VIVOS THERAPEUTICS,

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Transcript : Vivos Therapeutics, Inc., Q4 2021 Earnings Call, Mar 31, 2022

31/03/2022 | 23:00

Presentation Operator Message
Operator (Operator)

Good day, everyone, and welcome to the Vivos Therapeutics Fourth Quarter and Full Year 2021 Earnings Conference Call. [Operator Instructions]

I will now hand the call over to Julie Gannon, Vivos' Investor Relations Officer for introductions and the reading of the safe harbor statement. Please go ahead.

Presenter Speech
Julie Gannon (Executives)

Thank you, operator. Hello, everyone, and welcome to the Vivos Therapeutics Fourth Quarter and Full Year 2021 Earnings Conference Call. A copy of our earnings press release is available on the Investor Relations section of our website at www.vivos.com.

With us on today's call are Kirk Huntsman, Vivos' Chairman and Chief Executive Officer; and Brad Amman, Chief Financial Officer. Today, we'll review the highlights and financial results for the fourth quarter and full year 2021, as well as more recent developments. Following these more formal remarks, we will be prepared to answer your questions.

I would also like to remind everyone that today's call will contain certain forward-looking statements from our management made within the meaning of Section 27A of the Securities Act of 1933 as amended and Section 21E of the Securities and Exchange Act of 1934 as amended, concerning future events. Words such as aim, may, could, should, project, expect, intend, plan, believe, anticipates, hopes, estimates and variations of such words and similar expressions are intended to identify forward-looking statements.

These statements involve known and unknown risks that are based upon a number of assumptions and estimates, which are inherently subject to significant uncertainties and contingencies, many of which are beyond the company's control. Actual results, including results of Vivos' growth strategies, operational plans, future potential results of operations or operating metrics and other matters to be addressed by Vivos management in this conference call may differ materially from those expressed or implied by such forward-looking statements.

Factors that could cause actual results to differ materially include, but are not limited to, the risk factors described and other disclosures contained in Vivos filing with the Securities and Exchange Commission including our 2021 10-K, which was filed today and is accessible on the Investor Relations section of the Vivos website. Except to the extent required by law, Vivos assumes no obligation to update statements as circumstances change.

Now at this time, it is my pleasure to introduce Kirk Huntsman, Chairman and CEO of Vivos. Kirk, please go ahead.

Presenter Speech
R. Huntsman (Executives)

Thanks, Julie. And thank you, everyone, for joining us today on our fourth quarter and full year 2021 earnings conference call, which follows our first full year as a public company. I'm excited to review our results and provide you with an update on our progress. Afterwards, our Chief Financial Officer, Brad Amman, will review the highlights of our fourth quarter and full year financial results. Following that, we'll be happy to take your questions.

Both the fourth quarter and full 2021 marked periods of continuing market penetration and growth for Vivos. In the fourth quarter, we generated strong year-over-year revenue growth of 33%. And for the full year, we grew revenue by 29%. We were particularly pleased by this performance in sales growth given that it came about despite significant headwinds throughout our core customer base, mostly driven by COVID-19 variant resurgences in the middle and latter part of the year.

In December 2021, the American Dental Association reported that just 60% of dental practices were open and operating with business as usual. Another industry source reported that 92% of dental practices were struggling to hire or replace hygienists and 77% recorded difficulty hiring front desk positions.

These operational challenges across the dental community have a direct impact on both enrollments of dentists in our VIP program and patient case starts, as replacement dental personnel must be trained and the Vivos Method reintegrated into practice routines.

Regardless of such headwinds, throughout 2021, we continued to successfully execute on our 3 key performance metrics of: One, new VIP dentist enrollments; two, total Home Sleep Tests or HSTs performed; and three, new case starts.

In addition, during 2021, we also saw significant advancements in our regulatory status as well as ongoing research and publication efforts that we believe greatly strengthen and enhance our competitive position in the market. As for new VIP enrollments, during 2021, we continued our outreach efforts to independent dentists while launching our DSO program for large corporate dental groups and accelerating our penetration into the medical arena.

During the year 2021, we recognized $8.5 million of VIP enrollment revenue compared with $7.5 million in 2020 and enrolled 197 independent dentists as new Vivos Integrated Providers or VIPs compared to 248 during 2020.

The decrease in enrollments was due to COVID-19 variant resurgences during the last half of the year, but we did recognize VIP subscription revenue from prior periods. Also, we saw an 82% increase in prospective new VIPs attending our informational and sales events in the fourth versus the third quarter of 2021.

Our fourth quarter numbers for new prospects was positively impacted by our third annual Breathing Wellness Conference in October, attended by over 300 dentists, 147 of which were new prospects and the remainder were existing VIPs. Attendance at such company-sponsored events tends to be a leading indicator for future VIP enrollments. As is always the case with our marketing programs, we now have to turn those VIP prospects into paying customers.

Also in the fourth quarter, we officially launched our latest marketing and sales initiative into the rapidly growing U.S. and Canadian market for DSOs or Dental Support Organizations. As we have indicated on prior calls, we believe DSOs represent the single largest opportunity for Vivos to more rapidly scale and achieve broad market penetration for our products and services. Today, I am pleased to report that our Vivos sleep management program for DSOs has been extremely well received and demand has exceeded our forecast.

Throughout our extensive DSO marketing efforts to date, we have not encountered a single DSO that has successfully rolled out a sleep management program across their provider network despite lucrative top line and EBITDA growth potential.

Many DSOs have told us they recognize sleep and breathing treatment as the next frontier in dentistry but haven't known how to execute on a successful model. The barriers to entry most often cited by DSOs include the need for specialized doctor and staff training, difficulties in medical doctor collaboration, navigating medical insurance reimbursement requirements, and sleep apnea patient workflows that can vary markedly from dentistry.

Leveraging our experience with our VIP program, we believe our Vivos sleep management program for DSOs elegantly and effectively solves every one of those barriers, opening the door to an entirely new and highly accretive revenue and profit opportunity for DSOs. It is no surprise, therefore, that in the fourth quarter, we successfully initiated pilot trials for our Vivos sleep program involving multiple DSO practices.

We also furthered our active contract discussions for additional pilots with several DSO groups, representing close to an estimated $3 billion in total annual dental revenue derived from over 1,800 locations. Our DSO market penetration in the U.S. and Canada continues to accelerate as we move into 2022.

Our other dentist enrollment program, which we refer to as the Airway Alliance Program, was also established in the fourth quarter and launched here in the first quarter of 2022. This program is designed to attract the vast majority of the estimated 200,000 U.S. and Canadian dentists who are being strongly encouraged by the American Dental Association to screen their patients for sleep apnea and yet -- and don't yet know how.

The Airway Alliance Program gives these dentists a simple, yet profitable way to screen their patients for OSA using our Vivos Score program featuring the SleepImage ring Home Sleep Test and then refer them to fully trained local Vivos dentists for treatment.

As for our second key performance metric, total Home Sleep Tests or HSTs performed, we recently announced an 18x increase in the total number of average monthly tests being performed in the fourth quarter of 2021 versus the same period in 2020. This growth represented a change from under 300 tests per month across our network to over 5,000 tests per month. We also reported a 5.7x increase in the number of VIPs administering home sleep test and a 3x increase in the average number of home sleep tests being administered per VIP. We also continue to see approximately 1 out of every 2 patients testing positive for OSA.

We are very pleased by these dramatic performance gains in Home Sleep Testing as we believe diagnosis is essential in helping those suffering from OSA to get proper treatment. Also, these HST results allowed us to renegotiate our commercial agreement with SleepImage to lower costs and convert the entire diagnostic program from a loss leader into a potential recurring revenue center as we have shifted to leasing the SleepImage test rings to our dentists.

We expect our new pricing arrangement with SleepImage will yield positive financial results for Vivos in 2022 and beyond. Our primary focus now is helping Vivos-trained providers and their staffs convert those patients into treatment with the Vivos Method.

Maximizing new case starts is the third key performance metric that I referenced earlier. During 2021, we saw solid growth in case starts as we sold 40% more oral appliance arches during the year than we did in 2020. Also in the fourth quarter, we formally rolled out the systems and procedures for patients to readily and conveniently obtain their requisite medical diagnoses from the independent medical providers at Empower Sleep who are fully licensed in over 40 states. Empower Sleep reports that they expect to be fully licensed in all 50 states by the end of the second quarter of this year.

Having this relationship in place and working seamlessly with our VivoScore program using SleepImage technology is an essential step to increasing case acceptance and reimbursement from payers.

We executed on this essential program by conducting regionalized training events around the country. Through December of 2021, we successfully conducted 15 such trainings, which were attended by nearly 800 dentists and staff personnel from Vivos VIP offices throughout the U.S. and Canada. The primary objective in pushing to maximize Home Sleep Tests is, of course, getting as many patients as possible to become aware of their sleep apnea and to seek treatment from a qualified and trained Vivos provider.

Having made progress on our initial go-to-market objective of establishing a nationwide network of Vivos trained providers, in the latter part of 2021, we turned our marketing focus towards consumers. This effort involved a multifaceted digital marketing strategy, including digital advertising, social media initiatives as well as an overhaul of our website, which is now found at a new URL, vivos.com.

As part of that effort, we worked closely with our strategic marketing company, Stage Marketing, to produce over 150 new videos and start over 350 new content creation projects, which led to a fourth quarter growth of 92% in website traffic compared to the third quarter as well as a consistently branded customer journey.

We also saw our Facebook fan engagement ratios come in at an impressive 11.54% versus just 12.1 -- excuse me, versus just 7.12% and for a much larger direct competitor in the sleep apnea space. On Instagram, our engagement rate was 2.74%, which is just over 6x the 0.44% engagement rate for that same company during the same period. We began running Google Ads in February 2022 and are seeing double the industry average benchmark in lead conversions. This strong positive reaction to the Vivos Method by consumers is expected to grow as we build awareness through digital and other media channels.

During 2021, we further accelerated our exposure and penetration into the broader medical community through the formation of our Interdisciplinary Medical Advisory Board, formerly known as the Medical Consortium, co-chaired by Drs. Clete Kushida of Stanford and Cecilia Wu of Alberta, Canada, along with the appointment of internationally renowned cardiologists, Dr. Mimi Guarneri as our Medical Director of Clinical Education.

The medical doctors who serve as advisers to Vivos in these various capacities see and treat patients with sleep apnea every day in their clinics. Some of these doctors are actual Vivos patients themselves or have had family members who have gone through Vivos Method treatment.

These prominent physicians have seen our data and experienced clinical results from Vivos therapy firsthand. As a result, they have enthusiastically joined our mission to urgently get this message out to their medical colleagues.

One of the Medical Advisory Board's main directives is to strengthen Vivos' scientific foundation. So the evidence underlying Vivos technology will be robust enough to be widely accepted and adopted by physicians worldwide. New clinical data guiding physician awareness and practice is disseminated via 2 major avenues, highly ranked medical journals and medical conferences. Vivos is making great strides in both of these areas.

During 2021, we published multiple papers demonstrating and confirming various aspects of our technology and expect to see even more published studies and papers highlighting our technology during 2022. Production of high-quality manuscripts highlighting important clinical data are already in the works. For example, a study of 220 patients who underwent Vivos Method therapy has already been finalized and submitted to a highly ranked medical journal.

More recently, at the World Sleep Congress in Rome on March 14, Vivos presented a data set compiled in the fall of 2021 showing that Vivos Method treatment -- the Vivos treatment method modality is competitively effective at treating OSA at all severity levels and regardless of body mass index. This conference was attended by over 4,500 professionals in sleep and the presentation was very well received.

Members of our Medical Advisory Board will be presenting again on behalf of the company at SLEEP 2022, the Annual Sleep Conference of the American Academy of Sleep Medicine, which has over 11,000 members, to be held in June in Charlotte, North Carolina. There, they will present evidence showing that the Vivos Method significantly expands the maxilla or upper jaw and the airway.

At the same conference, Vivos technology will be discussed during a symposium during -- focusing on new and emerging technologies that will shape the future of sleep medicine. In the European Sleep Research Society to be held in Greece, in September, Vivos technology will be discussed at another symposium highlighting dental medical collaborative models for the diagnosis and treatment of obstructive sleep apnea.

As we move into 2022, Vivos will have, for the first time, a strong presence at all 3 major world sleep conferences and we expect this trend will continue into the foreseeable future.

Vivos technology has been reported by many patients to alleviate their headaches. We recently conducted a retrospective clinical study of 120 patients with headaches. The results in reducing headaches were statistically significant and another manuscript documenting those results is currently being produced for publication. The medical and clinical advisory boards are also performing -- or forming additional partnerships with large health organizations and forging future clinical trials. Details will be forthcoming as further developments occur throughout the year.

Meanwhile, in our 2021 Medical Integration Division -- meanwhile, in 2021, our Medical Integration Division launched 2 Pneusomnia clinics owned by medical doctors with local Vivos-trained dentists delivering the Vivos Method of treatment. As interest within the medical community continues to build, another 6 to 8 such projects are in the queue for opening in 2022.

These first few clinic start-ups have taken longer than expected, but this physician-backed initiative has been instrumental in legitimizing the interdisciplinary collaboration that can occur between the dental and medical communities on the effectiveness of the Vivos Method.

We believe that our 2021 growth is due at least in part to the success of each of these actions listed above. Our strong revenue growth in 2021 also indicates or includes new revenue streams that we either didn't possess in the prior year or that were still in their early stages of rollout. These revenues were derived from new products and services that are outside of our core VIP enrollment revenue and appliances and were just introduced in 2021.

This includes revenue from the value-added services we offer our VIPs and their patients, as well as management revenue from our Medical Integration Division, including Billing Intelligence Services and MyoCorrect myofunctional therapy.

Growing our revenue from these important ancillary streams remains a top priority for us in 2022, even as we continue to grow revenue from our core business of VIP enrollment and appliance sales. In addition to our solid revenue results, I'm pleased to report that for the fourth quarter and full year 2021, we -- as of December 31, 2021, approximately 25,000 total patients have been treated with the Vivos Method compared to 15,000 at the end of 2020. And as of December 31, 2021, we have trained over 1,450 dentists globally in the use and application of the Vivos Method, providing our VIPs with training and other related value-added services compared to 1,250 at the end of 2020.

We are very pleased with these operating and financial results, which speak to the growth we have achieved just this past year. Brad will review our financial highlights with you in more detail later in this call.

Aside from our strong financial and operating metrics, Vivos has also accomplished a number of key business milestones since our 2020 IPO. During the fourth quarter, we formed a strategic collaboration with Candid Care, a company that provides consumers and dentists with the latest invisible aligner technology for straightening teeth through a digital platform at a much lower price than the leading brand.

Candid recently announced that they were closing down their direct-to-consumer retail efforts in order to focus entirely on their CandidPro product and provider model, which is very much aligned with our model here at Vivos. In short, Candid is actively marketing to and recruiting the very same type of dentists as Vivos. And thus, we see the collaboration between Vivos and Candid to continue to evolve and grow as we move forward.

Through this relationship, our 2 companies will be sharing provider and DSO contacts, referrals, educational resources, training, and key opinion leaders to bridge the gap between airway health and orthodontic therapy. We are excited to be working with Candid and believe our combined strengths will enable us to offer a seamless solution for patients suffering from OSA.

On the intellectual property and regulatory fronts, we accomplished 3 important items in Q4. First, we filed 2 patents to ensure protection on device enhancements and developments. Secondly, we completed our official registration of Vivos products with Health Canada, a Minister Health Department responsible for helping Canadians maintain and improve their health through services and resources. Even prior to this, we have received high demand from Canadian dentists for our products and clinical protocols.

With this Health Canada registration, approximately 25,000 Canadian dentists now have complete access to Vivos products and services. These local dentists can now screen, clinically assess and properly treat patients suffering from OSA through complete and official access to the Vivos Method. We are very happy to deliver our much-needed products to millions of Canadians suffering from OSA and its related comorbidities.

In connection with this development, we expect to expand our contract manufacturing presence and capacity in Canada to better serve the needs of Canadian dentists and their patients. And finally, we achieved another regulatory milestone closer to year-end when we received acceptance from a Centers for Medicare and Medicaid Services Pricing, Data Analysis and Coding or PDAC contractor for our mmRNA oral advice. This acceptance places the mmRNA device on the PDAC list of oral appliances covered by and billable to Medicare.

This is an extremely positive development for Vivos, which makes benefits of this device available to millions of Medicare beneficiaries who seek effective treatment for mild to moderate OSA. The mmRNA is the first and only appliance on the PDAC list that offers patients the clinical advantages of Vivos' proprietary technology.

We are very happy about this and look forward to delivering our life-changing therapeutic technology to the millions of OSA sufferers in the U.S. who are either on Medicare or have commercial medical insurance coverage that follows Medicare guidelines.

Our progress did not stop at year-end. We have continued to realize several key catalysts in 2022 that we believe will help drive our continued growth. Adding to this, later in January, we filed a U.S. patent application for proprietary new and enhanced clinical protocols and methods developed within our Vivos Method for treatment of OSA.

This new patent application was based on early field data, which revealed an additional 58% average improvement in Apnea Hypopnea Index or AHI score reductions in OSA patients who had received treatment with Vivos Method where the revised clinical protocols were implemented. We believe this patent, if granted, will increase the scope of Vivos patent portfolio and demonstrates our commitment to delivering innovative technology in our mission to rid the world of obstructive sleep apnea.

These are all important achievements that we believe will leave us well positioned for the future. Complementing these milestones, Vivos has continued engaging in activities designed to increase our recognition with relevant audiences to help drive our future growth. These activities include forging key contacts and relationships with the U.S. Department of Defense, the U.S. Department of Transportation and the Veterans Administration, as well as large corporations with tens of thousands of transportation workers who need to be screened and treated for breathing and sleep disorders.

Recently, we announced a rebranding of Vivos proprietary offering of clinical treatment devices, modalities and protocols now called the Vivos Method to better capture the multiple ways in which Vivos can help independent dentists treat their patients. We believe this rebrand makes it clearer and easier for providers and patients to understand our offerings and the manner in which each can contribute to addressing dental facial and airway abnormalities in a relatable and more approachable way and to feel secure and proactively stay -- asking their dentists or medical providers about the Vivos Method.

As part of this process, and as previously noted, we recently launched an updated corporate website at www.vivos.com where medical professionals and patients can find information about OSA and its corresponding symptoms, testimonials from Vivos-trained dentists and their patients about their personal journeys and success stories and opportunities for Vivos partnerships, FAQs and much more.

In addition to simplifying information for patients, the new Vivos site also provides guidance to prospective dentists on becoming one of our VIPs. This turnkey program enables dentists to elevate patient services and care while also increasing the growth potential for practice revenue and income. This is just another example of the steps we are taking to increase our name recognition in the dental and medical communities as well as to drive VIP enrollments.

In summary, both the fourth quarter and full year 2021 were exciting periods for Vivos. We made substantial progress in all facets of our business, which drove strong year-over-year growth -- revenue growth driven by increased VIP enrollments and appliance sales as well as newer revenue streams. The company also achieved a number of significant milestones to position itself for further growth in 2022.

Considering all that we have achieved since our IPO in December of 2020, we are very excited about our future prospects. Complementing our progress to date, we will continue to expand our sales and marketing efforts, including enhanced social media marketing outreach to engage more directly with consumers, medical providers and large employers.

Also just yesterday, I attended the annual ADSO DSO Conference in Austin, Texas. And we expect to attend other DSO conferences later this year where we will be on stage presenting for the first time a comprehensive DSO program for all DSOs in the United States and Canada.

By continuing to increase awareness of our products and services, we remain confident this will drive further adoption of the Vivos Method, which in turn should generate increased VIP enrollment and appliance revenues in 2022 and beyond.

This concludes my opening remarks. Now I'll pass the call over to Brad who will review our financial results. Brad?

Presenter Speech
Bradford Amman (Executives)

Thank you, Kirk, and good afternoon, everyone. Today, I'll review our fourth quarter and full year 2021 financial results.

We reported total revenue of $4.4 million for the fourth quarter of 2021, a 33% increase compared to $3.3 million for the fourth quarter of 2020. This increase was mainly due to increased revenue from VIP enrollments, appliance sales due to volume increases, management fees from our Medical Integration Division or MID program, Billing Intelligence Service, subscriptions and additional revenue sources not present in 2020, including our MyoCorrect orofacial myofunctional therapy or OMT services and sponsorship revenue.

Fourth quarter 2021 revenue growth was partially impacted by lower VIP enrollment due in part to this COVID-19 Delta and Omicron variant resurgences. However, VIP enrollment revenue was actually up year-over-year due to recognition of revenue from prior periods.

During the fourth quarter, we enrolled 35 VIPs net of cancellations and recognized revenue of approximately $2.1 million compared to 54 VIPs and revenue of approximately $1.7 million during the same period last year.

During the 3 months ended December 31, 2021, we sold 2,707 total oral appliance arches for revenue of approximately $1.5 million, an increase from the 3 months ended December 31, 2020, where we sold 2,525 total oral appliance arches for a revenue of approximately $1.3 million. The increase in appliance revenue is due to volume increases.

For the full year 2021, revenue increased 29% to $16.9 million compared to $13.1 million for the full year 2020. This increase was attributable to the same factors I just mentioned.

During the 12 months ended December 31, 2021, we enrolled 197 VIPs net of cancellations for revenue of approximately $8.5 million, a 13% revenue increase compared to 248 VIPs and revenue of $7.5 million for 2020. The roughly 13% revenue increase was primarily driven by higher average price per enrollment, higher enrollments that took place in June, August and September, of which 50% of the enrollment fees were recognized during the year ended December 31, 2020, and revenue recognized from higher prior period enrollments.

VIP enrollment revenue is recognized 50% in the second month of enrollment and the remaining 50% pro rata throughout the following 11 months of the service contract. We evaluate each contract separately for applicable factors and meeting the definition of a contract under ASC Topic 606.

Additionally, our Billing Intelligence Service revenue increased $900,000 for the year ended December 31, 2020, up 46% compared to approximately $600,000 for year the ended December 31, 2021.

During the year ended December 31, 2021, we sold 11,355 total oral appliance arches for revenue of approximately $6 million, a 33% increase in product revenue and a 40% increase in appliance shipped from a year earlier and during the year ended December 30, 2020 when we sold 8,135 total oral appliance arches for revenue of approximately $4.5 million. Again, the increase in appliance revenue is due to volume increases.

Gross profit was $3.1 million for the fourth quarter of 2021 and $12.6 million for the full year 2021 compared to gross profit of $2.7 million and $10.4 million for the comparable periods in 2020, respectively. Gross margin for the fourth quarter was 71% compared to 81% during last year's fourth quarter, reflecting higher costs associated with VIP enrollments, which included home sleep testing rings. Gross margin for the year ended December 31, 2021 was 75% compared to 80% for the year ended December 31, 2020.

We are continuing to refine our sales, marketing and promotional efforts with potential VIPs in an effort not only to drive revenue, but to maintain our gross profit and margins. This includes our expanded social media marketing outreach that Kirk mentioned earlier.

Sales and marketing expense increased approximately $0.5 million to $1.3 million for the fourth quarter of 2021 compared to $800,000 for the fourth quarter of 2020. The increase was primarily due to new marketing campaigns, updating marketing materials for investors and consumers, improving the Vivos website and promotion of conferences and events taking place in 2021, such as the grand opening of The Vivos Institute in Denver.

Sales and marketing expense increased by approximately $3.2 million to $5.6 million for the year ended December 31, 2021, compared to $2.3 million for the year ended December 31, 2020. The increase was primarily due to the factors described earlier in the 3-month period.

General and administrative expenses were approximately $9 million for the fourth quarter of 2021 and approximately $26.7 million for the year ended December 31, 2021, compared to $4.9 million and $16.1 million for the 3 and 12-month periods ended December 31, 2020, respectively.

The year-over-year increase was primarily due to higher headcount and expenses related to support our sales growth, the impairment of a note related to the 2019 sale of our company-owned dental clinic in Utah, as well as our status as a public company, which started in late 2020.

Additionally, these increased expenses are related to higher revenues from our core business as well as revenue from new products and services offered in 2021, including our SleepImage HST diagnostic product, MyoCorrect therapy services, management fee revenue from our Medical Integration Division and sponsorship revenue, which accounted for approximately 9% of our fourth quarter 2021 revenue.

We continue to deploy capital to support our sales and marketing efforts as well as general and administrative expenses. We consider these strategic investments to support our future growth and have already seen these investments start proving and providing us returns in the form of strong revenue growth as demonstrated by our fourth quarter results. We continue to believe these initiatives will enhance our long-term growth potential.

Net loss was approximately $7.4 million for the fourth quarter of 2021 compared to $6.2 million for the fourth quarter of 2020. Year-over-year increase was primarily due to higher G&A and sales and marketing expense due to the factors I just discussed. Net loss for the year ended December 31, 2021, was $20.3 million compared to approximately $12.1 million for the year ended December 31, 2020.

Turning to our balance sheet at December 31, 2021, our cash and cash equivalents were approximately $24 million compared to cash and cash equivalents of approximately $18.2 million a year ago at December 31, 2020. With proceeds from our 2020 IPO and the follow-on offering we completed in the second quarter of 2021, we anticipate having sufficient financial resources to meet our capital requirements, fund our operations and continuing to execute on our growth strategy for the foreseeable future.

In conclusion, we made significant progress in 2021, which enabled us to generate strong year-over-year revenue growth, both for the quarter and for the full year 2021. This was driven by increased appliance sales and further VIP enrollments.

Our sales growth continues to be fueled by the strategic sales and marketing activities, including the deployment of the SleepImage Home Sleep Test rings that Kirk spoke about earlier. Also, fourth quarter revenue showed an increasing contribution from newer revenue streams outside our core appliance and VIP business, including products and service we introduced in 2021, such as MyoCorrect, the Medical Integration Division, and value-added services such as Billing Intelligence Services.

As we look forward to 2022, we expect the current sales momentum in our core business to continue as we refine our model and as more members of both the dental and medical communities see the benefit of the Vivos Method as a treatment for OSA. At the same time, we remain focused on exploring additional revenue streams to enhance our growth prospects.

We are very proud of what we have already achieved and look forward to providing you with further updates on our continued -- in our continued progress.

That concludes our prepared remarks. Now I would like to turn the call over for questions. Operator, please go ahead.

Question and Answer Operator Message
Operator (Operator)

[Operator Instructions] We'll take our first question from Alex Nowak with Craig-Hallum Capital.

Question
Unknown Analyst (Analysts)

This is [ Chase ] on for Alex. First for me, given the revamped SleepImage sales strategy, did it contribute in any sales in Q4? And how do you expect this to trend over the next several quarters?

Answer
R. Huntsman (Executives)

Great question. So we did not see any revenue recognition from sales of the SleepImage product in Q4. That was the time when we were transitioning the program over from what was essentially a loss leader to a profit center for us. And so it's here in the first quarter and really going into the second quarter of the year that we'll start to see some revenue contributions. And we'll have to explore just to what extent those revenue contributions are as we see how the rollout goes.

Question
Unknown Analyst (Analysts)

That's helpful. And second, could you expand at all on the revamping of the marketing initiative to not only gain more VIPs, but also more arches from those VIPs that you already have signed on?

Answer
R. Huntsman (Executives)

Yes. So we have seen -- over the course of time, especially throughout COVID, we've seen providers coming on and dropping off in terms of their production for implementing sleep in their practices. There have been a lot of distractions for dentists as they've wrestled with practice closures and loss of staff, et cetera.

So we have been out there actively in the market, retraining new staff personnel, getting systems reinstalled back in their offices, helping them to navigate these things. And we're seeing quite a great degree of reception to that, and we're seeing a great uptick from new purchases, new case starts from these doctors who had been either -- their production had fallen off or they had sort of lost their way a little bit.

So we're continuing to devote a considerable amount of our resources to reactivating or encouraging doctors to continue to grow their sleep business and their practices. And we're having some very, very encouraging success with that.

Question
Unknown Analyst (Analysts)

That's helpful color. And then that 220-patient study you mentioned, sounds exciting. Any other specific publications we should be watching for in the near to midterm here?

Answer
R. Huntsman (Executives)

Yes. I think you'll see -- in the next little while, you'll see some announcements from us with respect to important studies that have been ongoing and we'll have announcements coming out about that. But we're very, very excited about what we're seeing on the research and development front.

Question
Unknown Analyst (Analysts)

Sounds great. And then considering the departure of your CMO, any updates there you can provide on the search for replacement?

Answer
R. Huntsman (Executives)

No. At this point in time, Dr. Singh had already somewhat scaled back his time and efforts here because of his sabbatical. And so we had previously taken steps to allocate responsibilities and various aspects of what he was doing to other personnel within the organization or contract personnel that we hired.

So we feel like we're well positioned to navigate that, and we are in discussions with a number of potential replacements. We aren't yet prepared to make any announcements about that. But we're evaluating a number of different candidates at the moment.

Question
Unknown Analyst (Analysts)

And then just lastly for me, just a little housekeeping for Brad. But could you provide us the specific share count for the end of Q4? Not the full fiscal year, but I might have missed that in the release, but that would be helpful.

Answer
Bradford Amman (Executives)

We had 23 million shares outstanding at the end of the year.

Question and Answer Operator Message
Operator (Operator)

And that does conclude today's question-and-answer session. I'd like to turn the conference back over to management for any additional or closing remarks.

Answer
R. Huntsman (Executives)

I would like to thank everyone for joining us on today's call and for your continued interest in Vivos. I hope that throughout this call, you've been able to sense the optimism that we have here for this company and its prospects as we move headlong into 2022.

I don't think we've ever felt better about where we are in the stream of things and the potential that lies before us. So we are very excited about what's happening. We're very excited about what the future holds. And we appreciate each and every one of our shareholders and investors for supporting us and for all that you do.

I'd also like to extend a thank you to our amazing Board of Directors for the guidance and direction that they provide this company. They've done an absolutely amazing job of leading this company and doing the things that are necessary to position us for what lies ahead. So I want to express our -- on behalf of all of the management here, our appreciation for the active role that our Board of Directors is playing in our future.

And also that extends as well to our medical and clinical advisory boards and all the good work that's being done out there on behalf of this company. We really truly wouldn't be able to do what we do without them. So appreciate everyone and their contributions here, and we look forward to having more positive results to report in the future. Thank you very much. Have a great day, and we'll see you again soon.

Question and Answer Operator Message
Operator (Operator)

Thank you. And that does conclude today's conference. We thank you all for your participation. You may now disconnect.

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