Dentists: Shed the stigma of being the “black hole” from which obstructive sleep apnea patients never return. A Diplomate explains how to compose physician- and sleep lab-friendly letters that are appreciated by all parties.

Proper communication is essential to success in achieving common goals within the different disciplines in the sleep community. Effective communication is important not just to the physician/dentist relationship but to the relationship between physician/dentist/sleep technician/respiratory therapist as well.

When I began seeking referrals from physicians to participate in the management of their patients’ obstructive sleep apnea (OSA), I knew there would be obstacles to gaining their confidence. The objections raised were mostly those I expected, ranging from questioning the efficacy of mandibular advancement devices (MADs) to the fees that were charged for the device.

But the one complaint that stuck with me more than any other was the lack of communication after the physician referred the patient to the dentist. I still remember an especially stinging remark: “I referred my patients to the dentist and they fall into a black hole and I never hear from them again!” I couldn’t help but wonder, why weren’t those dentists keeping their referring physicians informed?

Communication Protocols

None of us likes to lose a patient. As dentists, we refer our patients to specialists such as endodontists or periodontists and not only expect the patient to be returned to us when the treatment is completed, but we expect a report from the specialist with detailed communication of what treatment was provided and its outcome. Why should our referring physicians, who trust us to help manage their patients, expect anything different?

Every introductory dental sleep medicine class I took stressed the importance of letters to the physicians detailing our patient interactions. Mentors such as Barry Glassman and Kent Smith strongly encouraged the importance of sharing information with physicians. One of my missions as I established my dental sleep medicine practice was to develop communication protocols, for both my team and myself, that would prevent patients from falling into the proverbial black hole that my referring physicians were concerned about. It also became apparent that this communication platform must also be extended to the sleep labs and the technicians who will be titrating our devices for objectifying the efficacy of our MADs.

The quest for adequate, yet not over the top, communication began with speaking to my referring physicians and labs. What were they looking for? What was missing? How should the communication be sent?

Physician-friendly Communication

The consensus among my referring physicians was a preference for brief and concise data. A letter longer than one page was not going to be read, they candidly said. Periodic progress notes letting the physician know the status of the patient were greatly appreciated. Some encouraged the use of the S.O.A.P. format for informing them about the patient’s progress. (S.O.A.P. is an acronym for subjective, objective, assessment, and plan.) Most importantly, they wanted to be able to feel comfortable that their patient was receiving the appropriate care. These forms of communication are imperative in constructing a long-standing referral relationship.

I found that using software designed specifically for dental sleep medicine is a great help. Most programs engineered for a practice focusing on dental sleep medicine have built-in word processing capabilities and include stock letters (and most have the ability to create custom letters). In my practice I developed a series of custom letters that I felt would accomplish the communication goal—a vital component to developing the necessary confidence needed in a referral-based practice. The letters generated are sent not only to the referring sleep physician, but also to the patient’s primary care physician, general dentist, and any other physician the patient listed on their intake forms. Going the extra step to keep all the practitioners in the loop is also a tremendous way of marketing a practice.

Generally, I send a letter after the initial examination and consultation with the new dental sleep medicine patient. This letter briefly discusses the patient’s initial diagnosis of OSA, my findings, and whether the patient is a candidate for a MAD. I also discuss with the patient the pros and cons of a MAD and that the most predictable means to manage OSA is with a CPAP device. I always mention that I will refer the patient back to the sleep physician upon achieving subjective maximum medical improvement for a titration polysomnography (PSG) to objectify the results of the MAD.

On the day of MAD delivery, another letter is generated alerting all involved that the patient has received the device. Care is taken to make sure that copies of any home sleep apnea testing or pulse oximetry used while titrating the device for maximum efficacy are sent to the physician.

When the patient is ready to return to the sleep physician for a titration PSG, a third letter is generated. (All of my patients, most of whom are Medicare beneficiaries, get a follow-up PSG.)

Occasionally, additional letters are created to enlighten the physician of unusual concerns, such as a patient intolerance to the MAD.

I pay close attention to alerting the physicians with further letters with the patient’s results following the titration PSG verifying the efficacy of the device. I also send letters documenting the patient being followed on a routine basis, such as annual recall evaluations, to ensure compliance and minimize risks associated with utilization of the device.

Sleep Laboratory-friendly Communication

The titration of a MAD can often be a detour from the normal routine of a sleep technologist’s night. As oral devices to aid in the management of OSA become more common, the importance of making the technologist feel comfortable with what they will be encountering cannot be overstated. Working closely with the sleep technologists is imperative to the success of the titration PSG and thus ensuring we achieve the maximum efficacy.

The letter I send to the sleep lab requesting the titration PSG includes a photograph of the device they will be titrating. Additional information I provide includes: how far the device has been titrated and how much further the device has the potential to be titrated in order to achieve maximum efficacy (see example letter below).


Example letter requesting oral appliance titration

Kenneth A. Mogell, DMD, DABDSM

Kenneth A. Mogell, DMD, DABDSM

I make sure any lab that will be titrating a MAD for one of my patients has a demonstration model to allow the technologists to “practice” the titration process prior to the patient’s arrival. I have found it invaluable for the labs to have a supply of the various advancement wrenches, should patients not bring theirs to the lab that night. The protocols for advancement of the device are provided for the lab as laminated documents to allow for easily visible posting in the control room. The technologists are aware that I am “on call” should they have a concern or question regarding the patient they will be studying that night.

Because the labs are certain to see a variety of devices, I have processed a “cheat sheet” for them (see below). This sheet has a photo of each device they are likely to see and the dimensions for each advancement they might make. We have the sheet laminated for convenience, permanency, and easy posting.


“Cheat Sheet”

The communication practices I have discussed have greatly enhanced my relationships with referring physicians, dentists, and technologists. They have allowed me to stay in front of potential issues by keeping all practitioners informed on the patient’s progress. We all lead busy professional lives in our practices. Between the responsibilities of attending to the cares and needs of patients and the growing demand of medical records, communication between the parties attending to our sleep-disordered breathing patients must be a priority. An imperative part of referral relationships must be to maintain a consistent and accurate exchange of data with the involved parties. Confronting these challenges will only improve the quality of care provided to our patients.

We are fortunate in today’s technologically advanced world that there are a multitude of options to facilitate the sending of pertinent facts. Letters and prescriptions are easily e-mailed, faxed, sent through EMR portals, or even sent through the United States Postal Service! This focus on the obligation to keep the lines of communications open between all practitioners builds trust with referrers, builds awareness of the efficacy of oral appliance therapy, and builds automatic assurances that prevent patients from falling into the “black hole” never to be heard from again.

Kenneth A. Mogell, DMD, DABDSM, has practiced general, neuromuscular, and cosmetic dentistry for over 25 years. In 2013, Mogell became the first Diplomate of the American Board of Dental Sleep Medicine in Palm Beach County and one of only three in the state of Florida. He is a member of Sleep Review’s editorial advisory board.