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.

When I speak with dentists who have dipped their toe in the waters of treating obstructive sleep apnea (OSA) in their practice, the number one reason they say they quit doing it or are not doing more is …

“I couldn’t get paid!”

You may be committed to helping patients achieve better health through treatment of OSA, but it’s challenging to make it financially possible. Here are three tips that will make dental billing for obstructive sleep apnea more consistent and predictable:

Use Practice Management Software to Simplify Dental Insurance

Understanding how to succeed in the complicated system of medical billing is a game-changer.

We have all figured out how to streamline our approach to making sense of dental insurance, but the rules are different for Dental Sleep Medicine (DSM). You should use a segment-specific software platform (DS3, NiermanDentalWriter, or other) for your SOAP notes and communication with physicians and payers.

These platforms ensure that you include the right notes, tests, patient status, and history to get paid. DSM and medical reimbursement are under the jurisdiction of rigid documentation of processes, protocols, and standard practices. Choosing the most effective DSM practice management software is the first step to payment because it will not let you forget to harness critical information.

Make It Easy for Patients to Say Yes to Treatment

My second piece of advice is the most difficult to implement because it requires a change in behavior. Talk less about co-payments, deductibles, and the patient’s responsibility than you may be used to in dentistry when dealing with obstructive sleep apnea.

As an example, consider this: When you visit your doctor and they suggest an x-ray, draw blood, or order a specific test, do you usually say, “How much will that cost?” No, you don’t. We know that tests and medical treatment recommended by our physician are necessary and not usually optional to achieve optimal health.

Plus, we know that their treatments will be covered by our medical insurance (after the deductible and with certain co-payments). As dentists, we are expected to have significant upfront financial discussions about how much the patient will have to pay out of pocket because of the different nature of dental insurance.

Unfortunately, this same approach when applied to a sleep apnea appointment may backfire. Treatment of sleep disorders can be life-changing, so it’s beneficial to the patient if you focus less on dollars and more on care outcomes.

When we get detailed about the financial arrangement, upfront copayments, and deductible discussion, patients think we are still treating them as a dentist, not as a medical care provider. Make it easy for patients to say yes by leaving out the money talk. Many will have good coverage and can make the treatment a possibility.

Outsource the Details to a Competent Billing Company

Hire a billing company to do the dirty work. Third-party billing companies (Four Pillar, Nierman, Pristine, Dedicated Sleep, GoGo, Brady) typically charge a small per claim fee around $50 and 8-12% of the paid amount. This fee is worth every penny.

I have seen far too many revolutions from the administrative teams in dental practices when they were forced to try to figure out the weird, ever-changing rules of insurance reimbursement.

Billing companies are experts. Plus, the cost as a percentage of sales works for medical practices, so why shouldn’t it for dentistry?

Treating patients for OSA with Oral Appliance Therapy (OAT) is easier clinically and technically than making bite splints in centric relation. And yet the minefield is littered with the remains of dental teams who tried to do the billing themselves.

If you only did one case per month, subscribed to a cloud software solution, paid a billing company their fair share, and risked not talking so much about money, you would still help patients get healthier, feel very fulfilled, and make more money than you are now.

That success can breed more success. You just might add $100,000 to your annual revenue! Curious how you can start incorporating treatment of sleep apnea into your practice workflow?

I’ll be holding a live, three-hour virtual course, “Treating Sleep Apnea In Your Practice With Oral Appliance Therapy,” on Friday, May 21st, 2021. Registration for my course is easy at Pankey Online.

Join me from 2 pm to 5 pm EST to learn more about the medical background of sleep conditions, marketing sleep appliance therapy, and more in-depth techniques I implement to transform medical billing.

Can’t wait to see you there!

Sign up for free at Pankey Online to access complementary and paid CE-granting webinars spanning hot dental topics like sleep apnea treatment, equilibration, and indirect bonded anterior restorations. 50+ cutting-edge courses at your fingertips …

In 2017 the American Dental Association adopted a policy encouraging dentists to screen patients for sleep-related breathing disorders (SRBD). This includes assessing a patient’s risk for SRBD as part of a comprehensive medical and dental history and referring affected patients to a physician as appropriate. When this happened, I called my friend Dr. Steve Carstensen, who is at the forefront of sleep dentistry and asked him what we should implement in our dental practice. One of the tools he suggested is a quick and easy visual assessment called a Mallampati score.

The Mallampati score is one of four things we now do in my practice as a four-part sleep screening. (In Dr. Kelly Brummet’s recent PankeyGram article, she wrote about what this score determines and how she uses it in her practice, so you will want to go back and read that article as well this one.)

We have laminated copies of the Mallampati visualization chart (see below), which we printed from the Internet. We used these for visual reference in both of my operatories and the hygienist’s operatory. To make a visual assessment of the back of the patient’s mouth, say to the patient, “Open wide.” You don’t depress the tongue. The patient doesn’t say “aah.” The patient just opens wide. Then you look to see which of the four Mallampati images most closely matches what you see and give the patient a 1 through 4 score based on the image.

This is just a simple way to see if we think anatomically the patient can move air past the base of the tongue. My hygienist and I do this in conjunction with the STOP BANG questionnaire, Epworth Sleepiness Scale and asking about nose breathing.

Screening our patients for airway and breathing issues is becoming a standard in dentistry. One of the things we have started to do every day in our Hygiene rooms, with our patients from three years old to very elderly, is visually looking at the back of their mouth and assign a Mallampati score.

The Mallampati score was developed by anaesthesiologist Seshagiri Mallampati, in 1985, as a non-invasive way to assess the ease of endotracheal intubation. The test is simply a visual assessment of the distance between the base of the tongue and the roof of the mouth.

In our practice, we begin a conversation about airway with patients. The Mallampati diagram (see below) allows both us and our patient to visualize, on a score of 1 to 4, the patient’s anatomical airway. We laminated the Mallampati diagram off of Google Images, and we can give it to the patient to hold while we screen them, or we share it with them after screening to let them see why they received the score they did. We then continue the conversation with them about their airway and why it might be a good idea for them to observe sleep patterns or be referred to a sleep physician for further diagnosis.

We are bombarded weekly with ads for this or that course in “airway management” or “how to make money treating sleep apnea.” And, we are dealing with airway management every day whether we like it or not.  

Who has not had a patient come in with a worn dentition who claims, “Doc, I can’t ever remember grinding my teeth.” How about the patient who keeps fracturing restorations and says the same thing? You might want to question these folks or their partners about sleep habits. It is very likely you will find they are members of the population with some form of sleep-disordered breathing.  

Do you remember why we learned to fabricate and adjust bite splints?  

Have you had parents ask you about what it means when they can hear their young child grinding his or her teeth at night? Childhood bruxing is almost always a symptom of some sort of airway issue. What is happening in a child who presents with proclined incisors and an anterior tongue position? Do you think putting the child in headgear is going to solve the underlying reason the tongue has to be forward so they can breathe? 

We don’t have to treat all these issues, but we certainly should be able to communicate with our specialists and medical community for appropriate diagnosis and treatment of underlying issues that have a direct impact on the success or failure of our restorative care. 

The American Sleep Apnea Association estimates that 22 million Americans suffer from sleep apnea. Since we see our patient base, on average, two times a year, it makes sense that we should be doing at least a basic screening for sleep-disordered breathing. This can be anything from mild snoring to serious sleep apnea.  

Basic diagnostics would include paying attention to a person’s body mass index, neck size, asking whether they snore, and providing the Epworth sleepiness scale as part of your standard health history. Be aware that some folks with the worst sleep apnea or narcolepsy are not overweight. These are often the very fit appearing folks who are serious bruxers. 

If you really want to get involved in treating these people, you need to get more education.

Either at The Pankey Institute or somewhere that has a multi–day course. You need to commit to going into the process deeply, as there is much to learn and treatment is not simple. You will quickly learn that unless you develop great systems and team members, it is not an easy way to make money. However, you will be truly saving lives. 

If that does not sound right for you, commit to being a good diagnostician and develop an excellent referral network with some ENT doctors in your area. Most of these doctors are looking desperately for a dental colleague with whom they can discuss cases and develop treatments beyond just the use of CPAP. If you can refer just one child for early treatment each year and help prevent a heart attack or stroke for a person with undiagnosed sleep apnea, you will have done great service whether you get involved in active treatment or not. 

(more…)

Sleep issues and sleep apnea is a very serious concern today for our patients’ health. I have been giving patients an Epworth sleepiness self-assessment for several years. It is a great way to find out if patients should pursue their sleep with a physician and inquire about having a sleep study.

Another incredible indicator of apnea is if someone else hears you stop breathing. Of course, there are challenges with this approach. First, there has to be someone near you when you sleep to hear what is happening. Second, someone has to be awake in order to listen and watch while you are sleeping. Third, someone has to interpret what is happening. I recommend the SnoreLab app that records and evaluates the sounds made while sleeping. It can even show you graphs of what was happening. Not only is this a great self-learning tool, but the recordings can be taken to the doctor as part of the information to determine if a sleep study is indicated. The product is available on the web and through the App Store.

Several of my patients have used the SnoreLab app and had follow-up studies in a sleep lab. Within my Glendale, AZ practice, I have a Dental Sleep Medicine practice and treat patients with sleep apnea appliances.

To serve patients to the best of their ability, I recommend general dentists learn how to competently develop a Sleep Dental Medicine niche within their practice. I can honestly and wholeheartedly say that The Pankey Institute’s 5-day immersion Dental Sleep Medicine course is one of the best programs in the nation. It is uniquely designed to give dentists the experience of being a sleep apnea patient themselves.

You are accustomed to consulting with patients about the association of TMD with craniofacial pain, but the link to sleep disorders should now be on your radar. Your patients want to know that you can help them sort out whether their frequently occurring headaches are the result of TMD, obstructive sleep apnea (OSA), a combination of the two, and/or other comorbidities.

Because research evidence suggests up to 50% of individuals suffering from morning headaches have OSA, every dentist likely has some sufferers they can detect, educate, diagnose, and refer or treat. If you are not already an expert in Dental Sleep Medicine, The Pankey Institute’s immersive Dental Sleep Medicine course is one of the best in the country.

A preclinical interview that includes questions about headaches will get you started with a co-discovery diagnosis for OSA related headaches and set you and your patient on the path for the most appropriate diagnostic testing and treatment.