Retooling an Implant Supported Hybrid Denture 

May 20, 2024 Lee Ann Brady DMD

By Lee Ann Brady, DMD 

A patient chipped a tooth on her lower hybrid denture and loosened an implant screw. The denture had been placed 18 years ago, so she had an old titanium bar with denture teeth and pink acrylic. That day, I put the screw back in and smoothed out where the tooth was chipped. During this visit we had a great conversation about the future of her hybrid denture. 

I have had a similar conversation with several patients in recent months. They have the original, traditional bar retained hybrid denture that is nearing the end of its lifespan. And so, what are the options? 

  1. If the bar is in great shape, new denture teeth and a new denture base can be milled and placed over the existing titanium bar. 
  1. Alternatively, we can get rid of the bar and go to something that is all zirconia. 

If there is a preference for the first option, the first requirement is to make sure the titanium bar is in good condition. After 18 years, we would take it off and have the laboratory examine it under microscopy.  

If converting to all-zirconia and the patient has had upper and lower dentures, we must consider if one arch can be converted without converting the second arch. A zirconia arch is going to wear an opposing original denture fast if there is parafunction, and the zirconia arch is likely to fracture the opposing original prosthetic teeth. 

We have options today we can think about with our patients, but many have in their minds that when they got their hybrid dentures years ago, the dentures would last. All the time, energy, and dollars to freshen up or replace their denture is a big deal to them. Shifting their mindset from “I thought I was done investing in dentistry” to “My denture is at the end of its lifespan” is a big hurdle. So, the earlier we can start those conversations before they need to invest, the easier they can transition their minds to accept care with grace when the time comes. 

When your bar retained hybrid denture patients visit for perio maintenance and your exams, inform them of the lifespan of their denture is at most 20 years and set expectations for discussing the best available options at some point in the future.  

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Worn Dentition: Direct & Indirect Adhesive Management Through a Non-Invasive Approach

DATE: October 24 2025 @ 8:00 am - October 25 2025 @ 2:30 pm

Location: The Pankey Institute

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Enhance Restorative Outcomes The main goal of this course is to provide, indications and protocols to diagnose and treat severe worn dentition through a new no prep approach increasing the…

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Lee Ann Brady DMD

Dr. Lee Ann Brady is passionate about dentistry, her family and making a difference. She is a general dentist and owns a practice in Glendale, AZ limited to restorative dentistry. Lee’s passion for dental education began as a CE junkie herself, pursuing lots of advanced continuing education focused on Restorative and Occlusion. In 2005, she became a full time resident faculty member for The Pankey Institute, and was promoted to Clinical Director in 2006. Lee joined Spear Education as Executive VP of Education in the fall of 2008 to teach and coordinate the educational curriculum. In June of 2011, she left Spear Education, founded leeannbrady.com and joined the dental practice she now owns as an associate. Today, she teaches at dental meetings and study clubs both nationally and internationally, continues to write for dental journals and her website, sits on the editorial board of the Journal of Cosmetic Dentistry, Inside Dentistry and DentalTown Magazines and is the Director of Education for The Pankey Institute.

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 Ask Questions About How Your Patient Feels 

May 13, 2024 Paul Henny DDS

Paul Henny DDS

I wrote about this topic last October in The Never-Ending Interview and wanted to revisit it to connect the timeless teachings with my most recent thoughts. Bear with me as I recount some of the history from that previous article. 

Dr. F. Harold Wirth had a very successful restorative practice in downtown New Orleans but he always felt that something was missing until he met Dr. L.D. Pankey and was influenced by his teachings. Dr. Wirth became a missionary for Dr. Pankey’s philosophy of dentistry and life, and he gave Dr. Pankey most of the credit for developing a deeper understanding of people, both physically and emotionally.  

One of Dr. Wirth’s key messages from the podium was that dentists are always presenting the case, even from the beginning of their first encounter with the patient. Another key message was that the patient’s feelings matter in accepting care and the patient interview should be forever ongoing. 

He said, “Every time the patient comes in, you’re doing a presentation. As a matter of fact, I think the interview is forever ongoing. It might only be one word, but every time the patient comes into your office, you should be interviewing them.” 

He said, “Ask questions that have to do with how the person feels. A case history is exploring what happened. An interview is about how they feel! You need to understand the difference!” 

We might ask, “Since I last saw you, have you noticed any changes in your oral health? How do you feel about these changes?” We might ask, “How do you feel about the appearance of your teeth?” or “How do you feel about the restorations we did?” We might ask, “At your last visit, you talked about the possibility of doing ortho; how do you feel about that now?” We might ask, “You mentioned last visit that you weren’t looking forward to Thanksgiving because it was difficult to eat all your favorite foods. Would you feel good about revisiting the possibility of replacing your denture with something more stable?”  

Do you feel better after a long conversation with someone who knows you well on the emotional level? I know I do. Over time, those kinds of conversations cause us to feel more positive and hopeful. They occur when a person gifts us their full attention while making no attempt to judge. And because we experience no judgment, we share more feelings, which leads us into an even deeper level of self-understanding. 

Doctor-patient conversations that tap into how a patient is feeling on an emotional level enable patients to grow in trust and to become more open to the possibilities we offer.  

In her recent blog series, Mary Osborne has encouraged us to journey toward health with our patients as fellow travelers because we all have health issues we hope to resolve. We can make connections over shared feelings and hopes. These connections bond us so we can pursue a mutual, positive goal with our patient.  

What I love and sticks with me from Mary’s blog is that the medical health review during each preclinical interview is an ideal time to check-in about feelings regarding health in general. So, if you and your team are not doing that now, you might want to add a question about the patient’s feelings about their current health. It’s ideal if the doctor or hygienist  asks the question. It may be as simple as “How do you feel about your overall health?” Wait for the patient to think and speak.  

One of my favorite quotes is this: 

Any kind of gesture that pulls another living soul out of despair is indistinguishable from magic. – Michael Xavier, Author 

The medical history review is a prime opportunity to demonstrate we care. Expanding our preclinical interview to routinely ask one or more questions that surface feelings related to health will give us opportunities to touch hearts on a deeper level. This will engender greater trust so patients more readily accept us as partners in their health.  

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DATE: October 2 2025 @ 8:00 am - October 4 2025 @ 1:30 pm

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Paul Henny DDS

Dr. Paul Henny maintains an esthetically-focused restorative practice in Roanoke, Virginia. Additionally, he has been a national speaker in dentistry, a visiting faculty member of the Pankey Institute, and visiting lecturer at the Jefferson College or Health Sciences. Dr. Henny has been a member of the Roanoke Valley Dental Society, The Academy of General Dentistry, The American College of Oral Implantology, The American Academy of Cosmetic Dentistry, and is a Fellow of the International Congress of Oral Implantology. He is Past President and co-founder of the Robert F. Barkley Dental Study Club.

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Partnering in Health Part 2: There Is No Suffering We Cannot Care About  

May 6, 2024 Mary Osborne RDH

By Mary Osborne, RDH  

Think for a moment: Is there a change you think you could make in your life that would contribute positively to your health? Is there anything you could be doing—or not doing—that could improve your overall health and wellbeing? Most of us can think of something we could do, or do more consistently, to improve our health. Next, ask yourself if the reason you have not made the change you need to make is because you do not have enough information. Our clinical training taught us that if we give people the right information they will change their behaviors. It’s easy to get disappointed in ourselves and our patients when that turns out to not always be true.   

Reflecting on our own past and current health challenges is a way to remind ourselves that health is a journey, not just a set of strategies. What makes perfect sense to us now, may not have been relevant 20 years ago. Often we have heard the relevant information before but were slow to act on it. We may have conflicting priorities, such as time, or money. We may have had fears or doubts. When we can look at our own journey with understanding and compassion we are better able to see our patients that way.   

I remember a patient who came to us with a lot of dentistry that needed to be done. As we talked with her about recommendations for treatment, her eyes welled up with tears. “It’s nothing,” she said when I asked her what the tears were about. Eventually she shared with us that she and her family had been saving up to build a deck on their house. Doing the dentistry she knew she needed would mean they could not build the deck. There was a time when I might have thought, “What’s more important, a deck or your dental health?!?” But I was moved by her struggle. I can’t judge what a deck may mean to her and her family, but I can relate to her sadness in letting go of something they had been saving toward.   

As you advise patients, it’s helpful to share that are you on a path to better health yourself, and that it is not always easy. In this way we can step outside of the role of “expert” and come to our conversations as fellow travelers. And when we do come as fellow travelers, we bring our empathy, our humanity, and we allow ourselves to feel compassion. We are likeable.  

One of my favorite books is Dr. Rachel Naomi Remen’s Kitchen Table Wisdom: Stories That Heal. She quotes the psychologist Carl Rogers, who said:  

Before every session, I take a moment to remember my humanity. There is no experience that this man has that I cannot share with him, no fear that I cannot understand, no suffering that I cannot care about, because I too am human. No matter how deep his wound, he does not need to be ashamed in front of me. I too am vulnerable. And because of this, I am enough. Whatever his story, he no longer needs to be alone with it. This is what will allow his healing to begin. 

Because we are on a journey of becoming healthier just like everyone else, we can sit side by side with a patient. We can say, “I get it. It’s not always easy.” We can allow ourselves to feel compassion—that urge to genuinely help someone, and gently invite them to understand they are no longer alone.

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DATE: October 2 2025 @ 8:00 am - October 4 2025 @ 1:30 pm

Location: The Pankey Institute

CE HOURS: 25.5

Tuition: $ 4795

Single Occupancy with Ensuite Private Bath (per night): $ 345

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Mary Osborne RDH

Mary is known internationally as a writer and speaker on patient care and communication. Her writing has been acclaimed in respected print and online publications. She is widely known at dental meetings in the U.S., Canada, and Europe as a knowledgeable and dynamic speaker. Her passion for dentistry inspires individuals and groups to bring the best of themselves to their work, and to fully embrace the difference they make in the lives of those they serve.

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Partnering in Health Part 1: The Missing Piece 

May 1, 2024 Mary Osborne RDH

By Mary Osborne, RDH 

There was a time when I thought “partnering in health” was just about getting people to take better care of their teeth. 

Many years ago, I had a patient who was excellent with her home care, but she showed up periodically with an acute periodontal infection. We asked about stress and her overall health, but she was not aware of any issues. We would treat the infection and she would be fine for a sometime. We knew she worked for National Public Radio, and one day we made the connection that her infections showed up concurrent with NPR’s fund-raising drives. That shared realization allowed us to help her see that her stress was affecting her dental health and her overall health. She was open to conversations about lifestyle changes that would help her be healthier. My relationship with her influenced my thinking and my ability to connect with my patients from a perspective of Whole-health Dentistry. I came to understand that I had been missing opportunities to influence the way people think and feel about health. I knew that I wanted my patients to see me as “a partner in health.” 

Unfortunately, most of our patients come to us with the perspective that we are fixers of teeth, not partners in health. 

In the culture today people are bombarded with information about what is healthy. From friends and families, social and news media, and a wide variety of health care practitioners, everybody expresses opinions on how they are supposed to take care of themselves. Why, then, are we surprised when our patients don’t know whom to trust? Why are we surprised when they shrug their shoulders or appear confused? It’s not always a case of conflicting facts but a case of various perspectives that people don’t know how to navigate. 

Think about where you place your trust. How do you decide whom to trust about decisions—whether it’s about your health, or about your finances, or about how you raise your children? When I ask myself that question, two criteria surface. They need to know their subject and to know me. I want that person to know what it is they’re talking about. I want them to be well informed. I also want someone who knows me, who understands my values. I want that person to have a sense of who I am and what is important to me. 

As we get to know our patients over the years, most of them come to see us as trusted advisors when it comes to their dental health—but fewer see us as trusted advisors when it comes to their general health. If we jump too quickly to making recommendations about their overall health, we are more likely to meet resistance. If we want to cross the bridge into influencing our patients’ overall health and wellbeing, I believe we need an invitation to cross that bridge.   

The Missing Piece in our quest to influence the overall health of our patients is the failure to invite patients to share their perspectives on health. Beginning a conversation with a new patient with the question, “What can you tell me about your health in general?” is an invitation for them to talk about their experience of their health, not just details. Instead of “reviewing” health histories, what if we “explore” health histories? As we connect and get to know each other we can learn to listen beyond information to hear attitudes, beliefs, fears, biases, concerns, barriers, etc. As you understand their perspectives on health issues that come up in conversation, it’s easy to ask if they would like your perspective on that issue. These conversations often lead to more questions and answers that invite more and more invitations from our patients to be their partner in health. 

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Mary Osborne RDH

Mary is known internationally as a writer and speaker on patient care and communication. Her writing has been acclaimed in respected print and online publications. She is widely known at dental meetings in the U.S., Canada, and Europe as a knowledgeable and dynamic speaker. Her passion for dentistry inspires individuals and groups to bring the best of themselves to their work, and to fully embrace the difference they make in the lives of those they serve.

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The Pre-Clinical Interview – Part 2 

March 11, 2024 Laura Harkin

Laura Harkin, DMD, MAGD 

Let’s delve deeper into the preclinical interview! 

It’s helpful to understand a patient’s perception of their overall health and oral health, as well as what type of restorative dentistry they’re hoping to have and why they feel the way they currently do.  

Sometimes, an integral family member has influenced the timing of care. For instance, you may hear, “My grandchildren are making fun of my teeth” or “My wife asked me to get my teeth fixed.” From this response, I know that I will need to be sure my patient personally desires treatment before rendering it. I’m also anxious to understand what type of restorative dentistry a patient is considering. For example, are they open to removable prosthetics, fixed crown and bridgework, or implantology? 

Recently a new patient came to my office with an emergency. Tooth #5 presented with the buccal wall broken to the gumline and a moderate-sized, retained, amalgam filling. He immediately said, “I do not want bridgework.” I listened quietly until he elaborated by saying, “When I had this front tooth replaced by my other dentist, I had to take it in and out, and I just found that so irritating.”  

I finally understood that he was referring to a flipper but calling it bridgework. So, it’s important to listen and ask questions when someone seems close-minded about having a certain modality of treatment. Delve deeper into the conversation because it may simply be confusion surrounding dental terminology. 

For the grandparents who ask for a better smile, I’d like to understand their thoughts on the scope of treatment and their expectations. Are they looking for a white, straight, Hollywood smile or a more natural appearance with a little bit of play in the lateral incisors? Are they mainly concerned about stains, gaps, or a missing tooth? Are there other problems they’re aware of such as tooth sensitivity, inflamed gums, or the need for a crown? This input is very important as we continue conversation with co-discovery throughout the clinical exam, diagnostic records, and treatment planning phase. 

Learn to count on your chairside for pertinent information. 

I’m fortunate to always have my assistant, Cindy, beside me for preclinical conversations, comprehensive examinations, and restorative procedures. Sometimes, Cindy interprets a patient’s statement or component of conversation differently than me. She may hear a message that I missed or read body language of which I wasn’t aware. Sometimes, auxiliary conversations between patient and assistant take place after I’ve left the room to complete a hygiene check.  

At the end of the day or in the morning huddle, we always take time to discuss interactions with our patients. Together as a team, we’re more efficient at acquiring accurate information so that we may approach the road to health most effectively for each individual. 

Determine if trust is present. 

As I’m getting to know a patient and before I choose to begin restorative treatment, I seek to understand if trust is present in our doctor/patient relationship. New patients often share past dental experiences, and, unfortunately, some have lost trust in dentistry itself. This may be warranted due to improper care, but it may also be due to a lack of understanding or unclarified expectations regarding a given procedure or material choice.  

It’s not unusual, particularly when a patient is considering a large scope of treatment, to serve as a second or third opinion. Building trust and waiting to be asked for our skills are key necessities before moving forward in irreversible therapy.  

The comprehensive examination, periodontal therapy, splint therapy, and gathering of records are all appointments during which opportunities exist to get to know our patients. True trust often takes time to establish, but the reward reaped is frequently one of empathy, friendship, and the ability to do our best work. 

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Single Occupancy with Ensuite Private Bath (per night): $ 345

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Dental Sleep Medicine in Restorative Practice Part 7: Team Investment

February 12, 2024 Todd Sander, DMD

Dental Sleep Medicine in Restorative Practice Part 7: Team Investment 

By Todd Sander DMD 

If a dentist wants to provide dental sleep medicine within a restorative practice, everyone needs to be on the same page when making room on the schedule for sleep patients. It would be best to have a couple of champions on your team to support you in your efforts. 

The first champion you need is a sleep patient coordinator who has excellent phone skills and a high interest in what you want to achieve. This team member needs a working knowledge of sleep medicine and to be able to talk with patients about dental sleep medicine over the phone. Ideally, this team member has excellent phone skills and cares about sleep-related breathing disorders and pulmonary issues.  

If another receptionist receives a sleep dental medicine inquiry, our protocol is to take a message and have our sleep patient coordinator call the prospective new patient right back. This has worked well in our practice with a high rate of conversion. 

The second champion you need is a motivated clinical assistant. Hygienists and expanded-function dental assistants make phenomenal sleep assistants because they are driven to learn and do new things. In Parts 3 and 4 of this series, I described tasks my clinical assistant typically performs, so I can best use my time with the patient. For many years, one of our hygienists who had a passion for dental sleep medicine worked with me in developing the sleep side of the practice and was my clinical assistant with sleep patients. In our practice, her role was half traditional hygiene and half sleep dental medicine. 

For years, I have taken our entire staff to sleep courses, even team members who are not helping a lot with dental sleep medicine. I want my team to understand why I am developing the dental sleep medicine practice inside my restorative practice, how they can support it best, and receive formal training to pitch in when needed.  

Don’t forget to invest in yourself because you are the key team member. Today, there are several good sleep dental medicine courses, including at The Pankey Institute. The Pankey Institute courses and its dental sleep medicine study club are excellent.  

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Todd Sander, DMD

Dr. Todd Sander is a graduate of The University of North Carolina at Chapel Hill, the School of Dentistry at Temple University, and a one-year Advanced Education in General Dentistry residency with the US Army at Fort Jackson, SC. He completed three years of active duty with the US Army Dental Corps and served in Iraq for 11 months. Dr. Sander completed more than 500 hours of postgraduate training at the Pankey Institute for Advance Dental Education and is one of only three dentists in the Charleston area to hold such a distinction. Dr. Sander is also affiliated with the American Dental Association, South Carolina Dental Association, American Academy of Cosmetic Dentistry, Academy of General Dentistry, and American Academy of Dental Sleep Medicine. Areas of special interest include: TMJ disorders; advanced dental technology; cosmetic dentistry; full mouth reconstruction; sleep apnea /snoring therapy; Invisalign orthodontics.

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Dental Sleep Medicine in Restorative Practice Part 6: The Question of Software

February 9, 2024 Todd Sander, DMD

Dental Sleep Medicine in Restorative Practice Part 6: The Question of Software 

By Todd Sander DMD 

Numerous companies offer software solutions for dental sleep medicine that integrate with billing services. These companies can take over the paperwork and billing for medical insurance. Some of them have letter templates built into them.  

I look at software all the time, and when I do, I evaluate the efficiency we would gain versus the number of appliances I would need to deliver to make using the software worthwhile. Their billing service fees are high. Currently, I average 10-15 dental sleep medicine patients per quarter and not all of these are candidates for oral appliance therapy. Remember, I have a busy restorative practice. Colleagues who practice full-time dental sleep medicine may see this number in a week! 

I’ve been fortunate to have team members who don’t mind researching how to file medical insurance claims for appliances. Most of my colleagues use a software platform designed for dental sleep medicine. So far, I have chosen not to use one. Instead, I have assigned the duties to team members and they have taken dental sleep medicine, Eaglesoft, and medical billing courses. Currently, we have customized template forms and letters in our Eaglesoft system but it is not set up for filing medical claims.  I must admit, it is getting harder to do this. and I may be forced to decide about dedicated software soon. However, the decision will be made considering financial feasibility as a primary concern. 

It did take time to develop our template forms and letters in Eaglesoft but now we are highly efficient. I dictate the notes for our records, the SOAP note for medical insurance, and the information we want to share in letters with physicians. In addition to the cost savings, I like that I am recording the data I want in my documentation in a structure I want for how I practice—not just for the SOAP note and representing my findings to referring physicians. 

One of my mentors has me considering the possibility that I might want to separate my dental sleep medicine patients’ charting from my dental patients’ charting. Using software designed for the practice of dental sleep medicine would give me a clean way to segregate the patients on my computers. So far, I’ve decided that the expense of the software will not give me a return on my investment. 

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Todd Sander, DMD

Dr. Todd Sander is a graduate of The University of North Carolina at Chapel Hill, the School of Dentistry at Temple University, and a one-year Advanced Education in General Dentistry residency with the US Army at Fort Jackson, SC. He completed three years of active duty with the US Army Dental Corps and served in Iraq for 11 months. Dr. Sander completed more than 500 hours of postgraduate training at the Pankey Institute for Advance Dental Education and is one of only three dentists in the Charleston area to hold such a distinction. Dr. Sander is also affiliated with the American Dental Association, South Carolina Dental Association, American Academy of Cosmetic Dentistry, Academy of General Dentistry, and American Academy of Dental Sleep Medicine. Areas of special interest include: TMJ disorders; advanced dental technology; cosmetic dentistry; full mouth reconstruction; sleep apnea /snoring therapy; Invisalign orthodontics.

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Dental Sleep Medicine in Restorative Practice Part 5: Selecting Appliances

January 31, 2024 Todd Sander, DMD

Dental Sleep Medicine in Restorative Practice Part 5: Selecting Appliances 

By Todd Sander DMD 

This article is written for dentists who are thinking about or just starting a dental sleep medicine practice. I do both restorative dentistry and dental sleep medicine, and by sharing what I do, I hope to help others with their planning. 

There are many other types of appliances you can consider and I am always looking at them. But to become most efficient, I have narrowed down the types of appliances I deliver. Most commonly, these are Dorsal and Herbst appliances. Both are titratable, as the patient needs more advancement over time. 

The dorsal appliance resembles a custom-fitted mouthguard, worn only during sleep. It uses advancement blocks with an orthodontic screw to advance the jaw. There are many manufacturers, and it is easy to deliver. It doesn’t impinge on the tongue, so patients find it comfortable. It is fairly durable and repairable, especially if milled out of acrylic. This is my go-to type of appliance for most patients because patients respond favorably to them. 

A Herbst appliance is more durable for parafunctional patients and fairly comfortable. Patients are sometimes intimidated when they first look at this type of appliance but I always point out that the advancement bars are in the dead space of the cheeks, and they won’t feel them. There are many types of Herbst appliances with different types of advancement arms. 

I sometimes deliver an EMA appliance or a TAP 3 appliance. I have found that the screw and bar assembly of TAP appliances can impinge the tongue a little. My preference is to use appliances that provide more room for the tongue to move forward. Milling and 3D printing have introduced many low-profile, stable, and comfortable appliances that deserve investigation.  

Whatever appliance you decide to use, become knowledgeable and proficient with it. You want to convey confidence to your patients. The more they trust in the appliance, the more compliant they will be with wearing it and the sooner they can achieve improvement of their sleep breathing issues. Oftentimes, they will feel better within a week or two and report this during their first recall visit. When they report improved symptoms, we can move on to confirming the treatment position with a home sleep monitor and refer them back to their physician. Treatment position can also be confirmed prior to appliance fabrication by using a MyTAP temporary appliance.  This can improve the initial treatment position and is necessary for non-titratable appliances. 

With most patients, we take two steps forward and one step back as we titrate an appliance to an effective treatment position. Sometimes I need to send an appliance back, so I’ve become used to taking a bite registration myself and sending it to the lab to reset the appliance in a more forward position.  Using a MyTAP to determine treatment position ahead of time helps prevent this. We prepare our patients for this possibility and provide encouragement to stay on course. Working as a team with our patients, we will get there! 

Related Course

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DATE: January 29 2025 @ 8:00 am - February 2 2025 @ 1:00 pm

Location: The Pankey Institute

CE HOURS: 37

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Single Occupancy with Ensuite Private Bath (per night): $ 345

TMD patients present with a wide range of concerns and symptoms from tension headaches and muscle challenges to significant joint inflammation and breakdown. Accurate thorough diagnosis is the first step…

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Todd Sander, DMD

Dr. Todd Sander is a graduate of The University of North Carolina at Chapel Hill, the School of Dentistry at Temple University, and a one-year Advanced Education in General Dentistry residency with the US Army at Fort Jackson, SC. He completed three years of active duty with the US Army Dental Corps and served in Iraq for 11 months. Dr. Sander completed more than 500 hours of postgraduate training at the Pankey Institute for Advance Dental Education and is one of only three dentists in the Charleston area to hold such a distinction. Dr. Sander is also affiliated with the American Dental Association, South Carolina Dental Association, American Academy of Cosmetic Dentistry, Academy of General Dentistry, and American Academy of Dental Sleep Medicine. Areas of special interest include: TMJ disorders; advanced dental technology; cosmetic dentistry; full mouth reconstruction; sleep apnea /snoring therapy; Invisalign orthodontics.

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Dental Sleep Medicine in Restorative Practice Part 4: Treatment Monitoring

January 26, 2024 Todd Sander, DMD

Dental Sleep Medicine in Restorative Practice Part 4: Treatment Monitoring 

By Todd Sander DMD 

One week after a dental sleep medicine patient is given their appliance I have them return for a follow-up appointment with my clinical assistant. During this appointment, we want to determine if the patient is having any issues. It takes a little time for patients to become accustomed to wearing their appliance and most patients have questions, so this appointment is a time to reassure them and reinforce instructions for advancement if the patient has a titratable appliance. After one week, many start to experience the benefits of 50 to 60% advancement. 

We bring them back again at four to six weeks, at which time, we review their medical history and see if there have been changes. We also evaluate their compliance. We have a sleep log for patients to fill out every morning after they wake. We ask them to make notes about the quality of their sleep. We also have a report form for the patient’s bed partner if the patient has one to make note of the patient’s sleep quality. Believe it or not, spouses/bed partners are accurate 80% of the time when compared with sleep monitors. My clinical assistant reviews the sleep logs and medical history, performs a preliminary appliance check, and lets me know the highlights. Then I come in and perform a thorough examination and lead a discussion to determine how well the patient is adapting to the appliance. 

If the patient is doing well with compliance and feels the therapeutic value of the appliance is adequate, I might decide to skip the eight to ten-week appointment and go straight to confirmation of resolution of symptoms with some sort of monitor. If the patient is not doing well or cannot advance comfortably, then we work out a plan. It is important to note that there are many effective appliances that are non-titratable and fabricated in a fixed position. With these appliances, I work out the titration to the treatment position in My TAP following a similar protocol before prescribing a treatment position in a final appliance. 

Note that we often see issues that cross over into the area of facial pain and temporomandibular joint problems. Many patients doing sleep appliance therapy have these problems, so if you want to do sleep dental medicine, be prepared to also manage your patients through facial pain and TMD issues as you titrate their appliances. 

Usually, in eight to ten weeks, we have successfully taught our patients to self-titrate the appliance to a comfortable treatment position, and we can move to monitor its effectiveness. We are always available to answer questions.  

People wearing Fitbits and iWatches can use snore lab apps. By self-monitoring, they have a good sense of when their appliance is in a good treatment position. In our practice, we always confirm this with either a high-resolution pulse oximetry monitor or a peripheral arterial tone monitor. These two types of monitors provide data we give the referring physician. I always send a letter and report back to the patient’s sleep physician and general dentist (if the patient is not also a general dentistry patient), and I ask the patient’s permission to include their primary doctor in the loop.  

After this, I see my sleep dental medicine patients for a six-month visit, then once a year for an annual visit. Often there are issues to be addressed. Sometimes the appliances need to be titrated a little bit more. Sometimes patients have been seating them improperly. Sometimes we see bite changes to address and document. 

Related Course

TMD & Orofacial Pain: Managing Complex Patients

DATE: January 29 2025 @ 8:00 am - February 2 2025 @ 1:00 pm

Location: The Pankey Institute

CE HOURS: 37

Dentist Tuition: $ 7200

Single Occupancy with Ensuite Private Bath (per night): $ 345

TMD patients present with a wide range of concerns and symptoms from tension headaches and muscle challenges to significant joint inflammation and breakdown. Accurate thorough diagnosis is the first step…

Learn More>

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Todd Sander, DMD

Dr. Todd Sander is a graduate of The University of North Carolina at Chapel Hill, the School of Dentistry at Temple University, and a one-year Advanced Education in General Dentistry residency with the US Army at Fort Jackson, SC. He completed three years of active duty with the US Army Dental Corps and served in Iraq for 11 months. Dr. Sander completed more than 500 hours of postgraduate training at the Pankey Institute for Advance Dental Education and is one of only three dentists in the Charleston area to hold such a distinction. Dr. Sander is also affiliated with the American Dental Association, South Carolina Dental Association, American Academy of Cosmetic Dentistry, Academy of General Dentistry, and American Academy of Dental Sleep Medicine. Areas of special interest include: TMJ disorders; advanced dental technology; cosmetic dentistry; full mouth reconstruction; sleep apnea /snoring therapy; Invisalign orthodontics.

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Dental Sleep Medicine in Restorative Practice Part 3: Exam and Appliance Delivery Protocols

January 22, 2024 Todd Sander, DMD

My regular examination and treatment protocols for dental sleep medicine patients are based on what I learned from mentors, but I’ve molded them for my style of practice.  

Screening—Years ago, I offered 15-minute consultations for anyone who wanted to learn about dental sleep medicine and alternatives to CPAP. I found that patients were already well-versed, so I don’t do that anymore. When my team members answer the phone, they often answer insurance-related questions, and my team members have learned to answer those questions astutely. While on the phone, they weed out those just curious about how a dentist might help them and focus on those likely to be committed to my process and accept treatment. I have team members who are knowledgeable about oral appliances and quickly answer questions about them over the phone. 

Pre-Examination Records—Referred patients scheduled for a comprehensive dental sleep medicine exam are sent paperwork to complete before their examination. My clinical assistants gather the paperwork, including a detailed medical history, the referral from a sleep physician, the letter of medical necessity, and their polysomnogram, if they have had it, and the hypnogram. We gather as much data from the physician as possible. I review this in advance of seeing the patient. 

Pre-Examination Records Created by My Clinical Assistant—When patients arrive for their initial two-hour appointment, my clinical assistant takes digital impressions (sometimes we take traditional PVS impressions) and x-rays. She also collects vitals and interviews the patient just as a medical assistant would in a medical office. 

Examination—During a thorough examination, I voice-record the information needed for the medical documentation. By the end of the exam, I know what the patient’s treatment options are going to be and the anticipated charge for treatment. Sometimes the patient is not a candidate for a sleep appliance and I refer the patient to their physician. We still get paid for the comprehensive exam. Our patients are prepared for this. Even if we can’t help them, they appreciate the time we spend. When each patient leaves the comprehensive exam, we have all the information we need, including a protrusive bite registration if the patient is to receive an appliance. 

Medical Reimbursement—In my practice, payment is due upfront for the examination. If they know this is coming in, they’re accepting of this. We have chosen to do our best to help patients seek medical reimbursement and submit the required medical documentation for their insurance. We operate on a fee-for-service model, and this requires intentional conversations with patients so they will value our care, skill, and judgment whether insurance reimburses them or not. 

Second Appointment to Start Appliance Therapy—My clinical assistant helps by initially trying in the appliance we have had lab-fabricated. She educates the patient about warming the appliance in warm water if it is a thermoplastic material and fabricates a morning repositioner. Then I come in and do a fit check, spend more time adjusting the appliance if needed, answer questions, confirm that the appliance has been fabricated correctly, and review instructions for wearing the appliance and using the morning repositioner. For titratable appliances, I usually start an appliance at 50 to 60% protrusive if it’s a mandibular advancement appliance. I ask the patient not to advance the appliance for one week. If the appliance is titratable, we educate the patient on how to advance 1-2mm every two to three days until symptoms alleviate.  

Part 4 of this series will discuss how I monitor my sleep dental medicine patients. 

Related Course

TMD & Orofacial Pain: Managing Complex Patients

DATE: January 29 2025 @ 8:00 am - February 2 2025 @ 1:00 pm

Location: The Pankey Institute

CE HOURS: 37

Dentist Tuition: $ 7200

Single Occupancy with Ensuite Private Bath (per night): $ 345

TMD patients present with a wide range of concerns and symptoms from tension headaches and muscle challenges to significant joint inflammation and breakdown. Accurate thorough diagnosis is the first step…

Learn More>

About Author

User Image
Todd Sander, DMD

Dr. Todd Sander is a graduate of The University of North Carolina at Chapel Hill, the School of Dentistry at Temple University, and a one-year Advanced Education in General Dentistry residency with the US Army at Fort Jackson, SC. He completed three years of active duty with the US Army Dental Corps and served in Iraq for 11 months. Dr. Sander completed more than 500 hours of postgraduate training at the Pankey Institute for Advance Dental Education and is one of only three dentists in the Charleston area to hold such a distinction. Dr. Sander is also affiliated with the American Dental Association, South Carolina Dental Association, American Academy of Cosmetic Dentistry, Academy of General Dentistry, and American Academy of Dental Sleep Medicine. Areas of special interest include: TMJ disorders; advanced dental technology; cosmetic dentistry; full mouth reconstruction; sleep apnea /snoring therapy; Invisalign orthodontics.

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