I have been practicing dental sleep medicine for over 20 years and have been educating dentists and their teams in the practice for at least 10 years.
It occurred to me recently, as I was teaching one of my programs at OSA University, that the practice of oral appliance therapy for Sleep Disordered Breathing really breaks down to 5 simple steps.
First we need to identify a patient in the practice.
Second we qualify the patient for therapy using a home sleep test (HST) or an in-lab polysomnogram (PSG), depending on clinician and patient preference, as well as medical benefits policies.
Third we create a sleep treatment plan that is personalized to that patient’s needs. This may require combination therapy, body position or weight loss discussions or a long term titration plan over several months to achieve a successful outcome.
Fourth we need to finish the case with a follow-up, titration sleep test to ensure efficacy of therapy. This will be the final confirmation that the patients is compliant with our treatment and allows us to document objectively that the patient is responding to therapy. This information can be communicated to the patient’s physician using SOAP notation.
The fifth and final step is to submit documentation and complete the billing for the procedures performed.
Simple, right? Naturally the great challenge that we all face is – how to begin creating a new area of practice without disrupting an already successful dental office.
Well, it all comes down to friends, family and team. The first phase of implementation is really just sharing the tools and techniques that you have learned at OSA University with your staff with no expectation of driving revenue. It is important to note that starting a dental sleep practice will take 30-60 days, however you start. Take the time to start screening everyone in the practice with questionnaires and HST’s just to start opening the discussions.
Every dental office has a closet full of products that have gone unused usually pretty soon after they were unpacked. I call this the “10 day syndrome”. It usually takes about 10 days for an office to get back into old habits after a course.
The best way I have seen to break this curse is through personal engagement with key staff members. This is particularly important with regards to sleep apnea therapy. When you start to describe the signs and symptoms of OSA to your staff they will begin to name friends and family that have this condition.
Many of them will volunteer themselves for screening. This is a critical time for your new business. As these discussions and screenings begin, you will notice a leader will emerge – either through personal experience or because sleep apnea is fascinating. You just found the “Captain” of your new program and this person will drive its success.
Pick 5 people associated with the practice who snore or have sleep apnea. Take each of them through the 5 steps of dental treatment for sleep disordered breathing. Don’t forget to waive your fees (this is still CE).
As your team Captain starts working with you on building your program you should review your Health History to include STOP-Bang questionnaires. Identify patients with co-morbid conditions like diabetes, esophageal reflux, heart disease and depression.
This is a time to rehearse positive language that supports your patients and highlights the health benefits of a good night’s sleep.
As these discussions and related patient interactions become more frequent, questions will come up. How many sleep apnea patients do we have in our practice? How many can we expect to identify in a week?
Since 80 to 90% of sleep disordered breathing patients are undiagnosed the number of patients in your practice that have the condition is very high. Consider that a practice that sees 20 patients per day may identify 4 patients per day that should receive some kind of screening.
This number does not include the CPAP intolerant patient who is still seeking a reliable treatment for a condition they already know they have. In a thriving dental practice the addition of sleep screening is a natural extension of our goal of total health for the patient.
The patient you have identified in your practice who is at risk of OSA needs to have a sleep test with a diagnosis to qualify them for treatment. A sleep diagnostic test that has been read by a sleep physician is a requirement for medical reimbursement.
The sleep physician may choose an in-lab PSG or HST depending on his/her preference, or the patients insurance coverage (some insurers require HST). I have found in my practice that the closer that you can work with the sleep physician, the better off you will be. In fact I work very closely with the sleep technician at our local sleep lab.
Some dental offices don’t have access to a local sleep physician that is open to the use of oral appliances. In these cases a national HST provider can be a good alternative…some who will even help you with a complimentary HST for yourself and discounted offerings for team members, friends and family to begin your quest in collecting your first five patients, kick-starting your dental sleep journey..
Once the patient has a medical diagnosis it is time to pick an oral appliance and take impressions and protrusive bite registration. I believe that the most important area for successful oral appliance fabrication is the impressions.
Alginate is a really great impression material if you pour the impressions in the office. My favorite material is Silky-Rock by Whip Mix, very accurate and will save you chair time. This also gives you the opportunity to visually inspect the models before they leave your office.
As to the protrusive bite I was a George Gauge fan for many years and have made some great appliances with that technique. Recently I have started using the Airway metrics system for my bites and really like the versatility of the system (click here to see the video).
When considering the choice of an oral appliance this is a topic for another article. I do however believe that you should work with a dental lab that has all of the appliances. This will allow you the comfort of working with technicians who can advise you across the spectrum of available choices based on what is best for the patient. I use Space Maintainers Lab for my patients and have found them to be excellent.
It is really important to build a small collection of the various appliances in order to better discuss features and benefits of the appliances with patients. Some dentists have appliances made for themselves so they can demonstrate the function and ease of use in a practical demonstration.
The value of the sample appliance for a possible referral source cannot be overstated. Perhaps the best practice building activity I ever did was to make a sample appliance for a local ENT who has become my biggest referral source.
Finally it is time to bill medical insurance for the Oral Appliance. The medical code for an oral appliance for sleep apnea is E0486. Reimbursement is regional and depends on variables like in-network and out-of-network benefits, policy and plan. There are all kinds of strategies out there to ensure that your patients get the most out of their treatment and less out of their pocketbook.
For this article let me say that medical billing and dental billing are as different as chalk and cheese. It will serve you well to find a third party medical biller who can navigate this area for you so that you and your team Captain can focus on identifying, qualifying and treating patients, so that you can build a thriving sleep practice and deliver a standard of care that your patients have come to expect from you in your dental practice.