Can dental sleep services add to your sleep lab's bottom line?

Working with a qualified sleep dentist can significantly improve the quality of many sleep patients' care and positively impact the percentage of successful outcomes. Typically it will increase the number of sleep studies performed in the sleep lab through qualified dental referrals.

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Recently, I interviewed Jamison Spencer, DMD, MS, who heads the dental sleep area of SCMI's Advisory Team. Dr. Spencer, a diplomate of the American Board of Dental Sleep Medicine is respected as a dental sleep leader and has treated patients who have been intolerant to CPAP with oral appliances for the past 10 years. Here are highlights from my interview.

What does having a relationship with a qualified sleep dentist do for a sleep lab?

Working with a trained and experienced sleep dentist will improve patient care service. Letting patients know in advance that CPAP may not be their only treatment option but an oral appliance may be considered often improves their willingness to have a sleep study done. It also frequently improves their acceptance of a trial of CPAP.

Normally, working with a sleep dentist results in an increase of sleep studies performed in the sleep lab. In fact, if all of the patients that have gone through sleep studies and have been unable to tolerate CPAP or would not try CPAP in the first place were contacted for follow-up and informed of the possibility that an oral appliance may work, many patients would return. The number who fit in this category in many sleep labs is as high as 30 percent to 40 percent.

If they turn out to be a candidate for an oral appliance and are fit with an oral appliance by a sleep dentist, that dentist would refer them back to the sleep lab for titration of the appliance and to evaluate the efficacy of the therapy. This would benefit many patients and improve the sleep lab's bottom line significantly both for previous patients in their files and for future patients they will serve.

Besides standard oral appliance therapy, what else can a sleep dentist provide to a sleep patient and sleep lab?

A sleep dentist can often improve patient compliance and acceptance of CPAP. For example is combination therapy where an oral appliance is worn while using CPAP. This frequently allows a reduction of CPAP pressures, eliminates headgear (when using an appliance like CPAP-Pro or an adaptation of such a system), and reduces mouth leak. I have been able to help many patients get back to using CPAP after they have given up due to some of these relatively easy to handle issues.

You have mentioned that working with a sleep dentist can improve a sleep lab's relationship with their referring physicians. Why is that?

Physicians want to know that their patients are going to be taken care of well and that their diagnosis and treatment is going to be cost effective. For example, I have local physicians who have become discouraged with sending patients for overnight sleep studies because they feel that the patient's only option will be CPAP, and they know that many of their patients will not be able to tolerate or accept CPAP. As a result they are unhappy when the patient has the expense of a sleep study, a titration study and the CPAP unit, and then they are unable to tolerate using it. As a result the patient is back in their office still devastated with their existing health problems.

When a sleep lab tells their referring doctors that they also work with a sleep dentist to increase the treatment options for the patients this is usually very well received.

Most physicians also understand that patients with mild to moderate OSA prefer oral appliances to CPAP and are more likely to use an oral appliance. Again, letting the physician know that this is a treatment option that is explained to the patient will improve relations with the referring doctor.

You have also talked about how working with dentists in the community can increase lab revenues through the follow up oral appliance titration study. Can working with dentists improve lab revenues in other ways?

As I mentioned, when the lab is following up with patients and find that the patient has given up on CPAP, they can suggest an oral appliance option. This level of follow up is not performed by most sleep labs and will set a lab apart.

Dentists probably represent the largest and best source of new patient referrals, and most sleep labs completely ignore them, or don't know how to approach them. Most dentists have approximately 2,000 active patients who are seen annually. Dentists and their staff spend a lot of time with their patients, not the typical five to seven minutes the patient spends with their medical doctor. The dentist and hygienist are already evaluating the oral cavity--they just need to be educated to focus their eyes a few centimeters back and also evaluate the oropharyngeal airway and ask the right screening questions.

Dentists are qualified to refer directly for sleep studies, to the sleep specialist, or they may run the referral through the patient's family doctor. I refer two or three patients per day to the sleep doctors that I work with. It is also a misconception that most dentists will want to see the patient back to fit them with an oral appliance. This is not true. First of all, a dentist will want the patient to receive the best treatment that they can, and if this means CPAP, then they will support the use of CPAP.

Second, most dentists will not be comfortable treating a patient with oral appliance therapy because they lack training and experience. This is why working with a qualified sleep dentist is so important. Most dentists also will not have a problem with their patient being seen by someone like me, because I do not do any type of general dentistry in my office.

When I help a patient with oral appliance therapy they are referred back to their general dentist for all of their normal dental needs. We all work as a team to help the patient with their sleep apnea and oral health over the long term.

How would a sleep lab get started working with a qualified sleep dentist or receive help in marketing to general dentists?

SCMI (www.sleepcmi.com) has a program that will provide leads to qualified and trained sleep dentists. These sleep dentists can even work directly in the sleep lab, or you can just refer patients to the sleep dentist. A major advantage to having a sleep dentist as part of your in house team is that you will not be referring a dentist's patients to another general dentist (which most dentists don't appreciate at all). The in-house sleep dentist also can be trained by SCMI to give lectures to the dental community to increase general referrals from other dentists and he/she will help other dentists treat their own patients.

In addition to SCMI, a great resource to find a knowledgeable sleep dentist in your area is the American Academy of Craniofacial Pain (www.aacfp.org). These dentists are generally familiar with TMJ problems--which is the most complicated part of treating patients with oral appliances--and they have access to educational programs through the AACP on oral appliance therapy. Also, the American Academy of Dental Sleep Medicine (www.aadsm.org) attracts excellent dentists who have a strong interest in oral appliance therapy. Look for a dentist who is credentialed by the AADSM, as this shows a high level of training and experience.

I have heard you issue a warning to not work with unqualified dentists.

Indeed! They may mean well, but the patient, the patient's referring doctor, your sleep lab and the dentist themselves will all be disappointed. I have seen this time and time again. When you work with a sleep dentist who knows what they are doing you will have a significant increase in patient satisfaction and referring physician satisfaction which will equate to improved financial health of the lab.

As we have heard Dr. Spencer say, "Sleep dentistry has a significant spot to fill on your sleep lab team, yet most sleep labs are missing this patient service and business opportunity." Be sure you capture this opportunity for your sleep lab!

by Duane M. Johnson, PhD

Duane M. Johnson, PhD, is co-founder and senior partner of Sleep Center Management Institute in Atlanta; [e-mail]