In Part 1 of this series, Dr. Todd Sander discussed their introduction to oral appliances for treating sleep disorders, highlighted alternatives to CPAP therapy, and his unique journey into dental sleep medicine integration.

Whether my new patient is coming to me for dentistry or dental sleep medicine, my initial examination is 90 minutes, preceded by 30 minutes with my clinical assistants to review their medical-dental histories, including the patient’s polysomnogram or home sleep test results; take digital or analog impressions; take radiographs or CBCT; and take photos and videos of the patient.

In my practice, I try to see dental sleep patients on Tuesday and Thursday afternoons. When an existing sleep medicine patient calls and is having an issue, we try to direct them to a block on a Tuesday or Thursday that is interchangeable with a restorative appointment. I prefer restorative procedures to be scheduled in the mornings and see emergencies and comprehensive new patients in the afternoons. I do not like to have other patients after I do a comprehensive exam with a new patient.

I have empowered my team to slide dental sleep medicine patients into our restorative schedule. Giving my team permission to do that and guiding them to understand that I want to provide both services was important. Otherwise, restorative dentistry would have filled my schedule and prevented me from working with sleep patients.

If an existing dental patient becomes a dental sleep medicine patient, I do a comprehensive sleep medicine exam, which is more like a medical exam. When my dental patients ask me if I’ll “just” make an appliance for them, I stick to my guns and explain that the documentation is different. I explain that we have now entered the world of medicine, and we cannot cut corners just because they have been a dental patient within the practice. So, on Tuesday and Thursday afternoons, I know I will likely have a new patient that’s a comprehensive dental patient or a dental sleep medicine patient.

We never want to tell a dental sleep medicine patient they will have to wait weeks to see me, so we might free up time on other days if slots are not filling up. This includes patients who are already within our dental practice. Many of our dental patients are referred for a dental sleep exam out of our hygiene department. Our hygienists are on board, looking at airways and helping guide patients who will benefit from OSA therapy. Part of your dental practice might be identifying airway issues as patients come through hygiene.

Scheduling may sound simple, but there is no easy button. Many of our colleagues who try to do dental sleep medicine become discouraged as they try to “fit this in” and treat it as just another appliance. So, I caution you. If you start working with dental sleep medicine patients, much more goes into the effort than delivering a simple dental appliance. It is the practice of medicine. The language and documentation that are required are medical in nature, and there is a lot to consider in treating and monitoring the patient, which I will discuss in future parts of this series.

I’m sure there are many aspects of your work that are really fulfilling, and I’m sure there are aspects of your daily work that you wish could be easier, maybe even less stressful. What about your work brings you joy? What would it take for you to provide your best work? What would it look like? What would it feel like?

I took an informal survey of dentists and hygienists about what they would need to have an ideal day. When I examined the dentists’ answers, I realized the answers would resonate with every member of a dental team.

The top five answers from dentists were:

1. Having the appropriate instruments to provide excellent care.
2. Opportunity to gain knowledge and skills.
3. Excellent performance/execution of their work.
4. Opportunity to implement new learning.
5. Working with patients who are grateful for their care.

All hygienists desired “time to provide appropriate care for each patient.” Specifically, they asked for:

1. Time to select and sharpen instruments for each person and for the specific procedures they will be doing.
2. Time to properly assess each person’s unique periodontal condition, including time to accurately measure gum pockets and recession, minimal attachment/thickness, and to assess bleeding (blood thickness, how much bleeding, and where it is coming from—is it systemic or localized?).
3. Time to explore possibilities with patients regarding their current condition, past condition, and potential future.
4. Time to debrief and collaborate with the doctor to explore the next steps for the patient.
5. Supportive teamwork across the practice to provide the best care.

Speaking of collaborating with team members, I invite you to ask your team members what their ideal day would include. Discuss, as a team, your shared ideals, and expectations. Consider where expectations do not match and discuss why this is and what must change to meet shared agreements.

Understanding and affirming the needs of others will have a positive impact. The exercise of writing down what works, what could be better, possibilities, goals, and a pathway towards implementation of superior supportive teamwork is likely to increase your practice joy factor.

In recent years, dentists, physicians, and the public have become highly aware of the interrelationships among occlusion, oral inflammation, airway problems, and systemic health. As dentists, we’ve stretched our care domain to coordinate patient care across all settings of care. Often, we are dismayed at the growing prevalence of chronic diseases among our aging patients. We want to help improve their lives. We know of ways to do this.

To do our best for our patients, it does matter if the patient has diabetes, cardiovascular disease, sleep apnea, gastric reflux, or poor nutrition. It does matter if we want to be master problem solvers in collaboration with our medical colleagues. Looking for oral and systemic health interrelationships every day with every patient is a basic element of many dental practices. Collaboration with physicians is a basic element of my practice.

Has your approach to patient care extended into at least the first phase of integrative dental medicine? This is the phase of sincerely asking the Why questions and searching for solutions. While I was in practice with Dr. Pete Dawson, for 40 years, I heard him say, “We’re going to ask why about problems until we don’t have to ask why anymore.” He called this “finding a better way.”

The 3 Pillars of Integrative Dental Medicine

In 2019, Dr. Shanley Lestini and I published a book titled The Shift: The Dramatic Movement Toward Health Centered Dentistry. In this endeavor, we were fortunate to have the support and input of two of the world’s most preeminent clinicians and educators, Dr. Peter E. Dawson and Dr. Bradly Bale. It was our goal to influence dentists and medical physicians toward fostering solutions together for their mutual patients in three pillar areas of integrative dental medicine:

1. TMD and Occlusion
2. Inflammation & Infection
3. Breathing and Sleep Disorders

Finding a Better Way Is Up to All of Us

My goal in this essay is to fuel your passion for operationalizing what we all know will make us better doctors – that which will enable us to be truly health-centered dentists. It comes down to relentless curiosity about the causes of diseases, the modalities for eliminating those causes, and how our best “individualized” efforts with a patient will have the greatest positive impact on the prevention, elimination, and management of health conditions that adversely affect their quality of life.

“We’re going to ask why about problems until we don’t have to ask why anymore.” – Peter E. Dawson, DDS

In this era of heightened awareness surrounding the intricate connections between oral health, overall wellness, and the growing prevalence of chronic diseases, we, as healthcare providers, find ourselves at a crossroads. It is our commitment to improve the lives of our patients that propels us forward. Embracing the principles of Integrative Dental Medicine (IDM) beckons us to explore the “Why” questions and seek innovative solutions. Don’t miss your chance to embark on a journey that redefines the boundaries of healthcare with the upcoming course “Integrative Dental Medicine: Creating Healthier Patients & Practices” – for more information visit the course page.

Team members can become a bit tunnel-visioned. Their day-to-day work life and CE are focused on topics related to their niched responsibilities, which puts them on an island of their own. One of my hopes is that all my team members — including hygienists, dental assistants, and administrative team members — will learn about all we do in our dental practices.

Faculty meetings at The Pankey Institute always invigorate my thinking about the Institute’s curriculum and the teaching I do with my own team members. Freshly energized by the last faculty meeting, I am writing my thoughts to hopefully inspire the many of you who are not faculty but, like us, have enthusiasm for leading your teams to a broad and deep understanding of the dentistry you practice.

In my own office, one of the things I look for in hiring is team members who are interested in learning, interested in dentistry and are even passionate about dentistry. They want to know as much about it as they possibly can. And one of the things I pay attention to is providing opportunities for them to learn about the many aspects of dentistry.

For example, I want my hygiene team to understand what happens in the restorative operatory. They don’t often get to see me working with a patient because they are busy with their own patients. But when they see a beautiful veneer case that we’ve done, I would love for them to have some background in the considerations and decisions that went into that treatment…the knowledge, the technique, the materials, and even the patient’s experience during treatment.

When hygienists see our patients, they may think something could appear better, for example, a crown margin. It helps them put what they are seeing in perspective if they have some understanding of the techniques, materials, and complexity. And I want to know the questions and concerns that occur in their minds as they do their hygiene exams. I also want them to understand the dentistry we offer in our practice so they can better answer questions and advocate for a treatment plan that hasn’t moved forward.

I want them to take CE that elevates their hygiene skills. I also want them to be fully integrated into our team and understand everything that happens in our office, so we can all work collaboratively to create more effective outcomes for our patients.

Accomplishing this requires that we set aside time and take advantage of open time. In my office, I regularly review a variety of cases with my clinical team before, during, and after treatment. This involves more than meetings in my consultation room. Sometimes, it involves chairside observation and conversations. Most of my patients are eager learners who appreciate the chairside teaching that I do with my team members. They are simultaneously learning and coming to a greater understanding of their dentistry.

I often hear that dentists return to their practices after a Pankey Institute continuum course or seminar with the inspiration to share what they learned with their teams—the enthusiasm for learning spills over naturally in the week following the dentist’s CE. Take advantage of that energy at that moment, and while you are excited make a commitment to continue sharing your knowledge on a regular basis, interesting case by interesting case.

In your dental practice, it’s important to create a restorative partnership with your assistants, hygienists & front office team. Make the handoff between your team seamless, build a stronger team & create lasting patient connections. Check out our three Pankey Team Courses that are coming up: Team Series.

Early in my career, I was introduced to oral appliances for treating OSA. While I was doing my residency in the Army, we saw patients with sleep disorders who couldn’t pass their flight physicals. Pilots were desperate for an alternative to CPAP because CPAP would ground them. Today, in my adult restorative practice, it’s clear that many patients benefit from an integrated approach to their oral health care and OSA therapy.

I started my private practice in Charleston, SC, in 2005. I was working with occlusal disorder and facial pain patients and several of them were non-compliant CPAP patients. One day, I was thumbing through my mail and noticed Dr. Henry Gremillion would be speaking at the Hinman Meeting on the connection between bruxism and sleep apnea. After hearing his presentation and reading the recommended literature, I thought sleep-disordered breathing may be at the root of many of my patients’ parafunction, evidenced by their persistent symptoms and the wear on their occlusal appliances. And it was this same population of patients who needed significant reconstructive restorative dentistry.

At the time, the American Academy of Dental Sleep Medicine was the only place where dental sleep medicine courses were available. So, I started with its introductory courses. It was clear that integrating dental sleep medicine into my practice protocols and educating my team and patients would take deliberate effort. There were questions I would have to address:

• How much time would I need to invest in training for myself and my team?
• How should I work sleep patients into my schedule?
• Which of the 32 FDA-approved appliances should I use? (Now, there are several hundred to choose from.)
• Should I invest in special software?
• Which medical providers could I work with, and how?
• How would I manage referrals?

My partner advised me to develop a vision and framework for my practice that would allow me to guide my team and focus my energies. I knew I would not be able to compete with others who were treating only sleep apnea patients. I decided that developing relationships with my patients would be as important for sleep dentistry as it is for restorative dentistry. And because I would also be dedicated to restorative dentistry, I would need to efficiently use my time to develop a niche practice in both restorative dentistry and dental sleep medicine.

With intentional forethought, my team learned how to screen interested patients and prequalify them for a comprehensive dental sleep medicine examination and consultation. I developed key people on my team to answer questions, gather the necessary information, and do preliminary work with incoming new sleep medicine patients. This preliminary work is much the same as that done by dental assistants in a restorative practice…reviewing the patient’s medical and dental history and taking digital impressions and X-rays.

When a comprehensive restorative patient comes to my practice, I do a 90-minute co-discovery examination, including sleep apnea screening. Then I take time in my lab doing diagnostic work with mounted models and plan treatment based on the radiographs, photographs, and other records we took during the comprehensive exam. The patient then returns for a consultation. If it is a complex restorative case, I spend time going over the treatment options, answering the patient’s questions, and developing my relationship with the patient. At this point, the patient is often ready to select treatment, and we move ahead with dental treatments. If the patient has the signs and symptoms of OSA, time is spent discussing the oral and systemic health benefits of having a sleep study and prescribed therapy. I refer my patient to sleep specialists I have developed a relationship with and know will provide a thorough evaluation. These specialists continue the OSA conversation and order a polysomnogram (sleep study) if deemed appropriate.

When a patient is referred to me by a physician to provide an oral appliance to replace CPAP or to be used in combination with CPAP, my comprehensive examination is a little different—with adaptations for medical documentation, but it is still 90 minutes. I have found that dental sleep medicine patients referred for sleep apnea treatment can usually be processed through their examination and treatment consultation in a single two-hour appointment. How I schedule my patients and the protocols I use will be discussed in future parts of this series.

We use the words “multilayer” and “multilayered” to describe lots of different materials from different manufacturers. If your lab tells you they use multilayered zirconia on a restoration or abutment, do you know what you are getting?

One of the ways we use the word multilayered is to describe a puck of zirconia that has two different types of zirconia.

Some of the pucks are a layer of 3y (the strongest but least aesthetic zirconia) with a layer of 5y (the weakest but most aesthetic zirconia). The laboratory technician puts the restoration design in the puck so that the 5y is on the facial of the restoration where you can see it and the 3y is on the incisal edge and lingual.

There are also pucks that are 4y zirconia layered with 5y zirconia. The 4y zirconia is a middle grade of both strength and aesthetics. In this case, the 5y is on the facial and the 4y is on the incisal edge and lingual.

Thus, there are two different ways to mix strength and aesthetics in one puck of zirconia and both variations are called “multi-layered.”

Complicating this even more, we use “multi-layered” to describe layers of chroma gradient or translucency. The laboratory technician can put the design pattern in the puck to achieve different gradient effects, but the restoration is all of one strength (one type of zirconia).

One of the challenges today with zirconia is that there is no place on a laboratory prescription to specify one of these varieties, and it needs to be clarified when communicating with your lab technician. Ask what your lab technician means by “multilayered zirconia,” and communicate clearly the multilayering you want used.