Dental Sleep Medicine in Restorative Practice Part 9: Marketing Dental Sleep Medicine 

By Todd Sander DDS 

How do you start reaching out to physicians and other providers to build a dental sleep medicine practice? Start with the ones you know. Start with your own personal physician and start a conversation. If your dental patient is on CPAP, get permission to converse with their doctor. I spend time contacting many primary care doctors and find they are the ones who know patients are non-compliant with their CPAP therapy. They help me get patients re-evaluated by a sleep specialist. 

This may not be true in your community, but in Charleston, SC, where I practice, many primary care doctors don’t know what to do with their non-compliant CPAP patients. They are thrilled to have someone to refer them to try alternative therapy. 

Years ago, I reached out to sleep testing centers to communicate my services. Both independent sleep labs and hospital-based sleep labs have been great sources of referrals. For many years, I was the dental advisor to a sleep lab. A great conversation starter with sleep physicians, is the potential of combining CPAP and an oral appliance. This often allows the CPAP air pressure to be turned down so their patients be more comfortable and compliant. 

When you screen your dental patients for airway issues such as sleep apnea and snoring, the next step is referring your patients with issues for a sleep study. When the patient discusses their symptoms with their primary care physician or a sleep physician, you are mentioned and often documented as making the referral. Over time, physicians come to know you as a go-to provider of dental sleep appliance therapy. This process is sped up when you take the time and initiative to contact your patient’s primary care physician with your patient’s permission. You can guide physicians and remind them of the recommended standards-of-care, including appliance therapy in place of or in combination with CPAP therapy. 

Some patients self-refer to me, as friends and family talk about their experiences in my office, but I am not spending money on digital advertising to bring in dental sleep medicine patients. Mostly, they are referred to me by physicians, dentists, and other patients.  This is the same for my dental practice. 

As mentioned in a previous part of this series, our hygienists have attended dental sleep medicine courses with me and screen for airway issues. They adeptly educate and guide patients who have signs and symptoms to schedule an examination and consultation with me. 

Note: When patients are referred to me for dental sleep medicine, I never encourage them to become dental patients in our practice. This is a choice they might make but I am extremely careful to refer patients referred by a dentist back to their referring dentist for all dental needs. I am an adjunct to help other dentists’ patients fulfill a prescription for a dental appliance. 

If a patient comes in for sleep-disordered breathing but is also experiencing facial pain or TMD, I understand that this patient’s two issues are likely connected and I will not be able to successfully treat one without treating the other. This is an opportunity to communicate in depth with the referring dentists and let them know I plan to treat the patient for both issues simultaneously. This has been easier for me to do because I have had years of experience in treating facial pain and TMD issues in my dental practice, as well as sleep apnea and snoring. 

Dental Sleep Medicine in Restorative Practice Part 7: Team Investment 

By Todd Sander DMD 

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

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

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

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

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

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

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

By Todd Sander DMD 

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

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

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

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

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

Dental Sleep Medicine in Restorative Practice Part 5: Selecting Appliances 

By Todd Sander DMD 

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

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

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

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

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

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

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

Dental Sleep Medicine in Restorative Practice Part 4: Treatment Monitoring 

By Todd Sander DMD 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.

I heard about the new Inspire sleep apnea device over a year ago. If you have not heard of “Inspire” yet, be on the lookout. TV commercials are everywhere.

What is Inspire? It’s an implantable device that helps treat sleep apnea. Much like a pacemaker, a surgeon implants a little control device with some electronic leads to manage neural inputs to the muscles around the airway in order to help hold the airway open.

After the device is implanted, the patient presses a button on a smart device app to turn it on and off. It’s as simple as pressing the button when they are ready to go to sleep and pressing it again when they wake up. There is no need to wear a CPAP or oral appliance.

Over a year ago, when I first learned about Inspire, I mentioned it to a patient who had already had orthognathic surgery, had tried CPAP, and was still struggling with his quality of life while dealing with OSA. He was tired of having a dry mouth and increased risk of caries. We had already had several conversations.

At a subsequent appointment, he shared with me that he was extremely grateful we had had that conversation about Inspire. It motivated him to talk to his primary care physician and look at having the device.

He also shared with me that this treatment was covered by Medicare and then his gap insurance. Why did they cover it? Interestingly, it was not because he was CPAP intolerant or he had failed—because he was regularly wearing his CPAP. They covered it because he was suffering dental decay, dry mouth, and other secondary issues due to the CPAP.

I think we’re going to hear about this device more from our patients, and there will be times when we think it is in our patient’s best interest to start a conversation about it. If you are not familiar with Inspire, I recommend that you hop on the Internet and learn more about it.

Interested in Learning More About Dental Sleep?

Course: Creating Healthier Patients & Practices: Integrative Dental Medicine
Date: August 11 – 12, 2023
Location: The Pankey Insititute | 1 Crandon Blvd Key Biscayne, FL 33149
Register: Click Here

Most people who seek help for a sleep breathing disorder like snoring or sleep apnea are diagnosed by a sleep doctor and given a pressure mask, or CPAP. Millions of these are sold every year. For World Sleep Day 2021, Phillips, one of the two biggest CPAP manufacturers, surveyed 13,000 people in 13 countries around the world. Of the people who were prescribed CPAP, only 18% of them were using it. Of the people who were at risk, 27% said they would not take a sleep test because they did not want a CPAP.

It gets worse. The US Agency for Healthcare Research and Quality released a draft report about the use of CPAP for obstructive sleep apnea that concludes there is low evidence that CPAP has any long-term positive health effects. Any such report is debatable, but it is clear that CPAP is not the universal therapy that cures everyone some physicians believe it is.

The reasons people won’t use the simple device that helps them feel better during the day and, as far as they’ve been told, helps them live longer, healthier lives are as varied as any group of people can be. Common reasons they tell me include:

• I can’t stand anything on my face.
• The mask moves around and blows air into my eyes.
• I swallow air.
• It leaves marks on my face. (More of a problem when people actually went to work!)
• My spouse hates it.
• I want to travel, camp, RV, boat, etc., and it’s too inconvenient.

It is a wonderful time to be a dentist involved in airway therapy – providing good solutions to manage and resolve your patient’s sleep breathing problems. Oral appliances are better accepted by patients in every head-to-head study that has ever been done. While many people go to bed with their CPAP on, by morning, it’s off. Oral appliances are still in their mouths. Research points out that many hours of therapy is better than fewer hours of it, so the health effects are the same.

How do you talk with your patients about their therapy? It isn’t productive to bash CPAP – believe me, they’ll do that themselves. I tell people I love CPAP – when it is used, it’s great. CPAP is the treatment of choice for my father and brother. As you scan through your patient population with questions about sleep and breathing (you are using a screener, right?) you will find plenty of folks who want a CPAP alternative.

If you want to be a provider of oral appliance therapy, there is much to learn. The device portion is straightforward, but there are medical concerns, TMJ joint issues, finance, and office systems to sort out. The challenge is well worth the effort, of course. Dr. Pankey always puts rewards at the center of the philosophy. Nothing I’ve done in dentistry is more rewarding than helping people breathe.

Not every dentist will foray into providing dental sleep medicine but becoming well informed and adding airway conversations to your consultations will impact the lives of many. If you would like to dive deeper and develop your knowledge about dental sleep medicine and learn about the realities of introducing it into your practice, I recommend the Pankey Institute’s 5-day immersive Dental Sleep Medicine course.