Chasing Sheep: Treating the Sleep Disordered Patient

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From Dentaltown
By Steve Carstensen, DDS and Gy Yatros, DMD


Dental sleep medicine (DSM) is currently one of the fastest-growing areas in dentistry.

In fact, Frost and Sullivan, an independent market-research firm, predicts a fivefold increase in DSM over the next five years. That could raise annual revenues to more than $0.5 billion by 2020.

Why all of the attention? Patients with sleep-disordered breathing (SDB) are on the rise, public awareness is at an all-time high, and there is increasing acceptance that dentists can provide a great solution for many patients afflicted with this disorder.

In short, DSM can be a very rewarding service to add to a dental practice.

Providing these services in our offices allows us to help our patients live better and longer lives, while simultaneously increasing our revenues and career satisfaction.

Then why isn't every office involved in DSM? Because treating the disorder isn't simple, and it comes with challenges. If an office can build “pillars” of knowledge and processes that will help support these challenges, then DSM can rapidly become profitable and enjoyable for the whole practice.

Here are the four pillars needed to support a DSM practice.

Pillar 1: Screening
Screening patients is where it all begins. Even dental practices not involved in treating SDB should be screening their patients. Most dental offices routinely do oral-cancer screenings, but have you considered why? Is it because we were told to do so, because oral cancer occurs in the mouth, to avoid litigation, or because we care about our patients' well-being? All are good reasons, and the same can be said for screening our patients for SDB.

Most offices may find only one or two instances of oral cancer in a year. Yet we still do it, because it is an important service and we care about our patients.

Screening for SDB takes no more time than an oral-cancer screening, while the number of our patients with airway problems far exceeds the number of oral-cancer patients we will encounter.

SDB affects more than 35 percent of the adult population, and as many as 20 percent of adults have obstructive sleep apnea (OSA). Yet less than 10 percent of patients are aware that they have the disorder.

SDB is often a hidden disease—it can be difficult to pinpoint and harder to diagnose. But leaving the disorder untreated can have serious, cascading health consequences for the patient, including inattention at school or work, academic and professional underachievement, headaches, an increased risk of motor-vehicle accidents, diabetes, high blood pressure, depression, cardiac arrhythmia, heart failure and cardiac arrest.

Compared with other medical caregivers, we spend more time annually with our patients and we are more familiar with the details of their craniofacial anatomy, which factors into the risks of SDB and OSA.

The first pillar needed for our DSM practice is to build a system to quickly identify our at-risk patients. This can easily be accomplished through sleep-screening questionnaires readily available online. Do an Internet search for “sleep questionnaire,” and you will find dozens of them at your fingertips.

Some of the more popular screening forms are the Epworth Sleepiness Scale, STOPBang, and the Berlin Questionnaire. You may even want to combine some of these or create one yourself. Regardless of which you choose, you just need a system that can quickly identify at-risk patients.

The questionnaire should also include common OSA comorbidities like hypertension, diabetes, weight gain, gastroesophageal-reflux disease (GERD), and cardiac problems.

Be sure there are questions about excessive daytime sleepiness, snoring, sleep quality, witnessed apneas/gasping while sleeping, morning headaches, and difficulty in maintaining sleep.

Once these at-risk patients are identified, there is still another brick that needs to go into this pillar of dental sleep medicine.

Our team needs to be educated and prepared to discuss these results with our patients. We need to be passionate and caring as we help our patients understand their risks.

The result of our informed and sincere conversation should be moving the at-risk patient to the next pillar of DSM—undergoing a sleep test. If screened correctly, the majority of at-risk patients who are tested will be shown to have at least mild OSA.

Pillar 2: Testing
The goal of sleep testing is to determine if the patient has an airway problem. Specifically, we need to measure—at a minimum—the patient's breathing, SPO2 readings (the estimates of arterial oxygen saturation) and heart rate, to determine if he or she has airway restrictions that meet the criteria for an OSA diagnosis.

This data needs to be reviewed by sleep specialists who are trained and licensed to make these determinations. Ideally, a registered polysomnography technologist (RPST) will review the data first, followed by an interpretation and diagnosis by a board-certified sleep specialist.

Sleep testing is one of the many areas of DSM that has dramatically improved over the last few years.

In the past, the only option was to refer our patients to a sleep lab where the patients would spend the night. Now a patient can take a sleep test in the comfort of his or her own home.

Dentists cannot diagnose OSA, but we can facilitate testing and work closely with the patient's other health-care providers to treat the problem. Our job is to build a pillar to support sleep testing for all of our patients. The last thing we want is to successfully screen our patients and encourage them to be tested, and then drop the ball there.

To build the testing pillar, we will need to have several systems in place. First, we should become familiar with a local sleep lab to which we can refer patients. We'll want to meet with the lab's director to discuss the referral process and protocols. We will also want to connect with a local sleep physician with whom we can consult.

Our office can then refer patients to local medical professionals for home sleep testing.

The other methods of completing home sleep testing are a bit less defined. There is debate in the medical community about whether dentists should be directly involved in facilitating sleep testing.

Furthermore, federal and state laws may regulate or prohibit our offices from these practices. (Check with the American Academy of Dental Sleep Medicine for more information.) Some practices request sleep tests from companies that provide these services directly for their patients. These companies have sleep specialists who provide an interpretation and diagnosis, and bill the patient directly.

Other dentists directly provide their patients with the test and submit the data to sleep specialists, who make the interpretation and diagnosis.

Regardless of how we build this DSM pillar, we need a foundation that will work for all of our patients.

Pillar 3: Treating
Once a patient has been diagnosed with a sleep breathing disorder, fixing it isn't always easy, but ignoring it isn't an option. The most common therapy, continuous positive airway pressure (CPAP), is used ineffectively by more than half of patients.

Sleep-disordered breathing is caused by the oropharynx either narrowing or closing down, which will cause the sympathetic (fight or flight) nervous system to react.

To avoid this, mandibular advancement devices (MADs) support the movable parts that lie ventral to the airway. The mandible, hyoid bone, and all the soft-tissue parts are stabilized or stretched forward a bit to keep the airway open. The differences in body shape, adaptations over time, and genetically influenced muscle tone explain the variations among people and make any diagnosis and treatment choices necessarily customized for each patient.

All effective MADs allow the jaw position to be changed until, hopefully, the optimum position is found and the airway is open during all phases of sleep and body position. There is no easy way to predict the effective position.

Surgery is helpful, but comes with risk. Oral appliances, including MADs, also create complications. It comes down to you, the sleep doctor and the patient, to choose which course has the fewest side effects, while still achieving the critical health goals.

Treatment can't be done without collaborating with other health-care professionals—especially board-certified sleep physicians, as MAD therapy requires a medical diagnosis and a prescription. Devices must be cleared by the FDA, and there are some 130 clearances, thanks to variations of materials, size, shape, adjustability, quality and cost. The trained dentist will master a few of them and be adept at a few others, and will be able to match the patient to the best choice of device. Dentists are the experts at fitting and dealing with oral appliances, while physicians are trained in evaluating whole-body systems and making sure treatments take many details into account.

To fully contribute, the entire dental team must be comfortable with the collaborative systems. This pillar is made sound through education that is readily available online, at meetings, and within each practice. That education should be led by the dentist and his or her team.

Pillar 4: Billing
As a medical problem, this is not covered by dental insurance, so it's left to either fee-for-service or medical insurance to pay for therapy. It is no surprise that a dentist's primary concern when thinking about providing sleep medicine services is whether he or she will get paid.

Dentists and financial coordinators are used to the frustrations that come with limited dental insurance plans. Many chose fee-for-service to work around those problems. That works fine in dentistry, in no small part because often what we propose for treatment exceeds dental benefit limits and are out-of-pocket expenses for patients.

Also, many dental treatment choices are elective and not covered by any plan.

Medical necessity drives coverage for MAD therapy into a different, mostly unfamiliar, arena for many financial coordinators. The easy route of fee-for-service, however, is all but unknown in medical care, so patients don't expect to have to pay for medical services out of their own pockets and medical colleagues don't know what to say when their patient reports to them that the dentist requests payment up front.

Additionally, most insurance companies require a preauthorization of benefits before treatment, which means that even if you give people a properly filled-out form, they may not get any insurance payment because the claim wasn't filed prior to date of service. It's easy to see how this creates unhappy patients and unenthusiastic referring physicians.

Several years ago, medical billing companies realized dentists need help; some of the medical-record software companies include billing within the range of services, while other billing companies stand alone. There are dozens of these companies in the market, and every town has professional billing companies who work for medical offices and can also work for dentists to support MAD therapy. Often these are independent contractors who bill by the hour or by a percentage of collections.

How would you choose what billing service is right for you? Here's a suggestion. Assign a task force consisting of your main financial coordinator and one clinical assistant, to search for solutions.

Have them do a Google search for billers, interview companies and individuals, and then come to you with a suggestion or at least a couple of choices. Have them ask about services offered, how the money is collected, and the fee. Is there only one person doing the billing, or will there be backup to cover for illness/vacation? Will they handle the preauthorizations? Most importantly, does your financial coordinator feel comfortable working with this person or company?

There will be considerable interaction between your office and the biller, so you want people who get along well. The professional biller will train your staff on what records are required to support the claim, and this involves proper notes, so ensuring that the clinical staff is involved will help you give the biller what is needed.

Conclusion
These four pillars describe what is critical to make a difference in your practice and community health.

Obviously, there is much to learn to be able to provide this medical treatment. If you've been thinking about adding these services, or you've done a few and hit barriers, maybe this information will encourage you to pursue additional training.

There is no shortage of learning opportunities. Choose training that is not based on a particular appliance, includes more than one lecturer, and offers some hands-on work with patients, home sleep testing, and appliances, and soon you'll feel confident to embrace what may become the most rewarding part of dental care!

Dr. Steve Carstensen is a diplomate of the American Board of Dental Sleep Medicine. He treats patients in Bellevue, Washington, and maintains a busy international teaching schedule helping dentists learn how to improve their patients' health. He directs sleep courses at Pankey Institute and Spear Education.

Dr. Gy Yatros has been practicing dental sleep medicine for more than 14 years and is an international lecturer in the field of sleep-disordered breathing and dental sleep medicine. His offices in Bradenton, Sarasota and Tampa, Florida are devoted exclusively to the treatment of sleep-disordered breathing. Yatros is a diplomate of the American Board of Dental Sleep Medicine (ABDSM), past president of the Manatee Dental Society and is an affiliate assistant professor of the Department of Internal Medicine with the University of South Florida College of Medicine. He is a cofounder of the Dental Sleep Solutions system for successfully implementing dental sleep medicine in dental practices.

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