In Part 1 of this series, Dr. Todd Sander discussed their introduction to oral appliances for treating sleep disorders, highlighted alternatives to CPAP therapy, and his unique journey into dental sleep medicine integration.

Whether my new patient is coming to me for dentistry or dental sleep medicine, my initial examination is 90 minutes, preceded by 30 minutes with my clinical assistants to review their medical-dental histories, including the patient’s polysomnogram or home sleep test results; take digital or analog impressions; take radiographs or CBCT; and take photos and videos of the patient.

In my practice, I try to see dental sleep patients on Tuesday and Thursday afternoons. When an existing sleep medicine patient calls and is having an issue, we try to direct them to a block on a Tuesday or Thursday that is interchangeable with a restorative appointment. I prefer restorative procedures to be scheduled in the mornings and see emergencies and comprehensive new patients in the afternoons. I do not like to have other patients after I do a comprehensive exam with a new patient.

I have empowered my team to slide dental sleep medicine patients into our restorative schedule. Giving my team permission to do that and guiding them to understand that I want to provide both services was important. Otherwise, restorative dentistry would have filled my schedule and prevented me from working with sleep patients.

If an existing dental patient becomes a dental sleep medicine patient, I do a comprehensive sleep medicine exam, which is more like a medical exam. When my dental patients ask me if I’ll “just” make an appliance for them, I stick to my guns and explain that the documentation is different. I explain that we have now entered the world of medicine, and we cannot cut corners just because they have been a dental patient within the practice. So, on Tuesday and Thursday afternoons, I know I will likely have a new patient that’s a comprehensive dental patient or a dental sleep medicine patient.

We never want to tell a dental sleep medicine patient they will have to wait weeks to see me, so we might free up time on other days if slots are not filling up. This includes patients who are already within our dental practice. Many of our dental patients are referred for a dental sleep exam out of our hygiene department. Our hygienists are on board, looking at airways and helping guide patients who will benefit from OSA therapy. Part of your dental practice might be identifying airway issues as patients come through hygiene.

Scheduling may sound simple, but there is no easy button. Many of our colleagues who try to do dental sleep medicine become discouraged as they try to “fit this in” and treat it as just another appliance. So, I caution you. If you start working with dental sleep medicine patients, much more goes into the effort than delivering a simple dental appliance. It is the practice of medicine. The language and documentation that are required are medical in nature, and there is a lot to consider in treating and monitoring the patient, which I will discuss in future parts of this series.

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.

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.