See if this sounds familiar: A young-50’s male, with a snoring history that includes his children begging for separate hotel rooms during family trips so they could get some sleep. The family says they considered Dad’s snoring to be funny and annoying, but not dangerous. The man has been observed falling asleep at his keyboard in the afternoon, and admits to being awakened by the bumps on the side of the interstate on long trips.
DSP readers who have begun talking with their patients about airway health have met this man. Probably won’t surprise you to hear that he had never visited a sleep physician, much less been diagnosed, in no small part because the man refused to consider using a PAP device and he was convinced that would be his only treatment option. Seeing doctors was never on his ‘to-do list,’ and, besides, he felt fine.
Richard “Sully” Sullivan, IV DDS, a new graduate, joined his father’s practice and soon invested in a Galileos CBCT from Sirona. Wanting to learn about their new fascinating tool and maximize their ROI, they attended SIROWORLD in Orlando in September of 2016. One of the featured speakers there was Tarun “T-Bone” Agarwal, DDS, with a talk about airway health and dental sleep medicine. Sully’s training in sleep had included only a brief talk during undergraduate dental school and a little bit of clinical practice in a residency, enough to be interested to sit in on that class, thinking he would find out more about what the Galileos could do.
Little did he anticipate that the dots would start to connect – the patient profile T-Bone presented was every bit his father! That family was his, and Sully knew immediately that he wanted to do something to help his Dad. They bought a Braebon HSAT device – the Medibyte Jr. – and tested his father as soon as they could. The diagnosis, using Braebon’s portal, came back from the board-certified sleep physician as “one of the worst we’ve ever seen.” The AHI was 78, with oxygen levels dipping into the 70’s, over and over through the night. That funny, annoying, snoring suddenly took on a whole new level of importance.
Sully knew two things immediately: he wanted to get his Dad treated as soon as possible, and he wanted to learn more about how dentists can help people. Using his Galileos and Cerec technology, he sent digital records to Sirona and soon his Dad was using an OptiSleep dental device. The precision technology allowed the device to ‘drop in’ with no adjustments whatsoever, and Sully says “Dad was really shook up. Immediately he was able to sleep through the night without multiple bathroom breaks, something he had not enjoyed, well, ever. Mom even checked on him with a flashlight to make sure he was still breathing!” The crazy part is this medical professional had, up to then, no clue he had any breathing problem.
Understandably thrilled with this result, Sully set out to fulfil the second part and signed up for sleep training in Raleigh with T-Bone and Dr. Erin Elliott, a dentist from Post Falls, Idaho, who complements T-Bone well with her fun, patient-centered and technologically adept style of teaching. Sully didn’t want to see more patients without learning more about what he was doing; what he learned there allowed him to see his practice with entirely new eyes.
Adding fuel to this passion was the realization that those improved symptoms were not enough to know that Dad was OK. A repeat test with the Medibyte showed an AHI of 6 and no time spent with an oxygen level below 90% – they are sure they’ve added years to Dad’s life; certainly, the improvement in lifestyle is worth everything they’ve invested so far. No more falling asleep in the afternoon and everyone feels safer with Dad at the wheel now. The kids, now adults, still get separate hotel rooms, but not as a means of escape!
Turning to the 3,000 patients in their practice of nearly 30 years, screening tools revealed many patients showing signs of sleep disorders that they’ve never noticed before. ‘Connecting the dots’ with their entire team during morning huddles, patients of the day that they thought might benefit from some directed conversation, such as those with nightguards, began to include more and more of the daily schedule. The hygienists, using the intraoral camera, pointed out pitted molars and scalloped tongues and talked with their patients about airway health. Galileos images showed compromised airways in detailed, color-coded pictures using Galileos software that showed the sometimes-dramatic compromises in airway present in their patients.
Sully talked with colleagues in town – his passion for this new service meant he pushed for quick solutions for his patients. What if there were more like his Dad in his chairs? With his limited training came fewer limits on possibility thinking – and he knew he wanted to establish some credibility as a young, passionate dentist. He saw 3 month waits for appointments with the sleep physicians as a barrier to healthy outcomes. His dental friends with more experience told tales of referrals and reports back of only PAP being presented as treatment choice – exactly what had kept his Dad from seeking diagnosis for many years.
“What if, instead of going to sleep physicians and primary care docs as an inexperienced, hopeful young dentist, I went with proven results? Can I expand to more than a case study of one? What would that mean to the patients I choose to help? I’ll have to come up with a plan to prove what we can do’ were some of the considerations Sully thought through, and decided to take action.
Using their modern Sirona technology, they were able to use CBCT and Omnicam to identify patients at risk for sleep disordered breathing. They’ve made using the Braebon HST part of their office culture – screening for sleep disordered breathing is simply what is done at Sullivan Dental Care. In just over four months, they’ve delivered over 50 OPTISLEEP appliances, using a totally-digital workflow. Sully says, “I’ve yet to have to adjust the fit in the mouth.” From the time the patient discusses risk with a dentist, hygienist, or team member in the practice to the first night of airway support with the OPTISLEEP is about three weeks. Compared to the 90-day wait just for an appointment with the sleep physician, Sully’s confident he’s providing significantly better health for his patients. “It also means a lot when my partner and Dad walks in and tells them how its changed his life. In fact, we have had our entire team tested and two of our hygienists are also wearing optisleeps.”
Focusing on time to treatment involves some compromises that Sully is aware of – in no small part due to the prompting by his mentor Dr. Elliot. Medical insurance billing is limited by those policies that require pre-authorization of benefits or a specific prescription from a local sleep doctor. While all the Medibyte tests are read by a board-certified sleep physician, often Sully proceeds to make the devices from that diagnosis alone. This is legal in his state, but he’s learning that there is a better protocol recommended by most sleep experts that he will be addressing soon. ‘But think about this,” says Sully, “when I go in to meet the local physicians, if I can bring in dozens of patient reports that have been successfully treated, won’t that mean more to those docs than if I just offered myself up as ‘ready to get started’?” His intention is to work out arrangements with physicians so they can evaluate the patient during the workflow and still maintain a fast time-to-treatment while incorporating the physician’s expertise for optimum patient care. With over 150 other mandibular advancement devices available for use, he’s also curious about using some others, but those perfect-fit OPTISLEEP devices are hard to beat, he says. “The next step in my education is definitely involving the primary care doctor more. I think it’s hypocritical of us as dentists to be annoyed when they don’t communicate, yet here I am doing the same thing. Its just better for the patients to have more providers involved.”
One thing he says about starting out without a lot of preconceived ideas is that he and his team feel sleep disordered breathing is not limited to older, overweight males – they consider it for every patient. It’s just part of their culture. One man, 27 years old with a host of symptoms you wouldn’t immediately associate with SDB such as dentin hypersensitivity and enamel erosion, and other complaints more commonly found such as tiredness and depression, was evaluated in the practice and found to have an AHI of 54. Having some other medical conditions, his mother stays involved in his health care and talked with Sully about how frustrated she was – that no one on his medical team had ever asked about, much less tested him for, sleep problems. She worries that he wouldn’t be able to tolerate a PAP to begin with and is beyond excited that treating his sleep disordered breathing could have a domino effect on some of the daily things he struggles with.
Sully is on his way to a major impact on his community health. More education, a better connection with physicians, and some office system developments will only improve his ability to help other people’s fathers and sons (and mothers and daughters, too!) enjoy a healthier, happier life.