Dentistry’s Value Added to Sleep Disorders by Bradley Eli, DMD, MS


How Important is Dentistry to the Sleep Community?

In a word, VERY!

In the early 1990’s, dentists became interested in Sleep Medicine. I remember those days well. The field was new and exciting, meetings were held annually, and attendance was small. The familiar few returned each year. Today, the field has grown significantly and most importantly, it has changed.

Sleep, its quality and quantity, have become a message that now is carried daily by the many players within the field. We can now measure better, faster, more completely and with more methods than ever before with no real end in sight; and with this opportunity, the options for the dental team is limitless. Dental providers have a unique relationship with patients that is one of health maintenance, not disease, interactions. For this reason, the dental team that truly knows and understands their value is critical to their success and success for their patients. Many of the current programs introducing or expanding the knowledge of the dentist’s role in this field focuses solely on a treatment. It is true that oral devices are a treatment option of sleep disordered breathing and that compliance with this treatment option exceeds the most ubiquitous option, PAP (positive air pressure). It is also true that dentistry has additional tools to assist in both current anatomy findings and the ability to monitor progress (CBCT, panoramic x-ray, etc.). Finally, there are new options that continue to enter the market daily.

So You Want to be a Sleep Provider?

As with any other professional services, you need to understand your value so your role will be well-defined. I have often used the example of periodontal disease as a good parallel for sleep. I invite the dental team to think about how they would consider a medical provider who was “interested in adding a periodontal soft-tissue program” to their clinic. What they would need to know in order to be an asset? As with this example, most would agree the method used for assessment of risk and identification of patients is first on the list.

In the dental office, what team members can be involved in risk assessment?

Answer: Everyone.

Information pieces on sleep disturbances can be part of the information available for patients in the reception area. You could run information on a TV or use wall posters. This “early education” of your population allows your patients to know your interest and service. But of equal importance the front desk must know how to handle an inquiry.

Snoring, weight, morning headaches, and tooth grinding can relate to sleep disordered breathing and can become part of your office initial questionnaire and as part of the update questions gathered at follow up visits.

Next is the hygiene department. This is the engine that drives any great practice. This is where relationships are built. This is where time for questions and answers occurs, and this is where the doctor is directed as to what message is ready to be reinforced to the patient.

In order to make this engine work, the hygienists have to be: interested, educated, knowledgeable, and supportive. Questions started in the hygiene chair must be support-ed and stratified for more earnest discussion. Assistants are also critically important in the process. Patient questions must be respond-ed to and directed either in printed format or to the appropriate caregiver within the fa-cility. As we know, the staff is critical to the overall success of all programs within dental practices. Dentists are now ready to provide this service, patients are interested in this service, and relationships already in place can be solidified.

Back to the periodontal example: What level of understanding would you expect of the doctor providing a periodontal soft-tissue program?

  1. What disease types, states and levels would be appropriate to be addressed in a first or second line treatment facility?
  2. What treatments are reasonable to offer and who within the facility offers the treatments?
  3. What supporting information do you have to help educate the patient on their disease state and the importance of not only initiating treatment but ongoing care?
  4. As with all special care, knowing who not to treat is very important.

Who within the office would you want to be able to receive information or have your questions answered?

This includes not only the care itself but information regarding insurance coverage, duration of care, cost of care, and number of treatment visits. I am concerned when the focus of most of the current educational programs is solely on the economic potential benefits of the addition of an alternative care strategy but fails to provide the doctor even the minimum amount of information or education on their particular role.

It is hard to not be intoxicated by advertisements quoting dollar figures, things that “could transform your practice”, that by completing their course, the doctor does not have to settle for a trickle of business.

For twenty years, I have personally been involved in the field, providing services to patients suffering with a disease state that progresses throughout their lifetime. The number of patients in need of these services truly is enormous and dentistry’s role and participation can be limitless. Practitioners interested in this field are generally interested in new challenges and opportunities to improve their patients, quality of life, which grows both their position in their community as well as value to their business.

At last check, little to no information or education is currently provided at the pre-doctoral level of most dental programs, dental hygiene programs or dental assisting programs. Therefore, the people who are interested in this field and adding it to their existing dental treatment model must recognize that unlike many other dental programs, which build upon their basic foundational understanding, dental sleep care requires a much greater level of commitment to foundational education for all of the office participants. Dentists are capable of providing a great service to the community with professionalism and respectability. The economic value gained by expanding services is rarely the driving force in a successful program. I caution any provider who is considering the treatment of sleep disordered breathing as a value added economic machine to an existing general dental practice to proceed cautiously. Most of the true hurdles encountered have nothing to do with providing care. Rather, they are the result of working within the medical model and require strong understanding of rules and pathways currently not part of the dental treatment community or algorithms. Persistence, setting goals with reasonable expectations for completion, and being educated at a level you would expect from a medical colleague interested in adding a dental procedure to their list of services will keep the process in context and prevent burnout and frustration that often comes from a revenue-only based model.

Remember, although mandibular advancement devices attach to the teeth, placement of these devices is treating a medical breathing condition. Having a strong understanding and respect for where your service benefits these disorders and and where it may not will keep you and your staff on the high value side for years to come.

Dr. Bradley Eli received his post-doctorate training at UCLA School of Dentistry in Oral Biology (1992), focused on head, neck facial pain, chronic headache, temporomandibular joint orthopedics, and treatment of sleep disordered breathing. In addition to his private practice in Southern California, he is a peer educator in medical and dental societies and on the medical staff at local hospitals for consultation. Dr. Eli has obtained patents and trademarks in the fields of pain and sleep, is qualified as an expert witness in San Diego and San Bernardino counties superior courts, and is an Associate Clinical Professor, School of Respiratory Therapy, California College San Diego.

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