the chlorhexidine antimicrobial solution Concepsis™ from Ultradent Products to clean off the tooth.

The question with both glutaraldehyde and chlorhexidine antimicrobial agents, he says, is how long do they continue to function? The research isn’t conclusive.

“Once you put the crown on, the effect of the anti-microbial agent is over…probably. But we really don't know the longevity,” Dr Auster says. “And if you go with your gut on this, anything that’s anti-viral at this point in time sounds good to me.”

There are new antimicrobial products coming on the market, too. Dr Auster thinks the new product FiteBac® Antimicrobial Cavity Cleanser by FiteBac Dental is interesting. The technology and chemistry behind the product created a new class of antimicrobial compounds. Unlike some of the other cleansers on the market, FiteBac is FDA-approved as both a cleanser and a bactericidal product. Dr Auster says likes the idea of it doing both.

“A new frontier in dentistry will be antimicrobial agents included as part of mainstream composites, cements, and other restoratives,” Dr Auster says. “Stay tuned…they are coming.” 

1. Ace Panel Report Bioactive Materials. Ada.org. 

https://www.ada.org/~/media/ADA/Science%20and%20Research/Files/ACE_Panel_Report_Bioactive_Materials_Q2

 _2018.pdf?la=en. Published 2018. Accessed February 4, 2021.

 Advancing antimicrobial strategies for managing oral biofilm infections. 

28 (2019). https://doi.org/10.1038/s41368-019-0062-1

Articles

Bioactive and antimicrobial materials are growing in popularity for treating specific patient populations. We take a closer look at these types of materials and what they can do for your restorative cases. 

Incorporating Bioactivity and Antimicrobial Benefits into Your Restorative Cases

You use dental composites in your practice every day, so you are likely familiar with how useful and versatile they are. As substances that are more robust combined than they are separate, the chemistry of these practice workhorses is hard to match.

But do you warm them up before you place them? If science tells us anything about warming dental composite, you probably should.

Research shows the there are many benefits to pre-heating composites before placement and curing. Studies reveal that pre-heating composites improves their handling characteristics, reduces sorption and solubility, enhances marginal adaptability while reducing marginal gaps, and increases microhardness. Research also shows that it reduces the complications that can occur with dental composites, like polymerization shrinkage that can lead to shrinkage stress, in some types or composite without compromising the degree of conversion.

Here we take a closer look at the science behind warming composites and why you could be getting more performance and fewer problems if you turned up the heat on dental composites.

The composite process is a chemical one. Dental composites are materials made of 3 parts: dimethacrylate monomers, fillers like glass or ceramics, and lesser additives, such as coupling agent, pigment, and photoinitiators. The resin binds everything together and provides flexibility, and the fillers give it strength. The coupling agent binds the fillers and resins into a solid material where the combined elements retain their individual qualities. Other fillers like the pigment give the composite color, while photoinitiators make polymerization of the resin possible.

Polymerization is a necessary process that sometimes causes problems with composite restorations. In particular, as the resins cure, they shrink. A little shrinking is not a big problem. However, too much polymerization shrinkage can cause shrinkage stress, which can lead to marginal gaps, microleakage, fractures, and postoperative sensitivity, among other problems with your restoration.

However, this versatile material is not always simple to place. It requires more technical skill and precision than its restorative material predecessors to get consistent and predictable results. From isolation to prep to curing to polishing, you should do everything correctly to get the best possible performance. Moreover, as many a clinician will tell you, you should "always follow the manufacturer's instructions."

Heating Composites Before Placing Enhances Their Performance

Warming composites before placing has a lot of benefits to their performance in the patient's mouth. There has been a lot of research that explores why this is.

, heating composites changes the physical properties of the material, which has benefits. As the composites' kinetic energy increases, the degree of conversion for monomers and free radicals increases when you cure it.

Water weakens the physical and mechanical properties of composites, and moisture is abundant in most patients’ mouths. If moisture infiltrates the resin, it negatively affects tensile strength, modulus of elasticity, flexural strength, and wear resistance. A 2016 study in 

suggests that preheating composite resins lowered the materials’ sorption and solubility of the material when compared to composites at room temperature.

Moreover, per Nathaniel Lawson, DMD, PhD, Associate Professor and Director, Division of Biomaterials at the UAB School of Dentistry, heating resin composites also improves the materials’ handling. Dr Lawson says clinicians typically heat composites to 68C (154.4F) to get the desired handling properties. For the 

 Study, researchers preheated the composites to 60C (140F).

“Composites are heated in order to increase their flow properties and allow better adaptation to cavity preparation,” Dr Lawson explains. “In this way, a conventional composite can behave almost like a flowable composite when first dispensed and then regain some of its sculpting abilities once it returns to room temperature.”

Heating composites also helps improve marginal adaptation and the prevention of marginal gaps. 

 published an article in 2010 that reported composites preheated to 68C had enhanced marginal adaptation.

 Specifically, the marginal adaptation for heated composites was better in the axial wall.

 published a study last year that tested whether heating composites reduced the marginal gaps in the material-tooth interface in Class 2 restorations. The researchers concluded that it decreased marginal gaps at both the enamel and dentinal walls in both the materials tested (Filtek™ P60 by 3M™ and X-tra Fil by VOCO America).

Preheating composites also increases the microhardness of the cured material. Microhardness is often the metric chosen to analyze the physical properties of restorative materials. It is associated with compressive strength, degree of conversion and wear resistance.

Journal of the Canadian Dental Association

 suggests that preheating resin composites not only decreased the viscosity of the material, but it increased the microhardness when tested against cured composite that wasn’t preheated.

 The researchers went on to conclude that “the effects of preheating resin composite may allow for easier placement of restorations and greater monomer conversion.”

 in 2018 supports these findings. Furthermore, the researchers found the literature supports the idea that heating dental composites does not affect the flexural strength and reduces polymerization shrinkage. However, they felt that “further studies with larger sample size and analogous experimental conditions are required.”

 Within the boundaries of the experiment, Filtek Superme Ultra resin Composite (3M), had the highest mean microhardness.

Also, there do not appear to be any downsides to heating composite. Dr Lawson says there have been studies which have showed that warming composite did not negatively affect the shrinkage stress or degree of cure of the composite tested. Per research out of University of Zurich, pre-heating high-viscosity bulk-fill composite materials and conventional restorative composites before curing decreases the polymerization shrinkage and does not compromise the degree of conversion.

“There are some composites for which the manufacturer has confirmed that relevant properties are not negatively impacted by heating, such as the 3M composites,” Dr Lawson says.

Dr Lawson adds that there are several convenient tools and ways to heat dental composite materials. Dental manufacturers produce devices that heat composite compules or syringes. Some composite dispensing guns have built-in heaters. Another strategy for heating composites and maximizing the time the materials are easier to handle is to use a composite dispenser with a metal tip that can also be warmed, he says.

However, special equipment isn’t necessary to heat composite resin. Research suggests that you can use hot water baths, thermocycling, microwaves, wax-warmers, hair dryers, and even your hands (although the researchers thought the hands were not a great options for consistent results).

 Dr Lawson says inexpensive options are to heat composite on a coffee cup warmer or on the back of an operatory light.

“It typically takes several minutes for the composite to get warm, about 5 or 6 minutes,” Dr Lawson says of the makeshift composite heaters. “The composite will cool faster, taking about two minutes to return to room temperature.”

Research shows the there are many benefits to pre-heating composites. We review why getting cool results from your composite may require turning up the heat.

The Science Behind Warming Composites

About 22 million Americans have sleep apnea, per the 

 Furthermore, 80 percent of them have yet to be diagnosed and treated.1 From a business standpoint, the potential market for treating sleep-related breathing disorders (SRDBs), such as obstructive sleep apnea and snoring, is significant. Furthermore, if implemented correctly, the business of dental sleep medicine can lead to substantial revenue for your dental practice's bottom line.

"Adding this new therapy could be a huge financial benefit for dental practices and a way to reconnect with patients about something critical for the patient's health and to rebuild the revenue stream," says Alice Limkakeng, CEO of SleepArchiTx.

There are a few different best practices that successful dental sleep practices employ when it comes to dental sleep medicine. From getting the proper education to networking with the medical community to outsourcing the administrative work, dental practices that understand how to implement dental sleep into their routines realize the potential revenue-building that exists.

Neal Seltzer, DMD, FAGD, and Jeffrey Rein, DDS, FAGD, partners at Long Island Dental Sleep Medicine, are believers in the dental sleep movement and have laid much groundwork for increased awareness. Their practice is 50 percent general dentistry and 50 percent dental sleep. As passionate dental sleep dentists with Diplomate level credentials in three different sleep academies, the partners each have 30 years' experience treating dental sleep and are the first office in New York state to fulfill the requirements of being a “Dental Sleep Medicine Accredited Facility” by the American Academy of Dental Sleep Medicine (AADSM). Dr. Seltzer was one of the five dentists in the US chosen to be part of a select group of healthcare professionals who spoke to a congressional caucus comprised of senators, congresspeople, and government officials about the problems of undiagnosed sleep apnea as part of his efforts to raise awareness about it.

"The repercussions of undiagnosed sleep apnea are monumental and permeate all walks of life and aspects of day-to-day routines," Dr Seltzer explains about his presentation to Congress. "There were a lot of obstacles to getting people treated, and we were there to explain it."

However, Congress is not the only entity where awareness is essential. Patient awareness is critical, too. The most successful dental sleep medicine practices start with awareness, education, and communication, according to David Schwartz, DDS, president of the AADSM and a Diplomate of the 

"Awareness begins with an open, frank discussion with the patient," Dr Schwartz says. "It also involves interaction with the patient's physician. Everything that comes after is only possible and effective if the dentist is qualified and the patients are comfortable with understanding the seriousness of the problem and the treatment the dentist can provide."

"Every patient that we treat has to come in with a diagnosis from a physician," Dr Rein explains. "It's malpractice for a dentist to be diagnosing anything related to sleep. It's not within our scope of practice. We have to work as a team member with a medical colleague."

Another critical best practice is having proper training in the science of sleep, according to Dr Schwartz. The average number of hours of sleep medicine education in dental schools is 3.92 hours, meaning that dentists must seek continuing education to be competent to treat SRBDs.

 A successful practice requires the qualified dentist to have the skillset to converse with the physician using proper nomenclature, current research, and experience to ideally communicate the treatment plan, he explains.

Practices need to be aware that they are treating medical disorders with a dental device, Dr Schwartz says. Treating patients diagnosed with obstructive sleep apnea (OSA) or snoring requires postdoctoral continuing education, training, clinical judgment, and excellent patient care, he explains. This training is essential to collaborating with patients’ medical physicians.

“Practices do not need to invest in any additional equipment to provide oral appliance therapy for sleep apnea and snoring, but they do need to invest in the appropriate education to ensure they have the competence and confidence to provide oral appliance therapy and build relationships with patients, physicians, and payers,” Dr Schwartz says.

It’s also crucial to measure the results of your treatments, Dr. Schwartz adds. This data will go a long way in networking with medical physicians.

"Dentists who track patient data, whether that be decreased symptoms, decreased AHI [

], compliance or satisfaction, can show the benefits of oral appliance therapy [OAT] to both their patients and referring physicians," Dr Schwartz says.

"We follow our patients," Dr Seltzer agrees. "We have a whole recall system. We send out reports continuously to our network organizations. It's amazing how much paper we put out in terms of letters to keep everyone in the loop. That helps market what we do, also."

The most successful dental sleep practices share four critical characteristics, according to Jonathan Greenburg, DDS, inventor of 

® and CEO and founder of Sleep Certified.

They should get the team involved and trained on the process.

Dentists should remember that they are the leaders of the practice, and if they aren't passionate about treating sleep, no one else on the team will be either.

Dental practices should dedicate time to their sleep medicine efforts every week.

"You need all those ingredients if you're going to be successful in treating sleep," Dr Greenburg says. "We have seen the winners and the losers, and the winners are all pretty consistent."

Bruxism, a condition patients have that often correlates with sleep apnea, presents another huge revenue stream for a dental practice, according to Brock Predovich, CEO of Bravrr. Bruxism is a $9 billion market globally and around $3 billion in the US.

However, convincing patients that they have bruxism is a problem, Predovich adds. Since it happens when they are asleep, many patients object to the diagnosis and prefer to blame the symptoms on something else. This may be due to the $400-600 price tag on the dental appliances that treat bruxism, Predovich says. 

 is a wearable AI technology that collects data about a patient's bruxism events while they sleep and sends the data to the patient and clinician for analysis, he explains.

"People out there need help and are not aware of their bruxism because they do it unconsciously," Predovich says. "To be able to have a device that so easily allows a dental professional to gather the data and uncover more patients that need help is huge for any dental practice."

Practices don't have to wait until a patient has already damaged or broken their teeth, Predovich says. By collecting data about the patients' bruxism, they can be proactive with the patient, leading to new revenue streams for the dental practice. Moreover, the BruxRelief app data convinces the patient that they need treatment and they're ready to go to the next treatment level, Predovich says.

, has been working with Grind Guard Technologies, LLC with their newest product GrindRelief® Pro. It is in clinical evaluations at the moment, with an early 2021 release date in mind. Hicks has helped bring to market over 50 products in his dental industry career. He has learned over the years that getting the routine down in the day-to-day dental practice is essential to success. Dentists should look for the clinical indicators of sleep bruxism, ask the screening questions, and present a solution after qualifying patients with a need, he advises. GrindRelief Pro is a solution that can be delivered efficiently and economically in the same appointment as the diagnosis, he adds.

"This is a way to start having the conversation," Hicks says. "And maybe, to build their confidence making the suggestion, take continuing education first to know what they are looking for. It's a consultative thing."

Drs Rein and Seltzer are big believers in using the dental practice team to champion your dental sleep efforts. They trained the entire team at 

 so the staff could communicate both with the patients and the referring physicians effectively. A well-trained staff that can interact confidently with patients and give them a sense of comfort can help build your practice, Dr Seltzer says.

"Our sleep hygienists are hands-on helping to adjust appliances," he says. "So, it's a whole team effort."

By making the hygienist the lead on this education effort, you can move more patients that need help toward treatment faster, according to Predovich.

"Hygienists can do that through the questions they ask and the things they look for," he says.

"The hygienist generally spends an hour with the patient, as opposed to the dentist who just pops in," Hicks agrees. "So, we can use the hygienist as screeners or even the assistants when they are seating the patient, etc., to ask the right questions."

"The hygienist is the first one to see any potential signs of bruxism," Predovich adds. "Also, they are talking to the patient, asking questions, screening the patient. So, the dentists we are working with have handed it off to their hygienists."

Making the hygienist a champion of the sleep effort is also a force multiplier, Predovich says. There are usually more hygienists than dentists on staff, allowing the dentist to create a more significant revenue stream than they could alone.

Having an excellent relationship with their dental lab partner is essential to their dental sleep practice, too, he adds.

"If you are getting started in this, make sure you have a great quality dental lab that can handle the cases you send them and do it in a timely fashion," Predovich says.

Working with patients on cost is also critical for dental practices getting into dental sleep, according to Dr Schwartz. Participating in insurance health plans is often tricky, and dentists should understand that going in, he says. Many patients cover these services out-of-pocket.

"We are working to change this, but it is a slow, difficult road," he says.

"There are several codes for different kinds of splints," Hicks says. "It varies a little from one insurance company to the next whether they'll cover a device for that or not. But there is also an insurance code for dental pain, an “emergency palliative” insurance code for dental pain, that some dentists use because that one is a catch-all."

Successful dental sleep practices are systematic about incorporating dental sleep into the workflow, Limkakeng says. If it is only something you do here and there, it's hard to be effective, she says.

"But once they get into a rhythm and have processes and protocols, documentation and communication, a successful practice will follow," Limkakeng says.

The way that dentistry helps with sleep really comes down to helping patients breathe better as they sleep by reducing or removing obstacles in the airway, according to Jon Caulfield, DDS, who has his private practice Epic Dentistry in Littleton, Colorado. Less resistance to airflow and more intra-oral tongue space is what results in better airway function and better sleep, he explains.

 to address underdeveloped jaws and airways to improve the breathing and sleep of his patients. He corrects the underlying anatomical issues to both manage and resolve the issues involved with sleep apnea and sleep-disordered breathing.

“We can address the anatomy and physiology of our patients by creating more tongue space to move the tongue forward and upward, out of the airway, to create a bigger and better functioning airway,” Dr Caulfield explains.

Dentists need to get into a rhythm and making a consistent effort to make dental sleep medicine part of their everyday practice is essential, Limkakeng says. Moreover, they shouldn't be afraid to ask for help with implementation, she says. If dental practices implement a sleep system on their own, they need a dedicated staff member to the practice’s effort. If they choose a third-party partner, they might only need one of their existing staff to manage it for around 30 minutes a day working in coordination with the outside partner. However, she advises that the dentist or office manager should ensure that a staff member can dedicate that time every day.

"In successful practices, sleep cases are a big source of revenue and patient referrals after they get going," says Dr Payam Ataii, DMD, MBA, co-inventor of the Aligner Sleep Appliance® and Clinical Advisor to SleepArchiTx. "It's a no-brainer to have someone spending 30 minutes a day overseeing the sleep effort and working with an outside program partner to ensure that these cases get done right."

 is designed to make it easy for dentists to take on sleep treatment in their practice without distracting them from their routine, according to Dr Greenburg. The program coordinates sleep testing, telehealth, and insurance billing for its member practices. Some dental practices might balk at the idea of outsourcing the entire sleep treatment effort, but Dr Greenburg says it's not like the usual specialist referral.

"This is all done via the phone, so the patient's not going anywhere. The patient is on the phone with our operator getting the sleep test done," Dr Greenburg explains.

With Sleep Certified 360, Dr Greenburg has detailed the system and process for dental practices. If a patient expresses interest in dental sleep medicine treatment, the receptionist asks if the patient wants to know if their insurance covers treatment, and he says most patients do. Then, the receptionist connects them with the Sleep Certified 360 team to do the insurance check. Sleep Certified 360 also shares where the patient is in the process with the dental practice via a dashboard.

SleepArchiTx™ offers a 360° turnkey solution for practices that want to begin delivering sleep treatment. From training and education to connect with medical sleep doctors for diagnosis, sleep appliances, patient education, medical billing, and support, SleepArchiTx is designed to be an end-to-end solution for dentists to treat their patients that suffer from sleep apnea. The program also focuses on implementation, case management, and case acceptance, which are typically the most challenging aspects for practices, Limkakeng says. Every patient case is evaluated and designed by a SleepArchiTx clinical advisor to help the dental provider gain the confidence necessary to successfully identify and treat patients, she says.

Whatever path practices choose, doing dental sleep medicine in-house or outsourcing aspects to a partner, dental practices should select the option that provides an ROI quickly and treats patients right away to keep motivation high with the team, Limkakeng says.

"We often see practices that make an effort to start providing dental sleep, but gets stuck, and then they get demotivated," Limkakeng explains. "However, once practices see that they are helping patients and you see revenue come in right away, then the momentum builds on itself."

Having tried to build a sleep practice on his own, and now working with SleepArchiTx, Dr Ataii believes working with an outside program provider makes a lot of sense.

“We doctors always think we will have the time to implement a new program, but the reality is, we just don’t. Holistic programs like SleepArchiTx bring the consistent focus, resources and expertise that we need to be successful,” Dr Ataii says.

The idea that a patient only has so much discretionary income to spend on oral care is another significant concern. If the sleep treatment takes up their funds, they might not move forward with their regular oral care treatment plans. However, that the Sleep Certified system is available at no cost for the patient, Dr Greenburg says.

"We're not using the patient's discretionary income. All this is directed back to the dentist, where the dentist is going to make money. We generate income," he explains.

Generating income is a driving factor in Dr Greenburg's strategy for the product. Because of COVID-19, many dental practices are hurting. He designed Sleep Certified to allow dentists to focus on what they do best and treat them for sleep as seamlessly as possible without spending a lot of time training themselves or staff.

"They don't have time to get distracted, and they don't want to be trained in this right now. They want to do their bread and butter and try to be as efficient as possible and make as much money as they can to get back in the black again," Dr Greenburg says. "They can treat their patients at an elementary level without having to become that sleep expert."

Dental sleep medicine is an area with a lot of potential for your dental practice. Patients need it and dentists are in a unique position to make a positive contribution to their overall health by treating SRBDs. Moreover, dental sleep medicine can positively impact a practice’s bottom line. However, there are still a few things to keep in mind.

“1 in 3 people exhibit signs of behavioral problems but only about 8% of those have been diagnosed or have received treatment,” Predovich says. “So, it’s a huge untapped market.”

Dental practices wishing to get into the business of dental sleep should be aware that many people have bruxism and other SRBDs if you consider the statistics. Incorporating dental sleep medicine and treating bruxism is serving a critical need for patient care, Hicks says.

"It's not a thing we are creating. It's not a problem that doesn't exist," he says.

Regarding contribution to the bottom line, Limkakeng emphasizes the need to get help on patient education.

“You have to remember that you need patient buy-in for case acceptance. At SleepArchiTx we have realized that short, engaging patient videos that are fun but still impart crucial health information are very helpful in driving case acceptance. Doctors and staff members don’t have time to create these or consistently talk to patients, so they use our patient videos to get these messages across and drive case acceptance,” Limkakeng says.

Sleep cases can make a significant contribution to a practice’s bottom line, according to Dr Ataii, something he's seen first-hand.

“It’s not just the revenue from the sleep cases alone. The patients I treat for sleep feel the health benefit right away,” he says. “They are so happy and grateful that they refer a lot of other patients to my practice. Sleep patients are the best sources of new patient referrals.”

Dental sleep medicine is changing fast, more than any other area of dentistry, according to Dr Greenburg. Although sleep medicine has been around for over 20 years, it's hitting an era of unprecedented growth.

"As a dentist, you need to expect change and embrace it," Dr Greenburg advises.

There are many essential considerations for incorporating the business side of dental sleep. However, if there was one thing that Dr Schwartz would want dentists to remember, it is that excellent patient care leads to the best possible outcome for your dental practice.

"Dental sleep medicine is not the ‘get-rich-quick’ scheme that some promote it to be," Dr Schwartz says. "But if you focus on providing optimal care to patients and communicate effectively with patients and their physicians, you can build a successful dental sleep medicine practice."

"We are the guardians of the airway in a sense," Dr Seltzer agrees. "The mouth is part of the airway, and so we were given this ability to save lives. We could help prevent someone from having a heart attack, high blood pressure, or getting in a car accident. So, that's the greatest impact we get out of this."

"It's a huge win-win for patients and dentists," Limkakeng says. "Dentists can do the right thing and feel proud that they're providing this essential and safe clinical health outcome and health service, while also doing well financially."

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Experts agree that there are millions of potential cases of sleep-related breathing disorders. However, will all those potential cases lead to business gains for your bottom line?

The Business of Dental Sleep Medicine

Millions of people have problems sleeping, and many spend a few minutes in your operatory at least once a year. Patients receive diagnoses of caries or gum disease, but what do they understand about bruxing, snoring, or sleep quality?

The American Sleep Apnea Association (ASAA) estimates 22 million Americans have sleep apnea, and 80% of them range from having moderate to severe cases of undiagnosed obstructive sleep apnea (OSA).

 Not only is sleep an area of medicine critical to patients’ well-being, but it’s also one that offers dental practices the opportunity to expand services and build practices. Dentists are well-positioned to diagnose and treat disordered sleeping.

OSA happens when the airway is blocked, typically by the tongue collapsing against the soft palate, which causes the soft palate to collapse against the back of the throat, according to the ASAA. Left untreated, OSA can lead to severe health conditions, including high blood pressure, chronic heart failure, atrial fibrillation, stroke, and other cardiovascular diseases. Moreover, sleep apnea is associated with type 2 diabetes and depression and plays a role in causing traffic and heavy machinery accidents. Although OSA often presents in obese men aged over 40, the ASAA reports that OSA affects individuals of all ages, including infants and children.

In 2017, the American Dental Association’s (ADA) House of Delegates adopted a statement about dentists’ role in treating sleep-related breathing disorders (SRBD).

 The ADA suggested that dentists play a vital role in a multidisciplinary approach to the care of patients with SRBDs. Moreover, the ADA says dentists are in an excellent position to identify at-risk patients. From medical and orthodontic referrals for children at risk for SRBDs to oral appliance therapy (OAT) for adult patients who have received diagnoses from a physician, the ADA recognizes dentists’ essential role in this effort.

Dentists should consider adding dental sleep medicine to their practices because of a shortage of health care providers throughout the country, especially physicians outside large metropolitan cities, according to David Schwartz, DDS, president of the American Academy of Dental Sleep Medicine (AADSM) and a diplomate of the American Board of Dental Sleep Medicine (ABDSM)

Dentists have become more integral in patients’ overall health in recent years to compensate for this shortage. What dentists see and do in the operatory has a direct impact on the overall health of patients. Dr Schwartz says OSA is a prime example.

“We have a straight view of the airway with every patient we treat. It stands to reason that if we suspect OSA, we can quickly act to formally screen the patient, order a home sleep apnea test for appropriate candidates and then work with the patient’s medical provider to treat the disorder,” Dr Schwartz says.

Sleep apnea…is even more crucial to…the patient’s overall health than decay. Yet, as dentists, we are never trained about the significant impact we can make for that patient.”

Neal Seltzer, DMD, FAGD, and Jeffrey Rein, DDS, FAGD, partners at Long Island Dental Sleep Medicine, recognize that OSA has been in the spotlight more recently because evidence links it to severe health complications. As “guardians of the airway,” dentists can save lives, Dr Seltzer says.

“We can help prevent someone maybe having a heart attack, high blood pressure, or getting in a car accident,” Dr Seltzer says. “That is the greatest impact we can have.”

Dr Schwartz, who has lectured on many aspects of dental sleep medicine, and authored and co-authored various articles, believes qualified dentists can have a positive impact on what he describes as a public health crisis. Moreover, treating OSA and snoring does not require new or specialized equipment investments, he says.

“It does require some investment in education and training, but the investment is not prohibitive,” he says.

Sleep is within the clinical scope of dental practices, according to Alice Limkakeng, CEO of SleepArchiTx, who says individuals with sleep disorders need immediate attention. In addition, because of the coronavirus disease 2019 (COVID-19) pandemic, treating patients for sleep disorders is vital to their health. Sleep comes in cycles, she says, and each sleep cycle accomplishes different tasks for our bodies, such as memory consolidation or releasing growth hormone. The deepest part of the sleep cycle, called N3 sleep, is where the body heals itself and rebuilds its immune system.

 This stage is essential for all patients, regardless of the virus, she says.

“If you’re snoring and having sleep apnea episodes, your sleep cycle is getting interrupted, and you never get to the deep stage of sleep where you rebuild and restore. Treating patients for sleep will increase the patients’ ability to rebuild their immune system and potentially protect them from COVID-19,” Limkakeng says.

Dentists are struggling right now and have patients who need their help with SRBDs, says Jonathan Greenburg, DDS, inventor of Zyppah, and founder and CEO of Sleep Certified. Just as a dentist would not ignore decay in a patient’s mouth, clinicians should not overlook OSA or evidence of other sleep-related disorders they observe in the oral cavity.

“Sleep apnea and severe snoring are even more crucial to the quality of care and a patient’s overall health and quality of life than that decay. Yet, as dentists, we were never trained about the importance and the significant impact we can make for that patient, and we should be addressing it,” Dr Greenburg says.

The Division of Sleep Medicine at Harvard Medical School lists many consequences of insufficient sleep. In the short term, patients can suffer changes in mood, decision-making, ability to learn and remember information, and increased risk of accidents or injury.

 In the long term, it can lead to obesity, diabetes, cardiovascular disease, and even early death.

 For all of these reasons, proponents of dental sleep medicine emphasize the benefits to patients the most.

“It’s about saving lives. It’s about adhering to the standard of care, doing the right thing, and giving back to your community,” Limkakeng says.

The connection between sleep and whole-body health is urgent, says Payam Ataii, DMD, MBA, co-inventor of the Aligner Sleep Appliance and clinical adviser to SleepArchiTx—so much so that he has put dental sleep topics at the forefront of his communication with patients and used these important health messages to reengage patients after the pandemic shutdown.

“The dentist should add sleep treatments to their repertoire because taking care of patients is what we do. This aspect of their health care is too important not to make ourselves better able to identify and treat these patients who have previously fallen through the cracks of our health care system,” Dr Schwartz says.

“If you care about your patients, sleep should be part of your practice,” Dr Greenburg adds.

The ASAA describes sleep bruxism as a sleep-related movement disorder that results in a patient’s unconscious physical grinding of teeth while asleep.

 The symptoms of bruxism are often shared by patients who also have undiagnosed OSA, although, to date, the literature only suggests a correlation between the 2 conditions, not a causal relationship.

Surveys suggest that 33% to 35% of patients have undiagnosed bruxism. I think that number is probably going up in this stressful pandemic era. There are signs of bruxism…right there in the oral cavity."

Like OSA, there is a lot of undiagnosed bruxism. In a 2016 study published in the journal Sleep, the prevalence of regularly reported sleep bruxism was 8.6% for the general population.

 The Academy of General Dentistry (AGD) fact sheet on bruxism estimates that 1 in 3 people suffers from sleep bruxism, which they attribute to people with aggressive and competitive personality traits, and people who feel stressed, hurried, or nervous.

“Surveys suggest that 33% to 35% of patients have undiagnosed bruxism,” says Norman Hicks, a consultant for GrindRelief Pro, a mouthguard for patients who clench and grind their teeth. “And I think that number is probably going up in this stressful pandemic era.”

Diagnosing and treating bruxism can build a dental practice and provide a new level of patient treatment that can reinvigorate dentists’ passion for dentistry. Plus, diagnosing bruxism does not require adding much to the daily routine.

“There are signs of bruxism that a clinician can see right there in the patients’ oral cavity, every day,” Hicks says.

According to the AGD, a dentist can easily diagnose bruxism, which includes the following signs:

Flattened appearance to the tips of the teeth

Increases in sensitivity from the exposed dentin, resulting from grinding

Jaw pain or popping in the temporomandibular joint

When the Bravrr team started working on its BruxRelief product—a wearable artificial intelligence and health tracking device meant to educate patients about their bruxism—they learned that a significant problem in treating bruxism is patient acceptance, according to Bravrr CEO Brock Predovich. Patients do not always accept a bruxism diagnosis, and many think there must be another cause for the symptoms, he says.

“Really, the patient is objecting because they don’t want to spend $400 to $800 on a dental splint or night guard,” Predovich says.

Dental sleep medicine is a field many practices are taking on for its patient care and practice-building opportunities. We spoke to experts in the area to get insight into how to build a successful sleep practice.