Welcome, I am Dr. Kathy Wilson, moderator for this evening's presentation on incorporating medical personnel into your dental sleep medicine team. I'm joined with our panelists, Ruben Avalos, Sarah Conklin, and Belinda Postel. And now I'd like to start off by asking this evening's panelists to answer a few questions. So the first question is, briefly describe your background and experience before entering into dental sleep medicine. And I'm going to remind you that I'm setting a three minute timer for each of you to make sure we can get through the rest of the questions and make sure we have time at the end. So I will start with you, Belinda, go ahead. I'm Belinda Postel. I am a registered nurse. Prior to engaging in dental sleep medicine, my background is primarily critical care. I've been a neonatal intensive care nurse, pediatric intensive care nurse, post anesthesia care unit nurse. So very aware of airway, comorbidities with sleep. I actually only retired about two years ago from the hospital. I'm doing this full time now. I've been doing sleep medicine for about 14 years. Nice. Sarah. Hello, I am Sarah Conklin and I am a licensed practical nurse. I graduated from Grand Rapids Community College in 2012 with a degree in licensure with my licensed practical nurse certificate. In 2008 to 2012, I was like a resident care aide. So while I was going through nursing school on a memory care unit, and I also did rehab. So it helped me kind of gather and tie in the pieces of school and real life while I was basically attending. And then I worked in a primary care setting after graduation. And I did basically like a typical rooming for patients and triage. And then I went to telephone triage. And I also was the on-call nurse for 16 primary care offices after hours. And that gave me a lot of insight and basically use your critical care thinking. And then I was promoted to a nurse navigator in that setting. And then I transferred to diabetes and endocrine. And I worked mainly as a nurse educator, nurse navigator, helping patients basically with insulin pump management, carb counting, and the understanding and education heavily on comorbidities. And as we all are well aware, sleep apnea is huge in that setting. So a lot of education and a lot of continuous learning. Fantastic. Ruben? Hi, I'm a licensed practical nurse. I have a bachelor's of applied science in nursing and also picked up my registered dental assistant license so that I can do a little bit of additional work and responsibilities here within the dental practice. I started training through the ASTEP program for the AESM in polysomnography and working towards completing my certified polysomnography technician license there. The experience as a nurse was primarily as the assistant director of 120-bed tracheotomy and ventilator facility. And so we assisted patients who suffered a variety of different medical conditions, which ultimately required mechanical ventilation. So polysomnography medicine has been a part of my career for my entire career as a nurse, and it's been able to be very valuable foundation stone for the treatment of the patients that we see currently here at our practice, which primarily focuses on obstructive sleep apnea and TMT disorder, TAMI disorder. Excellent. Thank you all. Okay. Next question. Does your background in education allow you to take on responsibilities that might otherwise need to be managed by a dentist? So I'll ask it in reverse order this time, Ruben. Yes. One of the things that we experienced here in Texas was that, and I think it's important to understand every state is going to be different, but the Texas Board of Nursing had some concerns regarding a nurse's ability to be able to be supervised and managed by a dentist. And so that would, that actually led for me to become a registered dental assistant because my own local board of nurses required me to have something that provided, I guess, a background, which allowed the local dentist here in Texas to be able to manage and provide services and for me to work directly underneath his license. But after that, I think it's very important to understand that in our role as assistants within these offices, focusing on the identification of patients who may be suffering from something like obstructive sleep apnea is important. But I think the background as a medical provider and as a nurse allows us to identify the possibility of symptoms regarding other parasomnias. So not to have a situation where we're hyper-focused on only looking for the signs and symptoms of that which we treat, but really getting a very good general information on the patient to be able to identify any potential problems. And then again, working in lockstep with the medical physician in the diagnosis and treatment of that patient. Melinda? In Missouri, unlike Ruben, our state does not have any issues with our supervision under a dentist. As long as we are not administering medications, we're free to go. So really, primarily in our role, it's educational for me. I provide a lot of the education that takes Dr. Postol's time away from that so that he is doing directly what he is required to do. Everything else is being done by me, which then saves him a lot of time. Because of my background, I'm able to help tie together for the patients their comorbidities and how they're affecting them directly. A lot of them have never even heard how their diabetes is affected, how their heart condition is affected. So that's, for me, the primary role is an educational role. But that makes the transition in our process a lot smoother and frees up the dentist's time so that he can do what he's actually absolutely required to do. Right. Sarah? Absolutely. Because it allows me the freedom to independently manage follow-up office visits, to piggyback Belinda, the nurse education, the educational side of it. Because it's not just, here's an appliance, bye. This is a lifelong education and everything changes, especially the more that the comorbidities and other underlying issues gain control. Everything kind of finds its balance and it's an ebb and a flow. But it's nice to be able to help interpret, review sleep studies at follow-up office visits, help assist patients titrate their appliances, have a better understanding, independently perform those nurse visits and virtual visits, things like that. So absolutely, it's great to kind of take a load off Dr. Wilson, but also collaborate with her. And it's all possible, I feel, due to my background. The nursing plays into it, but also the ongoing training that I'm continuously getting, it's never-ending, which is great. All right. All right. Sarah, I'm going to start with you on this next question. Are you able to perform expanded functions in relationship to dental sleep medicine? So we're not talking about dental expanded functions, but dental sleep medicine expanded functions that might otherwise not receive proper attention or require outsourcing. Yes. Managing the inbox tasks and follow-ups, I feel, are big because we want to achieve great patient outcome at the same time, not have them fall through the cracks. So we don't want them out the door and then basically kind of not have a navigation system for them, but also to collaborate with their care team. So being in touch with all of their providers, dentists included, but also just like the cardiologist, the primary care doctor, the referring physician, things like that. So I think it's big because we're not losing them to care, but also at the same time it's managed and we are committed to communicate with their whole entire care team. So they just basically have lifelong treatment and we just want to make sure that they stay with us and stay essentially a part of their care. When you say inbox, what do you mean by that? Can you expand on that a little bit? Absolutely. So a lot of it is to make sure that we have, we set tasks for each other. So we want to make sure if there's that patient that doesn't move forward that same day and they want to make sure that they're kind of juggling their financial and find out the background work of it. We want to make sure, again, they're not lost to care. So with the reminders that are set, following and collaborating big time with sleep centers to make sure if the referral is placed, that they're following through with it. The care team is actually giving us the results, making sure things don't drag out longer. And again, they're just lost completely. So the big thing is kind of just working very, very closely with all their care teams and managing their appointments, their followups, and making sure coming here, moving forward that they know what they need to do also. Okay. And Ruben? Same question. Are you able to perform expanded functions related to dental sleep medicine that might otherwise not receive proper attention or require outsourcing? Yeah, I think as many of the practices find growth in their sleep practice and the number of efficacy tests that a patient may be getting back, it's more and more raw data that the physician or the dentist is having to evaluate. And so one of the things that we're able to do is evaluate patients' pre-appliance and post-appliance studies to make sure that we're actually comparing apples with apples. One thing that we find is that many patients who are going back to their sleep physician and getting raw data evaluated for the efficacy of an appliance may have initially had their interpretation of their initial study, either done with a home sleep apnea test or with a polysomnography, and then had very different results using a different scoring method, perhaps. A patient may be scored on a 4% desaturation rule for their initial and a 3% on their efficacy. And so we always want to make sure that we can identify these cases, send them back to the sleep physician, and request amendments. Many cases, they're pretty simple for them to be able to recalculate the scoring method so that we're comparing apples with apples again, a 4% desaturation rule with a 4% desaturation rule on an efficacy test. And again, the bigger the practice gets, the more these tests become apparent, the larger the data structure comes into place, and the more we can triage this information for the dentist and provide the patient with more accurate comparison when looking and evaluating efficacy. Did you help develop those systems, or is that something that just evolved over time? No, we found early on that, you know, and again, everybody's experience is going to be a little different, but we'd run into one or two maybe local sleep physicians who hadn't really bought into the idea of an oral appliance. And you know, whether it was by chance or whether it was by design, many patients who would otherwise have received a very favorable efficacy test, we saw these kind of, you know, trends coming into place. And so we found that it was a requirement on our part to be that extra step in becoming an advocate for the patient so that we can clearly identify what's going on with the appliance, how it's working for them, and how it's benefiting them. Thanks. Belinda? I kind of, to expand on what both Sarah and Ruben said, really being the patient advocate in our case, sometimes the fact that the patient has so little information, and once you review that with them, I may be the advocate to actually get them on a CPAP because that's their best treatment. They didn't really give it their whole hearted best effort because they didn't understand it. I've had patients that, due to the size of medical offices, get lost in the cracks like Sarah was saying. And so I've been able to help navigate the system for them, get them where they need to be, whether it's ENT, whether it's back to their sick physician for a CPAP. Sometimes there's other involvement with other care providers. So you become really the patient advocate that is just not available in the healthcare system anywhere else. So that was your timer. That was a great response though. Okay. Did you have anything more I wanted to add? I don't want to totally cut you off dry like that. That was Ruben's timer. I promise I reset it. No, but it's, so it is really just being an advocate and educating. It's huge. It's missing the medical world. 100% agree. And I think it's very much needed when we venture into dental sleep medicine. And I think that we kind of forget that we have to do that. I think so often as dentists, we assume that the referring physician or the referring physician office did all that education. And that when that patient walks into our office, we just assume that they know what's going on and you're here to get an appliance. And for me, it wasn't until, you know, you start talking to them more and you start saying things that you assume that they've heard before. And they look at you like, okay, I don't know what you're talking about. Or you ask them also, did they go over your sleep study with you? And no, just someone called and told me that I can go to this place to get my CPAP, but I didn't want that. So that's how they sent me to you. So I think I can't really emphasize enough the value that you're all three of you, your backgrounds bring to that aspect of dental sleep medicine. So I can say, you know, Sarah happens to be my employee and I can say, it's absolutely wonderful and I can't be as awesome as I am without her. She's awesome. You are too much. Thank you. I'm not where I am without you, because honestly, this is not training you get in school necessarily. So that's the nice thing is it's a great collaboration and it works very well. Okay, next question. Did you take on any traditional dental roles? And let me outline what those might be, because without the perspective, you might not quite understand that. So for example, making an adjustment to an appliance or doing either x-rays or a cone beam or a pano, taking measurements in some offices depends, scanning or taking impressions. So things that are kind of specific to dental sleep medicine, those would be more traditional dental roles. So did you take on any of those? And if so, did you need special training? Who are we starting with? I will start with... What's that? Who are we starting with? Let me think about that a second. So I will start with Belinda. I have, yes, done some additional dental roles in the office. I am no longer doing those because my time is consumed with education and insurance. But yes, and in the state of Missouri, we do not have to have a certified dental assistant. So your dental assistant can have on the job training and that's how it occurred for us. There's a couple of little radiology things we have to do to make that all in line. But otherwise, anything we do can be taught on the job. And that's what my training was. Perfect. Ruben? As I mentioned before, my state obligated me to obtain some additional training and certification within the dental world. And so I picked up my registered dental assistant license here in Texas. And that really was instrumental in being able to get me the opportunity to do cone beams for our patients. Cone beams have been revolutionary for our practice. The underdevelopment of the oral cavity and the depth of the palatal depth and its impact on the nasal pharynx. When properly evaluated in treatment, I think diminishes the demand that the patient looks for on the oral appliance. If they're dealing with something in the nasal pharynx and they don't even know they're dealing with it. And a lot of times you ask them, how well do you breathe through your nose? And it's normal to them because they've been breathing through this horrible sinus cavity their entire life. And so by being able to get technology in place that helps identify and properly evaluate with the help of radiologists, a good radiology report that they can send over to the ENT with imaging, we not only get the buy-in from the patient who then has a diminished demand on advancement, we find that we don't necessarily have to do a lot of mandibular advancement. It's really more about controlling the negative ranges of motion of the jaw while they're asleep. So more stabilization than anything else. And also being able to utilize intraoral scanners has really been able to cut down on the amount of chair time, the amount of time that the patient has to come back. If let's say impressions were taken and you know, the amount of vertical that they initially got on their bite registration, you know, the lab's calling back saying this is just isn't enough. It's just great to be able to get that data in real time on a digital scan. And then if, if the lab still calls back and says, Hey, we need to do something, having that digital image there so that you don't have to scratch, start from scratch, you can get started again, pull up that image and be able to do whatever changes are necessary. Maybe that's increased the amount of vertical or change the original placement of the appliance for the patient. I think it, it diminishes their anxieties that they sometimes get when they're pursuing something that's kind of new to them and that they can't rely on a family member who's gone through it before. Maybe they're the first person in their family that's ever experiences. And by being able to diminish that kind of anxiety for the patient, I think we ultimately increase their buy-in and their overall success. Nice. Sarah. Yes. I took on a lot of roles in this new world and assisting essentially with measurements is big. I had a medical background in scribing, so it's nice that Dr. Wilson's able to do and perform the exam while I can kind of be behind the scenes, kind of getting that all in that speeds up the visits fairly quickly too. A lot of special training with the intraoral scanner that we use for impressions, panoramic x-rays. I've never had to do x-rays before in my career. Appliance titration protocols and also how to perform them, especially if we're teaching that back for patient's education and George gauges, because that to me was just so foreign on the purpose of the use of it and now I get it and I love it. So kind of seeing and learning and now actually handling and applying is great. So yeah. And adjusting appliances too in lab is, it's fun. It's fun to have a whole new world of education that's continuously changing, but a lot of different roles that don't exist in the traditional nursing environment. So a couple of you brought up a really good point that I kind of want to hammer home because it's incredibly important to remember for any of the dentists that are listening right now is it is state by state variances of who can work under a dental license. For example, I'm in Michigan. So under Michigan law, I could have an RN or an LPN, but I couldn't have like a PA. So you just need to make sure that you're checking with your dental board and the nursing boards to make sure that you are able to have certain types of providers under your license. So just want to make sure that point is drilled home. I don't want you guys getting in trouble. Okay. So next question is, do you have any insight into the differences between dental and medical practice models? Reuben, I will start with you on this question. Yeah. No, my answer on this one, you know, I actually looking back at what I used to think about dentistry before I started working within the field, almost a little ashamed, you know, you work as a nurse and you're doing a head to toe assessment and you're focusing on all the different aspects of the patient, but you get to the mouth and you're like, Oh, don't worry about that. You talk to your dentist about that when you make your next appointment, we almost act like we can just write that off and it's not really something that we need to focus on. I think it goes to the core of what many patients do and feel is that unfortunately, incorrectly, many patients find that maybe some of the suggestions that are made in their dental office fall more in the elective category than they do in the medically necessary category that they think feels in the medical world or the medical framework. And it's important, I think, and again, it's to understand that what dentists do on a daily basis, being able to keep and maintain good oral health is vital and important to the overall systemic health of the patient. Within SLEE, it's a great way to be able to provide an avenue of treatment where a patient may have no other alternatives. And so I think it's really important to be able to see that the differences for many patients may be that the medical model or the dental model facilitate very different levels of necessity. But by being a medical professional, we can provide the patient education that Belinda was talking about to really re hone in the idea that this is a serious medical problem that just happens to have a dental solution. Thanks, Belinda. I think the biggest thing that I noticed is if you're in the dental world, changes are so small. You do a filling the same way you've done a filling, the materials change, but in the dental world, there's not a lot of change. In the medical world, changes are constant. Every day there's a new process, a new procedure, new information, new research. I'm sorry, but it's constantly changing. And so when I really kind of got into this, my dental staff was a lot more resistant because it was too much change. And it was overwhelming for them because that is not what they see in the dental world. In the medical world, change is constant, happening all the time. So that's the biggest thing. That's not something I would have any perception of. So that's a very interesting type of insight. That's actually super interesting because I think, so I guess in my life anyway, transitioning, selling my general dental practice in 2019 and transitioning to only sleep and TMD, I guess I feel like I have experienced a lot of change in the last couple of years, just making that transition. But yeah, thinking back on it, And there is a whole lot of routine that like you said, there isn't a lot of change. And I would say, oh shoot, my old timer went off on me. I would say that's really interesting perspective. So thank you for sharing that. It's definitely something for the dentist to keep in mind when dealing with their staff, when you're bringing this in, this is probably gonna be uncomfortable for your dental team because they are not used to so much new information all at once. So be gentle. I can say, I had to learn that the hard way with my team. I did have one team member that she would almost get physically ill at knowing that there was gonna be another change coming. So I did, thank goodness she was able to share that with me. And I was able to kind of understand her perspective. So, and then, from now on the way we make changes are a little bit different so that we're still getting the changes made, but in a way that doesn't overwhelm her. So I think that's really important. We talk all the time as dentists, we go to a weekend course and we learn something really cool. And while we're gone and super excited, all of our team is back home going, oh crap, here it comes, here it comes. And they know that when we come back, we're gonna be all excited and say, okay, we're gonna make all these changes. And the team is just like, oh, no, no, no, or freaking out or even worse, smiling, going, okay, sure, uh-huh. That sounds great, fantastic. And then all those thoughts and all those ideas go right out the window and then nothing changes. So it's interesting that you say that. Okay, did I ask everybody that question? No, Sarah? Okay, sorry. No, you're fine. I took your time slot. Okay, here you go. You're fine. My insights more, because I'm a freshman in this world, it's more from the patient perspective. So the dental world is a whole new environment and the exploration is completely new. So to see it from a patient standpoint, them working in it is completely reversed. So that's why it's like how Belinda says, the nursing world is forever changing. But the sad thing is, is I feel this doesn't exist much in the nursing world. Like Ruben said, from the head up, sorry, not my business. So to educate two previous colleagues and talking with past physicians and doctors I work with, it's like, they really don't know the education or the option out there, but to have them understand the importance and how this is all tied together. Dental is not just cleaning teeth. It's the, this is the start to the whole entrance of the body. So it's big to me to have that perspective on being in the chair previously, but also not really knowing the depth of outside of the chair, because it's not just cleaning teeth. Very cool. Okay, the last question here, does your understanding of a medical model, medical model, benefit you in your role? And a follow-up question to that, do you feel your perspective also benefits the dental office you are in? Sarah, I'll start with you on this one. Okay, understanding the medical model and disease process gained an insight on obstructive sleep apnea and multi-system effect in relation to like comorbidities and mortality. And it benefited the dental practice model, I feel to help them more closely align with their physician colleagues, with the understanding of it's a whole system approach. And so the treatment is just not one-sided, it's basically multifaceted. So I feel like that crossover basically, although they're very vastly different, they're also extremely similar. Great, Ruben. I think that for me, the most important benefit within using a medical model would be in many ways that what we experienced as a consumer, as a patient. You go to a patient perspective in a dental office, and before you got in the chair, you know what your insurance is gonna cover likely, you know what your treatment's gonna be, and you know more or less what your out-of-pocket expense is gonna be for the services you're about to provide. In the medical world, it's significantly different. You go into the doctor, you're gonna get the test they told you to get taped because the doctor says you're gonna take them. And you know, you'd be surprised what sometimes the bill comes about at the end. But you don't get that approach necessarily in the dental world. In the dental world, it's like, look, before you even touch me, I wanna know how much money I'm gonna be charged for this specific service. And if you're off a little too often, I might get a little upset as a patient. But in the dental world, I think it's very different than you see in the medical. Because of that, our experience and our background, I think, helps facilitate the use of patients' medical insurance and really advocating and fighting for the use of that medical insurance benefit to be able to facilitate the receipt of that device. And so where many dental staff members in the past maybe say, look, I've looked up your policy, you have coverage for X, Y, and Z, this is what it's gonna cover, and it's pretty black and white. It's a little different when you're having to do pre-authorizations, gap exceptions with insurance companies. You're trying to be able to explain to them why you don't need a, or why you can exclude the need for an opportunity or a failed attempt at CPAP before you provide them an oral appliance. And so it's really being able to advise the patient and their insurance provider of why the patient's choice in selection of an oral appliance may be prudent and why they should be able to use their benefits to be able to facilitate that. It creates a better environment overall. The dental staff continue to keep doing what they're doing and what they're comfortable doing. The medical staff within the dental office are able to facilitate and provide the type of medical necessity and documentation needed to successfully be able to utilize their benefits. And the consumer walks away with being able to get excellent care without having to pay for out-of-pocket expenses that would otherwise be covered by their medical insurance. You bring up a good point, Ruben. I think that historically when you go to the dentist to get a procedure done, but let's say it's not a cleaning, it's a filling or a crown, you're told ahead of time or you know almost ahead of time, almost down to the penny, how much it's gonna cost you. And crossing over into the medical world and the medical model of medical insurance, sometimes we might check benefits online, but it doesn't update to the minute. So if there's an outstanding claim that just hasn't posted to the insurance yet, the patient is thinking, well, it should only cost me X. And you're like, well, no, actually it's Y based on what we're seeing today. And there can sometimes be a disconnect and a little bit of a surprise. So that can definitely be a challenge at times. So that's a great point you bring up. Belinda, I'll just repeat the question again. Does your understanding of a medical model benefit you in your role? And do you feel your perspective also benefits the dental office you're in? So the medical model, every procedure has criteria that has to be met. And you understand that coming from the medical world, they don't take out your tonsils just because you want them out. There are certain criteria that has to be met. So having an understanding of what the criteria is is very helpful. And you can, as a medical personnel, you know that it's not always Dr. A that has all the answers. So it's kind of like being a detective. I have to kind of go out, research, find stuff, call multiple offices so that I can pile everything together to back up what I need for my patients. So that is a little bit different. And as a medical person, you understand that sometimes little pieces get dropped off. The patients are not the best historians. So as you kind of dig through, you find more stuff, which is totally different than the dental model. The dental model, you look, you have an X-ray, there you go, boom, bang, you're done. And it's pretty straightforward. The other component is, and the communication with the physicians, because it's coming from a dental office and the respect may not be there yet when you're starting off, if you have the medical information and you can converse with them in that intelligent level, I think it brings a whole different component to that relationship. Yeah, and you said something interesting that reminded me of early on in practice with dental sleep medicine, as dentists, well, I'm gonna do a crown prep or a filling on this tooth because I said so. There's no diagnosis code that's associated with our procedure code that we're going to do. Whereas in medicine, you have to have the diagnosis code and sometimes the awkward part is, and depending on where you practice, you may not be able to give that diagnosis code. And I think that it's in all states that dentists cannot diagnose sleep apnea. So I'm not sure if that's a controversial thing or not. I thought it was pretty well-established that we can't, but I'm not sure about that. So check with your local board if you are allowed to diagnose or not. I know in my state, you are not. So it's weird that you know what the patient needs, the patient's asking for it, but we can't bill for it because we technically don't have that diagnosis code. And so it can't just be like, well, I wanna do it because I want to, because I say so. So that is a little bit of a different perspective on things. So that's a great point you bring up. Does anyone have any follow-up comments to any of the questions that we asked? Otherwise, I'm gonna go to the Q&A. Well, I was just gonna mention, my experience with dentistry was a little different as far as the level of change that we see. I had a funny experience. You walk in one day and my general dentist, the time that we first started doing this, was still doing a lot of general dentistry. And so I'd walk in one day and he's got a blowtorch in a hand one day, and two minutes later, he's got a drill. Next minute, he's got some alginates. The next minute he's working on a CT, he's got an X-ray. And so the diversity of science and the acceptance of that technology by dentistry is something I don't really see in medicine. In medicine, we continue to use a lot of the same types of equipment and technology to provide the very specific services that we offer. As a ventilator nurse, I saw every ventilator you can imagine. And I saw over and over and over again, masks, tubing, things that are associated with that. But the diversity of technology that dentistry embraces to me is not parallel in the medical world. You don't go to a podiatrist and see all that relatively changed in the last 10 years. But cone beam images, implants, guided surgical instruments, I mean, these things are really, I think, part of everyday practice in dentistry today. But the level of technology that dentistry embraces to me, it leaves me really in awe. Because you sit there, again, as medical experts or medical staff members, and you think, well, that's just dentistry. Now, it's really fascinating to see what dentists do on a daily basis. And being able to be a part of the journey for dentists to also assist patients and being able to treat for their obstructive sleep apnea and other sleep-related disorders, I think is a privilege. It's one that I certainly look at very differently now, having seen the other side of the spectrum. I will say, kind of along with Ruben's line, because, and I'm sure Sarah would agree with this, because of the amount of education that we do with the patients, I have never been so appreciated as the patients. I mean, they're like, oh my gosh, you have spent so much time. I understand it. And that is very rewarding. And I never, I didn't really get that in my nursing career. I mean, sometimes, but for the most part, no. Different situations. Rarely, yeah. Yeah. I like the outside-of-the-box thinking in the dental world, because kind of how Ruben said, too, it's, in the nursing world, it's, you could have 10 patients present, they're all different, but it's this diagnosis, follow the stepladder. Everybody is different. And I like the outside-of-the-box thinking and the deep digging, so it's more personal and tailored to each patient in the dental world. So that's the thing that I like, is how that world is just, not saying that there's no fear in the medical, but I feel like there's a little more freedom in the dental world to explore. Absolutely. So I'd like to make a comment as well as having assistants versus having nurses. And I get asked all the time, well, why do you have an LPN on staff when you're a dentist? And I can say from perspective, and this is zero disrespect for dental assistants, it has everything to do with why you got into nursing to begin with, because you have a complete look at a person and a complete overall health of somebody as your forefront driving desire to help people. Whereas a dental assistant is really just like all about teeth and that's really cool and they like it, which there's nothing wrong with that. But when we're doing dental sleep medicine, your perspective as a nurse and your understanding of sleep apnea and all the comorbidities and different interrelations and your ability to communicate that with your patients, it is unbelievable. And it makes my job as a dentist infinitely easier because then I don't have to be the one to try and make these connections and ties all the time. You've already laid that groundwork for me so that I can walk in and really zero in on some of the more important items associated or not even zero in, just drive the message home on some of those more important items and tie them into their health history. So I can say, set my own timer on myself again. So I can say that it's really fantastic. So in the Q&A, a question about what about massage therapists for physical therapy or a physical therapist for TMJ issues following oral appliance therapy? So there's actually, that's a pretty multifaceted question. That's not just about the massage therapy or the physical therapy. You really need to kind of back up a few notches and play Columbo and figure out why that person is having TMJ issues to begin with and understanding what is that TMJ issue that they're having? Is it muscular? Is it joint? Is it both? Is it bilateral? Is it one side? That needs to get figured out first and then figuring out the cause of what is causing that TMJ issue and then making the proper treatment. So yes, I know of some offices that have a massage therapist on staff or a physical therapist on staff. Again, you want to make sure that in your state, you're allowed to have that. And then also it depends on a person's insurance. There's some people with medical insurance that will actually cover those. And then it's a question of, will that be covered under your roof because you're under now a dental license? Whereas if a physical therapist under their own entity would be able to be in network or something like that. But it totally depends on if you're in network, out of network, how you run your practice. So that's a little bit more of a loaded question. So I can say yes with an asterisk or no with a question mark. It just depends on the situation like most things. I'm not sure who asked that, but if you have any other follow-up questions regarding that, feel free to post it in the chat. The other thing would be your return on investment for those professionals. Do you have enough of those types of pieces that it would make it worthwhile and how do you determine that? Absolutely. Do you have the physical space in your office? Do you have the volume of patients that you're seeing? So it's a little bit of a loaded question there with a lot going on. I think part of the return on investment also is the potential loss of relationships that you can establish with other professionals who are already established in that industry and can not only facilitate that specific need and care off of your books, of course, to be able to provide that service to the patients, but more importantly, the ability to channel patients who they may not be able to facilitate services for or identify a treatment solution that maybe only exists in the dental world. Yeah, I can vouch the fact that I have established really good relationships with physical therapists out there and I thank God every day that I have that relationship. They're fantastic, but I also receive plenty of patients from them as well. So it for sure goes both ways. So it can be way more beneficial for me than having a PT on staff, that's for sure. Does anyone have any further questions or comments? If I'm able to comment on something that Belinda said earlier, and I think everybody listening really could benefit from what she said, and that's, we're not in a position to advocate against any therapy. It's not a CPAP bad or appliance good world. I think nurses do a great job of being able to identify the kinds of potentially anxieties or proclivity away from or towards a certain type of therapy. And so it's about being able to help match patients to the therapy that's ultimately gonna be able to return them to the best systemic health. And so sometimes that becomes a becoming a cheerleader for PAP therapy. You know, hey, let's get you over to that ENT after we did the CBCT, and we might wanna reevaluate that mask and whether or not the pressure is able to go down now after you were able to get that procedure. But that catalyst is the technology that the dentist is able to provide through something like a cone beam, and the amount of, I think, care to not exclude a potentially successful therapy for some patients, just because it's not something that we do. It's important for everybody, I think, listening to understand that the human body is as dynamic as it gets, and the answers necessary to be able to treat and solve some of these problems are just as dynamic. They don't always stay within our office. Sometimes we're trying to work on getting them to become a more effective CPAP patient, and an appliance may be a way to do that. Combination therapy may help facilitate a lower pressure setting. CBCT may help facilitate a balloon sinuplasty surgery or treatment for the patient that helps them become more tolerant of it. But we're a very pro-CPAP dental office, because whatever it takes to help treat the patient and to help return them to, again, a good night's sleep and overall health is gonna be something that I think everyone here on the panel can agree with is really has to be at the forefront of anybody's dental sleep practice. That's a great final comment there, Ruben. I think we can all nod our head in agreement to that. I know personally that's also the way we practice, and I know the Postles practice, that's their mantra as well. We're gonna wrap it up for this evening. I wanna thank our panelists for their participation. So thank you, Belinda, Sarah, and Ruben. Very much appreciate it. Appreciate your generosity in participating in tonight's webinar.

dental sleep medicine

medical personnel

patient education

collaboration

personalized care

medical knowledge

systemic impact

optimal outcomes