Every dental practice has an abundance of patients who can benefit from dental sleep medicine. Finding and successfully treating them takes commitment and persistence by the entire team, but it’s well worth the effort. Here’s how one practice does it.
Maybe you’ve read about dental sleep medicine (DSM) and see its potential to help many people lead healthier, longer lives, but you wonder how to get your staff working as a team to implement the nuts and bolts into your dental practice. DSM is different from general dentistry, so most dental teams are not used to the mechanics of administering it effectively. I hope by sharing the principles Smile for Life Dentistry has learned through our modest success thus far that I can help other practices implement DSM.
Smile for Life Dentistry is a small-to-medium general dentistry practice in Phoenix, Ariz, that sees an average of 250 patients each month for hygiene recall. We’ve completed over 50 oral sleep appliance cases since the start of 2015. Our doctor, Chia Wu, DMD, is pursuing diplomate status in the American Board of Dental Sleep Medicine.
How DSM Is Different
- DSM requires multiple steps to achieve a diagnosis, whereas in general dentistry we diagnose and recommend a comprehensive treatment plan for most patients during their first visit.
- DSM requires the cooperation of physicians with specialized training and licensure.
- DSM must begin with a screening process that requires subjective input from the patient on their conditions, such as asking about observed snoring. Unlike identifying a cavity or a broken tooth, there are no objective measures a dentist can employ (for example, radiographs or probe scores) that immediately indicate the presence of a sleep condition. Though cone beam computed tomography (CBCT) is used by some dentists with patients who are suspected to have obstructive sleep apnea (OSA), at Smile for Life Dentistry we don’t think CBCT scanning alone is sufficient to indicate the presence of a sleep-breathing disorder, due to the natural variability in airway collapsibility while asleep from patient to patient. (In other words, a CBCT scan may show a large airway while the patient is awake and vertical, but the patient may still suffer while asleep.)
- DSM involves the patient’s medical insurance, not dental insurance.
The DSM “Pipeline”
I recommend thinking of your DSM practice like a pipeline. In order to achieve a consistent patient flow, you must continually load the pipeline every day, often months in advance. If you stop loading the pipeline, you will lose momentum and focus. It must be a daily discipline.
We start with patients seeking general dentistry. That’s because people suffering from sleep disorders walk in a dental practice’s door every day. Previously, we tried advertising directly to patients for sleep apnea and snoring relief and never got very far; we wasted many thousands of dollars on everything from direct mail to roadside billboards. Don’t go that route. Instead, tap into your current patient base.
Once you gain more confidence, you can seek referrals from medical professionals, such as primary care physicians, cardiologists, sleep physicians, and many others. This year our practice will be working to build such a referral network.
Screening Your Patients
I’m a firm believer in confidently and repeatedly sharing the “why” behind what you do with your team. I won’t stand up in a staff meeting and declare that we’re going to “do” sleep appliances, then expect everyone to be on board. Instead, I educate the team on how exciting this field is and how much real impact they can have. Dr Wu and I are passionate about the topic and let that show every day. This translates through the team to our patients.
Brandon Quijada, MBA
Once your team is on board, you must screen each patient who comes to your practice. There are different screening forms available, from the STOP-BANG to the Watermark Medical ARES Questionnaire, to my personal favorite because I find it predicts an OSA diagnosis with high reliability, the Sleep Health Questionnaire (SHQ) by Ez Sleep. (I am not affiliated with Ez Sleep, nor do I receive any compensation for mentioning them. I do use Ez Sleep for most of our patients’ OSA screening.)
In our experience, we found it works best to not screen new patients on their first visit; that is, unless you observe signs of bruxism and think it could be related to sleep-disordered breathing (research shows some correlation between the two). We’ve found that new patients have plenty to think about at their initial visit and we focus on general dentistry then, so as not to overwhelm them. We screen patients on their second visit.
To get ready for the next day’s screenings, each evening our front office team assembles blank sleep questionnaires for scheduled patients or reprints already completed questionnaires. The patient fills out the screener in the reception area, and it accompanies the patient’s general routing slip throughout the appointment. At an opportune time, the sleep questionnaire is reviewed by the dental assistant or hygienist. It could be at the beginning of a hygiene recall visit, while the patient is waiting for anesthesia to set in, or anytime that works for you.
The dental assistant or hygienist has a brief conversation with the patient and writes notes directly on the screening form. They ask clarifying questions. For instance, if a patient indicates he has been told he snores, our staff member will ask, “Who has told you that?” Our favorite question to get more detail from a simple “yes/no” questionnaire response is “please tell me more about that.”
Sometimes a patient answers the questionnaire in a manner that suggests they are at low risk. This may be true…or they may be answering “no” because they don’t understand the value of the process. So, regardless of the patient’s written responses, we will ask at least three follow-up questions, as detailed in the next section.
Three Follow-Up Questions for Every Patient
- How many times per night do you wake up? (This is a more effective question than “Do you wake up at night?”)
- After a regular night of sleep, what’s your daytime energy level?
- How long does it take you to fall asleep once your head hits the pillow?
Having your team member write notes directly on the screening form serves two purposes:
- It helps provide evidence to the insurance company that the payor should cover a sleep test and potentially a sleep appliance.
- Next time you see the patient, you’ll have a copy of this completed form and will be able to pick up the discussion right where you left off. Make sure your team scans the forms after the patient comes back to the front at the end of the appointment!
We also gather biometric data like height, weight, and neck size, as well as a list of medical conditions such as hypertension, stroke, depression, etc. All of these factors are considered when evaluating the patient’s level of risk.
Home Sleep Testing
We generally broach the subject of a sleep study in one of two ways. If the patient is clearly suffering from poor sleep, our staff is empowered to discuss the possibility that a home sleep test (HST) will likely be recommended. Our staff has access to a physical model of an HST unit to show—and many of them have taken the test themselves and can speak from experience. Then Dr Wu enters the discussion. Other times, the patient does not indicate a problem on the sleep questionnaire, but an oral exam and medical history review reveal risk factors for sleep-disordered breathing. In this case, it’s up to Dr Wu to introduce the topic, since the patient will require more education and effort to enroll in sleep testing.
Some of our patients have kept their HST kits unused for literally months and, in one case, almost a full year. I don’t know about you, but our practice can’t afford to finance a $5,000 HST kit sitting under a patient’s bed for months! You must have a lot of test kits “in the field” to keep your DSM pipeline flowing. So, we highly recommend using a sleep testing company that holds a lot of kits in inventory and specializes in managing their back-and-forth movement. These companies generally also have board-certified sleep physicians who will interpret the study and make the diagnosis. We find it’s best to let the HST service provider worry about the logistics. That way, the dental practice just sits back and gets the sleep reports and diagnoses.
What about Medical Insurance?
We also recommend outsourcing billing for DSM services. More and more medical insurance billing firms are now specializing in DSM. With some research, we’ve found services at reasonable costs. Via outsourcing, you’ll spend less than if you try to educate your own staff in the complicated ins-and-outs of medical billing. Better for them to use their time speaking with and following up with your patients!
And the Rest?
Once you have a diagnosis of sleep-disordered breathing, the patient needs a prescription for oral appliance therapy from an MD. (Many states and insurance companies require a physician’s prescription in order to start treatment. Additionally, having the patient’s doctor prescribe your therapy speaks volumes to the patient.)
Enrolling the patient in therapy then treating them effectively is a discussion for another day, but I truly believe that once your DSM pipeline gets flowing, the momentum will carry you through to success!
Updated 8/29/16:
Thank you for the comments so far on my article. We absolutely agree that dentists are not qualified to make a sleep disorder diagnosis. That is why we only screen for the possibility of a disorder, then refer the patient to a board certified sleep physician for the home sleep test. If the physician makes the relevant diagnosis, we always give the patient information about PAP therapy and the oral appliance option. If the patient is diagnosed with severe sleep apnea, we always recommend the patient see his physician for PAP treatment and only proceed with oral appliance therapy if the patient is PAP intolerant.
Whenever a patient proceeds with oral appliance therapy we refer the patient back for another home sleep test to assess the efficacy of the appliance and perform further titration if necessary. Throughout the process we keep the patient’s personal physicians appraised of the patient’s status.
We see ourselves as partners in the collective effort to educate our patients about the need to treat life-threatening sleep disorders and to assure that they receive the care that best suits them, within the guidelines of the established standards of care.—BQ
Brandon Quijada, MBA, is practice owner/manager at Smile for Life Dentistry in Phoenix, Ariz.
Dental devices are approved for the treatment of OSA, in certain patients, the decision of the treatment modality depends on the patient, degree of OSA, age, weight, full evaluation of the upper airways, among others.
The only universal, 100 % effective treatment without significant side effects is PAP.
The evaluation, diagnosis and treatment choice for OSA is the responsibility of a licensed and board certified physician. Dental devices are a tool in the armamentarium of treatments available and have to be prescribed by such specialist.
I find very concerning this MBA presentation, even a DMD “seeking dental board certification” can not diagnose or treat medical conditions (i.e. Practice medicine).
The apparently contract with a company that orders and performs a sleep study without a doctor evaluation, recieve a report with the recommendations for dental device and ask a doctor to provide the order?
I have been practicing Sleep Medicine for 26 years and I’m fully familiar with the standard of practice and current guidelines of OSA management, and the descriptions in this article do not seem to adhere to them
Dr. Lechin’s analysis of this article is correct.Diagnosis of OSA is not within the scope of a dentist’s training or license. Preliminary screening for OSA with Epworth, Berlin,and STOPBANG questionaires,and use of overnight pulseoximetry is appropriate. This should ideally be followed with a referral to a Physician who is trained in sleep medicine. Subsequently providing oral appliance therapy for CPAP intolerant or non-compliant patients who have a letter of medical necessity from that physician is appropriate. Academic based post graduate Dental Sleep Medicine mini residency programs such as the program offered by the U.C.L.A. School of Dentistry provide excellent,non-commercial training in sleep apnea and sleep breathing disorders.
I believe it is time for doctor’s like Dr. Alex Lechin and serioius Dental Sleep doctors to join forces in the effort to truly offer the options needed in the treatment of OSA. It is proven that OAT is successful in the treatment of mild to moderatie OSA, as well as snoring cessation. In our practice we are seeing fantastic results in combination therapy, especially with severe, CPAP intolerant patients. The key here is compliance, and success. I feel if the medical world (including Dentists) can look outside themselves and actually treat and successfully improve the lives of our patients the world would be a better place. Time to put our swords away and work towards the real goal! That is why we studied so hard to serve and heal right?