If you are searching for a way to increase referrals to your sleep center, consider paying a visit to your local dentist. Not in pursuit of a more dazzling smile, but to cultivate a collaborative relationship.
Enormous benefits emerge from a healthy relationship between a sleep disorders program and a dentist specializing in oral appliances (OAs) for the treatment of obstructive sleep apnea (OSA). By combining their respective skills and expertise to provide patients with highly effective and individualized treatment plans, therapeutic success is much more likely, patient satisfaction is maximized, and, ultimately, business volume is improved for both parties via appropriate cross-referrals, professional referrals, and self-referrals driven by word of mouth.
At Jupiter Medical Center Sleep Disorders Center, we have further developed this concept of collaboration by leasing space within the sleep disorders facility to a dental sleep practitioner through a time share arrangement. This allows patients diagnosed with OSA to see a sleep dentist on-site for consultation, obtaining dental impressions, fitting of appliances, and subsequent follow-up visits. In-lab OA titration polysomnograms are performed on-site by technologists trained to adjust appliances during the recording to fine-tune advancement of the appliance for maximum efficacy and minimum discomfort.
On-site consultation, communication, and collaboration of the dental and sleep center teams to educate patients, as well as review data and sleep studies, are highly beneficial to the patient seeking an effective solution for OSA. There is great synergy between sleep and dental teams that can offer comprehensive CPAP resources such as free clinics and support groups, and also fitting, titration, and adjustment of OAs, and, in some cases, implement combined or hybrid therapy.
Sleep clinicians and educators can use information about OA therapy to motivate hesitant patients to follow through with sleep apnea testing and treatment. Several years ago, I represented our sleep center at a corporate wellness fair, educating local employers’ staffs about sleep disorders and providing tips on getting a good night’s sleep. It is not unusual for patrons of these events to make clear efforts to pass by my sleep information table without stopping, even craning their heads in the opposite direction, to avoid any kind of screening tests or information on OSA.
At this event, I observed a woman who attempted not only to stealthily sneak by using a plant for cover, but also to hide her face with her hand. Then she blushed and blurted out that she was afraid of being recognized by me. I asked her why, and she said her physician had told her to have a sleep study about a year ago, concerned that she has OSA. He faxed an order for a sleep study to our sleep center. Despite her own certainty that she had OSA, she did not return any of our calls to schedule the study and had been avoiding her doctor since then. Indeed, she was hiding her face because she feared that someone from the sleep center would recognize her. We assured her that we never issue “wanted posters” for patients who don’t return our calls and asked her what was holding her back from having the test.
She related that she had no apprehension with the sleep study itself. However, she was sure the study would result in a positive diagnosis, and the inevitable result would be that she would have to wear that awful “mask thingy,” adding, “I absolutely do not want that.” Therefore, her logic was that because she absolutely does not want CPAP therapy, there is no point in having the test to diagnose OSA. I informed her that while CPAP is highly effective and not as bad as she imagined, it was not her only treatment option. After showing her an appliance and discussing OA efficacy, she scheduled testing.
Due to the dramatically expanding population of CPAP users coupled with increasing appearances of CPAP in television and other media, much larger portions of the public are at least vaguely aware of the existence of CPAP as a primary therapy for sleep apnea. A growing number of people know someone who is using CPAP. Even my son’s peer group is now familiar with it thanks to Homer Simpson’s futile struggle with his CPAP system (regrettably, Marge was inserting the hose directly into his mouth). Many carry an overall negative image of CPAP. While falsely convinced that a CPAP prescription is the inevitable outcome of a sleep study, their anti-CPAP mindset becomes a barrier to OSA assessment and treatment.
The use of dental appliances to treat obstructive sleep apnea and snoring has been around since 1982; however, in many cases dentists and sleep centers have found it challenging to collaborate. Sleep medicine physicians complain that their patients who are referred to dentists do not return for follow-up evaluation, and dentists complain that sleep physicians do not refer patients for OA therapy, particularly those who do not tolerate CPAP therapy. “The Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015,” jointly released by the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine earlier this year, provides a framework for dentists and sleep clinicians and sleep centers to work together effectively by clearly delineating roles and establishing standards.1
Neal Nay, RPSGT
In the past, many dental sleep practitioners and sleep medicine physicians found themselves more in competition rather than cooperation with each other. At our sleep center, however, we have found a potential win-win-win in working closely with area dentists to offer mandibular advancement devices to our patients. The sleep center benefits by gaining more referral sources, addition of other treatment choices for our patients, being able to offer titration studies to “fine-tune” the mandible positioning allowing optimization of OA effectiveness, and using education about the OA to eliminate the patient’s fear that the diagnosis of OSA always leads to the inevitable dispensing of CPAP. The dentist benefits by gaining referrals from the sleep center for OA candidates, particularly those patients who will not or cannot tolerate PAP therapy. The third and most significant winner in this scenario is the patient, who benefits greatly from the collaboration of experts to find the most effective customized treatment plan.
Neal Nay, RPSGT, RST, is manager of Jupiter Medical Center Sleep Disorders Center in Jupiter, Fla.
Reference
1. Ramar K, Dort LC, Katz SG, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015;11(7):773–827.
Thanks for publishing this! I wish we could all work together more with the overall health of the patient at the forefront, and Dr. Ken Mogell (the dentist who is the “dentist on site”) praises this collaborative model to us, his dental sleep medicine colleagues.
Mr. Neil Nay,
Looks very interesting. Where can I get more info on management of the pt by the dds and the financial arrangements eg rent of space based on days used;who purchases supplies; who bills for tx? Any other info that would be helpful in discussing with interested groups.
Neal Nay wrote a great article and is correct in many ways, but as the CEO of a sleep medicine company comprised of Independent Diagnostic Testing Facilities (IDTFs), I must make you aware of the risk with this type of arrangement. Hospital based sleep labs like Jupiter Medical Center and IDTFs have different guidelines as far as sharing/leasing space to other providers. IDTFs are strictly prohibited from having two different Medicare providers in the same office. This is a serious offense which could lead to serious consequences from Medicare. Whether you are a Hospital based sleep lab or an IDTF, you should always seek the advice of a certified regulatory healthcare attorney before entering into any kind of relationship with another Medicare provider. Just because others are doing it doesn’t make it legal. Again, great article Neal. You are lucky to be working with such a knowledgeable dentist for your oral appliances. Keep up the good work.