Early in my career, I was introduced to oral appliances for treating OSA. While I was doing my residency in the Army, we saw patients with sleep disorders who couldn’t pass their flight physicals. Pilots were desperate for an alternative to CPAP because CPAP would ground them. Today, in my adult restorative practice, it’s clear that many patients benefit from an integrated approach to their oral health care and OSA therapy.
I started my private practice in Charleston, SC, in 2005. I was working with occlusal disorder and facial pain patients and several of them were non-compliant CPAP patients. One day, I was thumbing through my mail and noticed Dr. Henry Gremillion would be speaking at the Hinman Meeting on the connection between bruxism and sleep apnea. After hearing his presentation and reading the recommended literature, I thought sleep-disordered breathing may be at the root of many of my patients’ parafunction, evidenced by their persistent symptoms and the wear on their occlusal appliances. And it was this same population of patients who needed significant reconstructive restorative dentistry.
At the time, the American Academy of Dental Sleep Medicine was the only place where dental sleep medicine courses were available. So, I started with its introductory courses. It was clear that integrating dental sleep medicine into my practice protocols and educating my team and patients would take deliberate effort. There were questions I would have to address:
- How much time would I need to invest in training for myself and my team?
- How should I work sleep patients into my schedule?
- Which of the 32 FDA-approved appliances should I use? (Now, there are several hundred to choose from.)
- Should I invest in special software?
- Which medical providers could I work with, and how?
- How would I manage referrals?
My partner advised me to develop a vision and framework for my practice that would allow me to guide my team and focus my energies. I knew I would not be able to compete with others who were treating only sleep apnea patients. I decided that developing relationships with my patients would be as important for sleep dentistry as it is for restorative dentistry. And because I would also be dedicated to restorative dentistry, I would need to efficiently use my time to develop a niche practice in both restorative dentistry and dental sleep medicine.
With intentional forethought, my team learned how to screen interested patients and prequalify them for a comprehensive dental sleep medicine examination and consultation. I developed key people on my team to answer questions, gather the necessary information, and do preliminary work with incoming new sleep medicine patients. This preliminary work is much the same as that done by dental assistants in a restorative practice…reviewing the patient’s medical and dental history and taking digital impressions and X-rays.
When a comprehensive restorative patient comes to my practice, I do a 90-minute co-discovery examination, including sleep apnea screening. Then I take time in my lab doing diagnostic work with mounted models and plan treatment based on the radiographs, photographs, and other records we took during the comprehensive exam. The patient then returns for a consultation. If it is a complex restorative case, I spend time going over the treatment options, answering the patient’s questions, and developing my relationship with the patient. At this point, the patient is often ready to select treatment, and we move ahead with dental treatments. If the patient has the signs and symptoms of OSA, time is spent discussing the oral and systemic health benefits of having a sleep study and prescribed therapy. I refer my patient to sleep specialists I have developed a relationship with and know will provide a thorough evaluation. These specialists continue the OSA conversation and order a polysomnogram (sleep study) if deemed appropriate.
When a patient is referred to me by a physician to provide an oral appliance to replace CPAP or to be used in combination with CPAP, my comprehensive examination is a little different—with adaptations for medical documentation, but it is still 90 minutes. I have found that dental sleep medicine patients referred for sleep apnea treatment can usually be processed through their examination and treatment consultation in a single two-hour appointment. How I schedule my patients and the protocols I use will be discussed in future parts of this series.