When I speak with dentists who have dipped their toe in the waters of treating obstructive sleep apnea (OSA) in their practice, the number one reason they say they quit doing it or are not doing more is …

“I couldn’t get paid!”

You may be committed to helping patients achieve better health through treatment of OSA, but it’s challenging to make it financially possible. Here are three tips that will make dental billing for obstructive sleep apnea more consistent and predictable:

Use Practice Management Software to Simplify Dental Insurance

Understanding how to succeed in the complicated system of medical billing is a game-changer.

We have all figured out how to streamline our approach to making sense of dental insurance, but the rules are different for Dental Sleep Medicine (DSM). You should use a segment-specific software platform (DS3, NiermanDentalWriter, or other) for your SOAP notes and communication with physicians and payers.

These platforms ensure that you include the right notes, tests, patient status, and history to get paid. DSM and medical reimbursement are under the jurisdiction of rigid documentation of processes, protocols, and standard practices. Choosing the most effective DSM practice management software is the first step to payment because it will not let you forget to harness critical information.

Make It Easy for Patients to Say Yes to Treatment

My second piece of advice is the most difficult to implement because it requires a change in behavior. Talk less about co-payments, deductibles, and the patient’s responsibility than you may be used to in dentistry when dealing with obstructive sleep apnea.

As an example, consider this: When you visit your doctor and they suggest an x-ray, draw blood, or order a specific test, do you usually say, “How much will that cost?” No, you don’t. We know that tests and medical treatment recommended by our physician are necessary and not usually optional to achieve optimal health.

Plus, we know that their treatments will be covered by our medical insurance (after the deductible and with certain co-payments). As dentists, we are expected to have significant upfront financial discussions about how much the patient will have to pay out of pocket because of the different nature of dental insurance.

Unfortunately, this same approach when applied to a sleep apnea appointment may backfire. Treatment of sleep disorders can be life-changing, so it’s beneficial to the patient if you focus less on dollars and more on care outcomes.

When we get detailed about the financial arrangement, upfront copayments, and deductible discussion, patients think we are still treating them as a dentist, not as a medical care provider. Make it easy for patients to say yes by leaving out the money talk. Many will have good coverage and can make the treatment a possibility.

Outsource the Details to a Competent Billing Company

Hire a billing company to do the dirty work. Third-party billing companies (Four Pillar, Nierman, Pristine, Dedicated Sleep, GoGo, Brady) typically charge a small per claim fee around $50 and 8-12% of the paid amount. This fee is worth every penny.

I have seen far too many revolutions from the administrative teams in dental practices when they were forced to try to figure out the weird, ever-changing rules of insurance reimbursement.

Billing companies are experts. Plus, the cost as a percentage of sales works for medical practices, so why shouldn’t it for dentistry?

Treating patients for OSA with Oral Appliance Therapy (OAT) is easier clinically and technically than making bite splints in centric relation. And yet the minefield is littered with the remains of dental teams who tried to do the billing themselves.

If you only did one case per month, subscribed to a cloud software solution, paid a billing company their fair share, and risked not talking so much about money, you would still help patients get healthier, feel very fulfilled, and make more money than you are now.

That success can breed more success. You just might add $100,000 to your annual revenue! Curious how you can start incorporating treatment of sleep apnea into your practice workflow?

I’ll be holding a live, three-hour virtual course, “Treating Sleep Apnea In Your Practice With Oral Appliance Therapy,” on Friday, May 21st, 2021. Registration for my course is easy at Pankey Online.

Join me from 2 pm to 5 pm EST to learn more about the medical background of sleep conditions, marketing sleep appliance therapy, and more in-depth techniques I implement to transform medical billing.

Can’t wait to see you there!

Sign up for free at Pankey Online to access complementary and paid CE-granting webinars spanning hot dental topics like sleep apnea treatment, equilibration, and indirect bonded anterior restorations. 50+ cutting-edge courses at your fingertips …

In 2017 the American Dental Association adopted a policy encouraging dentists to screen patients for sleep-related breathing disorders (SRBD). This includes assessing a patient’s risk for SRBD as part of a comprehensive medical and dental history and referring affected patients to a physician as appropriate. When this happened, I called my friend Dr. Steve Carstensen, who is at the forefront of sleep dentistry and asked him what we should implement in our dental practice. One of the tools he suggested is a quick and easy visual assessment called a Mallampati score.

The Mallampati score is one of four things we now do in my practice as a four-part sleep screening. (In Dr. Kelly Brummet’s recent PankeyGram article, she wrote about what this score determines and how she uses it in her practice, so you will want to go back and read that article as well this one.)

We have laminated copies of the Mallampati visualization chart (see below), which we printed from the Internet. We used these for visual reference in both of my operatories and the hygienist’s operatory. To make a visual assessment of the back of the patient’s mouth, say to the patient, “Open wide.” You don’t depress the tongue. The patient doesn’t say “aah.” The patient just opens wide. Then you look to see which of the four Mallampati images most closely matches what you see and give the patient a 1 through 4 score based on the image.

This is just a simple way to see if we think anatomically the patient can move air past the base of the tongue. My hygienist and I do this in conjunction with the STOP BANG questionnaire, Epworth Sleepiness Scale and asking about nose breathing.

Screening our patients for airway and breathing issues is becoming a standard in dentistry. One of the things we have started to do every day in our Hygiene rooms, with our patients from three years old to very elderly, is visually looking at the back of their mouth and assign a Mallampati score.

The Mallampati score was developed by anaesthesiologist Seshagiri Mallampati, in 1985, as a non-invasive way to assess the ease of endotracheal intubation. The test is simply a visual assessment of the distance between the base of the tongue and the roof of the mouth.

In our practice, we begin a conversation about airway with patients. The Mallampati diagram (see below) allows both us and our patient to visualize, on a score of 1 to 4, the patient’s anatomical airway. We laminated the Mallampati diagram off of Google Images, and we can give it to the patient to hold while we screen them, or we share it with them after screening to let them see why they received the score they did. We then continue the conversation with them about their airway and why it might be a good idea for them to observe sleep patterns or be referred to a sleep physician for further diagnosis.

We are bombarded weekly with ads for this or that course in “airway management” or “how to make money treating sleep apnea.” And, we are dealing with airway management every day whether we like it or not.  

Who has not had a patient come in with a worn dentition who claims, “Doc, I can’t ever remember grinding my teeth.” How about the patient who keeps fracturing restorations and says the same thing? You might want to question these folks or their partners about sleep habits. It is very likely you will find they are members of the population with some form of sleep-disordered breathing.  

Do you remember why we learned to fabricate and adjust bite splints?  

Have you had parents ask you about what it means when they can hear their young child grinding his or her teeth at night? Childhood bruxing is almost always a symptom of some sort of airway issue. What is happening in a child who presents with proclined incisors and an anterior tongue position? Do you think putting the child in headgear is going to solve the underlying reason the tongue has to be forward so they can breathe? 

We don’t have to treat all these issues, but we certainly should be able to communicate with our specialists and medical community for appropriate diagnosis and treatment of underlying issues that have a direct impact on the success or failure of our restorative care. 

The American Sleep Apnea Association estimates that 22 million Americans suffer from sleep apnea. Since we see our patient base, on average, two times a year, it makes sense that we should be doing at least a basic screening for sleep-disordered breathing. This can be anything from mild snoring to serious sleep apnea.  

Basic diagnostics would include paying attention to a person’s body mass index, neck size, asking whether they snore, and providing the Epworth sleepiness scale as part of your standard health history. Be aware that some folks with the worst sleep apnea or narcolepsy are not overweight. These are often the very fit appearing folks who are serious bruxers. 

If you really want to get involved in treating these people, you need to get more education.

Either at The Pankey Institute or somewhere that has a multi–day course. You need to commit to going into the process deeply, as there is much to learn and treatment is not simple. You will quickly learn that unless you develop great systems and team members, it is not an easy way to make money. However, you will be truly saving lives. 

If that does not sound right for you, commit to being a good diagnostician and develop an excellent referral network with some ENT doctors in your area. Most of these doctors are looking desperately for a dental colleague with whom they can discuss cases and develop treatments beyond just the use of CPAP. If you can refer just one child for early treatment each year and help prevent a heart attack or stroke for a person with undiagnosed sleep apnea, you will have done great service whether you get involved in active treatment or not. 

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Sleep issues and sleep apnea is a very serious concern today for our patients’ health. I have been giving patients an Epworth sleepiness self-assessment for several years. It is a great way to find out if patients should pursue their sleep with a physician and inquire about having a sleep study.

Another incredible indicator of apnea is if someone else hears you stop breathing. Of course, there are challenges with this approach. First, there has to be someone near you when you sleep to hear what is happening. Second, someone has to be awake in order to listen and watch while you are sleeping. Third, someone has to interpret what is happening. I recommend the SnoreLab app that records and evaluates the sounds made while sleeping. It can even show you graphs of what was happening. Not only is this a great self-learning tool, but the recordings can be taken to the doctor as part of the information to determine if a sleep study is indicated. The product is available on the web and through the App Store.

Several of my patients have used the SnoreLab app and had follow-up studies in a sleep lab. Within my Glendale, AZ practice, I have a Dental Sleep Medicine practice and treat patients with sleep apnea appliances.

To serve patients to the best of their ability, I recommend general dentists learn how to competently develop a Sleep Dental Medicine niche within their practice. I can honestly and wholeheartedly say that The Pankey Institute’s 5-day immersion Dental Sleep Medicine course is one of the best programs in the nation. It is uniquely designed to give dentists the experience of being a sleep apnea patient themselves.

You are accustomed to consulting with patients about the association of TMD with craniofacial pain, but the link to sleep disorders should now be on your radar. Your patients want to know that you can help them sort out whether their frequently occurring headaches are the result of TMD, obstructive sleep apnea (OSA), a combination of the two, and/or other comorbidities.

Because research evidence suggests up to 50% of individuals suffering from morning headaches have OSA, every dentist likely has some sufferers they can detect, educate, diagnose, and refer or treat. If you are not already an expert in Dental Sleep Medicine, The Pankey Institute’s immersive Dental Sleep Medicine course is one of the best in the country.

A preclinical interview that includes questions about headaches will get you started with a co-discovery diagnosis for OSA related headaches and set you and your patient on the path for the most appropriate diagnostic testing and treatment.

When the tongue can’t function properly (especially the middle portion), a cascade of events can happen. This is a very important point because many assess proper tongue function by mobility alone, but this does not uncover a posterior tongue restriction.

Assessing a tongue by how far a child or adult can move it is simply not enough. The middle portion of the tongue must be addressed because it is the biggest driver in normal development.

Tongue Restriction or Dysfunction

Following the Functional Matrix theory, if there is a tongue restriction or dysfunction while in utero and the tongue cannot reach the palate, the facial muscles will be the biggest factor shaping the palate. This  results in a high, vaulted palate at birth.

In infancy, a lack of function may lead to an inability to nurse properly or create a proper seal. This can be worsened by a high vaulted palate. If the palate is not stimulated, oxytocin release is limited and the facial muscles continue to be the largest influence on the shape of the palate. Symptoms of this problem can show up in both mom and baby immediately or a few days after birth. They can include: 

• Swallowing too much air resulting in: gassiness, reflux, spitting up, colic, getting “full” on air, or not draining breast, which leads to frequent feedings.
• Increased effort needed to eat, so falling asleep when nursing, short nursing sessions, and poor sleeping/frequent waking.  
• Excessive non-nutritive sucking/thumb sucking to stimulate palate and release oxytocin.
• Incorrect latch, which can be painful and lead to cracking/bleeding nipples or not fully draining breast, which leads to mastitis, etc.  

So many times, a “simple” answer to these problems would be switching to bottles or special formula and/or reflux medications instead of addressing the real issue. This is all too often missed by the medical field. When the underlying dysfunction goes untreated because the symptoms have been pacified by those treatments, the dysfunction continues and more symptoms develop.

The function or dysfunction of a tongue can lead to more health issues than many realize. Recent research has linked tongue dysfunction to a myriad of issues such as skeletal and bite changes. These issues can also lead to sleep apnea and TMD among other things. 

The evolution of recent thought is that sleep apnea and TMD are chronic “end stage” diseases whose roots develop early in life. Interventions as early as birth may help prevent or at least curb the severity of these diseases.

Exploring Tongue Function

The tongue is used not only for speaking, swallowing, and tasting, but also for other less obvious functions. The most important may be the tongue’s function of protecting the airway. When touching the palate, the tongue releases oxytocin, which has a calming effect.

The tongue is a large factor in normal growth and development of the face including the nasal and oral spaces. The Moss functional Matrix theory in essence states that the soft tissues will dictate how the hard tissues form. Or, in other words, form follows function.

According to this theory, the tongue will influence development of the palate, nasal cavity, and overall facial form. It then stands to reason that normal function is important for normal facial growth and development.

Development of Swallowing Patterns

The normal function of a tongue begins at the 18th week in utero when the fetus begins swallowing. Infants are born with a congenital suckling/swallowing reflex. At birth, the infantile swallowing pattern (called a “Tooth apart” pattern) is characterized by positioning of the tongue between the gum pads and the jaw slightly apart.

Stabilization of the mandible is from facial muscles and the interposed tongue. The middle portion of the tongue must lift and touch the roof of the mouth to create a seal when nursing and also release oxytocin.

Then, as teeth erupt, children change to a transitional swallow pattern. They will fluctuate between the infantile tooth apart pattern to an adult tooth together pattern. In the tooth together pattern, the teeth are together and the tongue is to the roof of the mouth.

This transition may be altered if the tongue cannot learn the proper position. An altered swallow pattern such as a tongue thrust may occur. Issues that can alter swallower pattern can be a tongue tie, poor or hyperactive muscle tone, a high vaulted palate, delayed non-nutritive sucking habits, or essentially anything that will not allow the tongue to reach the proper spot.

To be continued …

Dentists make thousands of choices during their careers. From practice style to how to shape retirement plans, we get to decide how to do things. No matter what style of practice the dentist chooses, the mix of services the involved dentist gets to pick from is ever expanding. Dental sleep medicine is one of the newest services we have added to the list and many dentists are curious about adding it into what they already do.

Practicing Dental Sleep Medicine

Dental sleep medicine may be the closest thing to practicing medicine any non-oral surgeon dentist will get. Managing a chronic disease – sleep disordered breathing – is much like managing another one, periodontal disease. More and more dentists every day are taking up the challenge of helping their patients breathe better during sleep.

Membership in Dental Sleep Medicine organizations, like American Sleep and Breathing Academy, has grown by double digits each year. The calendar is crowded with courses on how to make oral appliances. Dentists are finding the rewards that come with this area of practice energizing and fun. Whole office teams are being reshaped to learn new skills.

Dentists are taught some medical basics during professional school, but years of concentrating on what we do for oral health can dilute the attention paid to patient health history, pharmacology, and medical comorbidities.  

Since every sleep disorder is a medical diagnosis, collaboration with medical professionals requires the dentist to revisit whole body health and recover the ability to communicate with physicians with appropriate detail. Patients certainly expect their dentist to understand their diagnosis and treatment strategies.

Once the person is diagnosed with sleep disordered breathing, treatment choices include positive air pressure masks, surgery, and oral appliances (mostly mandibular advancement devices). Dentists must have a working knowledge of each of these strategies, especially as we are relied upon for expert application of the third choice. Advancing the mandible to open the airway is the description of what we do, but the implications of that choice involve every bit of scientific based health knowledge dentists know. Incorporating sleep dentistry into your practice can bring new learning and new energy to your practice at the same time that you significantly improve the health and quality of life of your patients.

For more information join Steve at the Dental Sleep course.

It is estimated that 22 million Americans suffer from sleep apnea, with 80 percent of the cases of moderate and severe obstructive sleep apnea undiagnosed. Integrating dental sleep medicine into your practice can be a great way to engage your self and your team and serve your patients in a powerful way that will improve their overall health.

Dental Sleep Medicine Involves the Whole Team

Adding dental sleep medicine to your mix of services requires the entire team to gain new knowledge of the role of sleep and the diagnosis of a sleep breathing disorder, as well as how we can utilize dental devices as an adjunctive therapy. This has to be combined with ‘dental’  concerns such as muscle pain, temporomandibular joint disorders, missing or loose teeth to finalize a treatment recommendation. Working through complex multi-factorial diagnostic and treatment planning decisions is part of practicing dentistry, and we simply apply these skills to the additional medical information that is pertinent for patients with a sleep breathing disorder.

When any new service or technique is added to our daily repertoire in a busy dental practice it can cause disruptions, stress, and challenges that some dental teams won’t be able to see past to get the rewards that come from all the hard work. In addition to acquiring the technical expertise make sure you have prepared your team, and you may benefit from expert advice and finding meaningful mentors that can assist you.

A complicating factor for many offices is the choice to submit sleep therapy to medical insurance. Most dental offices are not equipped for medical billing and many financial administrators, perfectly comfortable with dental claim forms, find themselves mystified at the nuances of submitting to a host of unfamiliar payers. Fortunately, professional medical billers have stepped up to help, but even making this agreement requires dentists to stretch their knowledge and get expert advice in new areas of healthcare.   

Choosing Dental Sleep Medicine

Why do this? While dentists often improve people’s lives in fantastic ways with pain relief, reducing infection and inflammation, and beautifying smiles, rarely do we have the opportunity to give them a chance to live longer. Obstructive sleep apnea left untreated is proven to shorten life expectancy.

Treating the disease will enable people with persistent hypertension to reduce their blood pressure. Bed partners of snorers whose airways are opened improve their quality of life. Often married partners who had chosen to sleep separately reconcile into one bedroom. When someone sits with our team and tells us how much better they enjoy dreaming again after years of missing it, our days are brighter!

Are you trying to decide if treating sleep-disordered breathing is right for you? Dental continuing education provides plenty of introductory courses. I’m honored to be the editor of Dental Sleep Practice Magazine, dedicated to practical education.

There are academies and associations dedicated to supporting every member of the dental team as we expand our medical involvement to provide a service that only dentists are capable of performing. Mini-residencies are forming at leading educational institutions to provide in-depth, multi-disciplinary learning.

Is it worth the effort?

The first time your team celebrates together after a happy patient gives everyone a hug because of how much better they feel now that they’ve used your oral appliance, I think you’ll know the answer.