Across the country, dentists are finding motivation and pathways for helping people with sleep apnea uncover they have the sleep disorder and locate therapies to which they will adhere.
By Karen Schotanus
At ADA 2017 – America’s Dental Meeting, the American Dental Association’s House of Delegates passed a resolution emphasizing the role of all dentists in screening for sleep-disordered breathing, as well as noting that dentists are the only healthcare providers with the knowledge and expertise to provide oral appliance therapy.
But questions remain about how best to begin conversations with patients, how to bill for services, and how far to take dental sleep while continuing to manage a dental practice focused on other types of services.
Five dentists who have embraced differing roles in dental sleep medicine explain their choices.
Meghna Dassani, DMD (Texas)
When Meghna Dassani, DMD, purchased her general dental practice a decade ago, she did it with the intention of integrating dental sleep.
Seven years prior, her father-in-law died from sleep apnea. What’s more, the sleep disorder is the suspected cause of premature death of many other men in her husband’s family. “My family is in India, and back home, we didn’t have the options that we now have,” she says. “I wanted to make sure our family didn’t suffer from this again. I wanted to see what we could do. That’s truly how I got into dental sleep medicine: asking what can we do and how can we help.”
Dassani Dentistry, based in Houston, Texas, is about 40% dental sleep now. She credits her success thus far to having a motivated, supportive team.
The team is trained to have conversations with patients and look for symptoms in health histories. Because a team member will typically ask the open-ended question “How are you sleeping?,” the chat often finds evidence not only of the patient’s own sleep disturbances but also those caused by a snoring or gasping spouse or child. (In those cases, the team member advises the patient to encourage the family member to make an appointment either with the dental practice or with another healthcare practitioner of their choice for a consultation.)
To screen adult patients, the practice employs the STOP-Bang and Epworth Sleepiness Scale; for children, the practices uses the OSA-18 Quality of Life Survey.
Dassani also looks clinically to connect the dots between dental issues and other health maladies in her patients. She views working with sleep physicians as “building a team focused on the patient.” She says, “If I can send information that the doctor needs—that is going to be helpful—hopefully the patient is one step closer to getting what they truly need.”
Many general dentistry practices run into challenges when it comes to billing for dental sleep medicine. Dassani too has found medical billing to be a more complicated, lengthier process than dental billing. Her practice has a team member dedicated to that process, as well as many protocols in place to keep it as streamlined as possible. Dassani advises that organization and structure are the keys to handling medical billing in-house. “One you have those in place, it really comes down to having systems,” she says.
Her advice for dentists considering dental sleep medicine is simply this: get started. “As dentists, we wait to gather every single piece of information we can get to be able to do something. But with sleep, it could be just start having conversations with your patients,” she says. “Once you get in, you realize how many people need your help.”
Darren Ramsey, DDS (North Carolina)
Patient screening, along with the general public’s increased awareness of sleep disorders, has helped to build the dental sleep services at Darren Ramsey’s cosmetic dental practice in Charlotte, NC.
“We screen every patient when they come in,” says Ramsey, DDS, who includes a basic sleep questionnaire with the regular intake forms at the cosmetic dentistry-focused practice. Sometimes the questionnaire itself spurs a sleep-focused conversation. And for patients whose questionnaires indicate potential sleep apnea, a clinical team member will proceed to an oral and/or physical screening for additional symptoms. “The questionnaire really helps us get to the point and then we screen after that,” he says.
For patients who then need a sleep study, Ramsey’s team works with a sleep study group and stays in contact with the physician throughout the process.
Many of Build a Smile’s patients have already been diagnosed with sleep apnea but are nonadherent with CPAP. “That’s what really shocked me. I didn’t know there were that many people who were noncompliant with their CPAP,” Ramsey says. The high number of those neglecting treatment motivated him to want to help them more.
His practice is now about 30% dental sleep and 70% cosmetic dentistry. In addition to their own marketing and awareness efforts, Ramsey teamed up with several physicians from a local health system for referrals. He simply reached out to the physicians and got a “great” response.
Ramsey uses a third-party billing company to manage the medical billing and insurance aspects of the dental sleep services to save time and streamline the process. The practice’s office manager handles getting all of the information to the third-party billing company. “It’s a complicated thing to do on your own, and it’s a lot of work,” he says.
Continuing education courses have been helpful to Ramsey, but even more relevant has been what he has learned from others in the industry. “For me, what was most helpful was talking with other dentists,” Ramsey says. He credits representatives at oral appliance maker Oventus Medical with introducing him to several dental sleep medicine practitioners. Ramsey visited their offices and now has a network of dentists he can reach out to for professional advice.
For other dentists considering dental sleep, Ramsey encourages them to screen their patients and inform people previously diagnosed but nonadherent to CPAP that they may be able to try an alternative therapy.
Jay Ohmes, DDS (Missouri)
Jay Ohmes, DDS, runs a full-service dentistry practice in Dardenne Prairie, Mo, that includes orthodontics. “As a solo practitioner, I maintain about 10% to 15% of my practice in dental sleep medicine,” Ohmes says.
At Advanced Dentistry of Saint Charles, Ohmes had treated temporomandibular disorders in adults and oral development issues in children for several years. As awareness of obstructive sleep apnea (OSA) increased, recurring oral signs and symptoms in these patient populations became linked to airway complications. “This discovery got me more involved in assisting sleep physicians with their OSA patients,” he says.
Ohmes’ team uses patient questionnaires and educational posters for presenting sleep disorder information to their patients. Also, hygienists are educated on recognizing oral clues that could signal OSA. They use the Epworth Sleepiness Scale as a screener.
For external referrals, his practice reached out to sleep physicians, pulmonologists, and otolaryngologists in the area. “Most importantly, we built a strong network by maintaining frequent communication with these specialists during the process of fitting, adjusting, and evaluating the success of the patient’s oral sleep appliance,” he says.
Ohmes has found that education is important to physician referrals. “Pursue your sleep medicine education to the level of obtaining a Diplomate certification in order to present a degree of knowledge that appeals to sleep specialists in your area,” Ohmes says. He recommends the American Academy of Dental Sleep Medicine (AADSM) annual conferences, as well as courses by the American Sleep and Breathing Academy.
Bringing dental sleep medicine into the practice and helping people with their overall health has been satisfying for Ohmes. But he recognizes dental sleep medicine can also be time consuming and labor intensive—especially dealing with medical insurance. Ohmes has a dedicated employee to assist with clinical treatments such as appliance fabrication and adjustment. He advises other dentists to consider creating a separate clinic or area of practice to treat sleep apnea patients.
After a bad experience with a medical billing service when he first started treating OSA patients, Ohmes added an employee to handle the medical billing and insurance in-house. But he cautions that in-house billing can be a double-edged sword, noting the administrative time can limit the number of patients who can be seen.
Chad Witkow, DDS (Michigan)
Chad Witkow, DDS, had been practicing general dentistry for nearly 13 years before he became involved in dental sleep. His interest in sleep medicine began in 2015 with a video that his wife took of him while he slept.
Watching the video, Witkow saw himself stop breathing and gasp for air. Even though he suspected he had a sleeping problem, the video was a revelation. “You can say it’s a surprise, but at the same time, it was more of an explanation,” he says.
After that, Witkow decided to explore dental sleep medicine. He began taking continuing education courses and reached out to a dental sleep acquaintance to ask if the fellow dentist could help him make a device to treat his sleep apnea.
Witkow experienced immediate improvement with the oral appliance. But with the feeling of relief also came a feeling of responsibility. “I thought, ‘Wait a minute, now I know something and it’s time to help others,’” he says.
He teamed up with Mark Williamson, DDS, who had been working toward building a sleep practice (and who has earned the AADSM Qualified Dentist designation), to learn from him and build Michigan Dental Sleep Center Inc, which shares a building with Witkow’s general practice Clio Family Dentistry.
Witkow is in the beginning stages of how he would like the sleep practice to run, and he currently sees sleep patients two days per week. “My goal is to treat sleep full time. I have an awesome general dentistry partner and we are right in the middle of figuring out what our plan is for the next year,” he says.
While Witkow’s general dentistry practice screens for sleep apnea, most of the dental sleep patients come from physician referrals. “We work closely with a couple of sleep physicians and ENTs,” says Witkow, who began offering education to physicians in 2017 through lunch and learns.
All members of Witkow’s team have been through dental sleep training from OSA University so they have awareness and knowledge, but the practices stay separate. “It is two separate jobs,” Witkow says. He says otherwise dental teams will be spread too thin.
Because of the challenges of medical billing, Witkow recommends using a third-party billing company, which can help dentists get started while providing an opportunity to train. His practice uses Pristine Medical Billing.
Witkow advises dentists to make sure they have a good reason to get involved with sleep medicine, noting it’s much more than just another service. “It’s hard to dabble in this,” he says.
Meena Goel, DDS (Illinois)
Meena Goel, DDS, has been practicing dentistry for 20 years, but it was her daughter, now 14, who led her into dental sleep medicine. When her daughter was 6 years old, she began experiencing snoring and grinding issues. Goel took her to an orthodontic colleague, who discovered her daughter’s obstructive sleep apnea. “When I saw the airway scan, I was absolutely shocked,” Goel says. “As a mother and a dentist, I was not aware of my child’s sleep-disordered breathing.” Goel then decided to educate herself and others about these conditions.
When Goel was starting in dental sleep medicine, she’d dedicate one hour per day, five days a week, to reading up on the subject. After educating herself and her staff, she began integrating dental sleep into her practice, Avid Dental Lindenhurst, in Illinois. She recommends Rondeau Seminars, by Brock Rondeau, DDS, DABDSM, who has been teaching in orthodontic, orthopedic, temporomandibular joint (TMJ), and snoring and sleep apnea for the past 30 years. Goel also recommends dentists first learn about orthodontics before dental sleep to build a foundation in airway-centric treatments.
Avid Dental Lindenhurst is primarily a general dentistry practice (about 60% to 70% of the services) but also offers orthodontics (about 30%) and temporomandibular joint (TMJ) treatments; dental sleep medicine currently comprises slightly under 10% of the business. There is a team of two dedicated to TMJ and orthodontics, and two more for sleep. Until recently, Goel felt she was becoming a “master multitasker”—before realizing she was actually spreading herself too thin. Her advice to other dentists is: Don’t try to cross-train. She is now building out Avid Dental Sleep Medicine, which will be a separate business entity attached to the current dental office. By the year 2023, “the goal is to have space, time, and my attention to be 100% dedicated to dental sleep medicine,” she says. Goel plans to hire additional associate dentists to help with the general dentistry services.
Goel advises dentists who are interested in sleep medicine to get trained, educate their patients, and aspire to reach Diplomate status. The program offered by Pedro Cuartas, DDS, with Dental Sleep Services was particularly helpful to Goel and her team. “Dedicate yourself to the highest level of education to make a statement that dentists can do this,” she says.
She has seen a shift in how the general public views dentists as more comprehensive healthcare professionals. Goel says dentists have a responsibility to evaluate for sleep disorders, and when the intention is focused on patient health, it’s not difficult to relate signs and symptoms presented by oral health to sleep disorders. “Your teeth definitely are telling a story; it’s time to listen,” Goel says.
Karen Schotanus is a Kansas City, Kansas-based communications professional with more than a decade of writing and editing experience. This is her first article for Sleep Review.