In Your Own Words

The pages of Dental Sleep Practice have been filled with dentists’ experiences and opinions about collaborating with physicians. These views usually follow the narrative that a multi-disciplinary approach to treating sleep patients is the only way – in an ideal world. This is often followed by pages of animus about unrequited referral relationships and languishing lunch and learns.

But what do physicians have to say about this same subject? In each issue of Dental Sleep Practice, we ask experienced subject matter experts the same 3 questions. Here are their insights about physician and dentist collaboration… In Your Own Words.

1. What qualifications, traits, or history are you seeking when considering a referral to a dental practice?
2. What is a non-starter for a medico-dental referral relationship in your opinion?
3. Why do you collaborate with dentists & what impact has this had on your patients?

Lee A. Surkin, MD, FACC, FCCP, FASNC, FAASM

1. The qualifications I look for in a sleep dentist are, first and foremost, their training and experience. I send my patients to qualified sleep dentists, who, in my professional opinion, have dedicated the time and effort to obtain the educational foundation on sleep medicine through an accredited academy (preferably a not-for-profit one – either the AADSM or ACSDD).

Next is their dedication to patient care. Just as a practicing and board-certified sleep physician individualizes the best possible treatment for their patient, so too should a dentist determine whether the patient to whom they have been referred is an appropriate candidate for oral appliance therapy. There must be a collaborative relationship between the sleep physician and sleep dentist. The next significant factor for me as a cardiologist is willingness to provide care to CMS patients and not up-charge beyond what CMS reimburses. I know this is a tall order but when an elderly patient is simply unable to afford the out-of-pocket cost of oral appliance therapy, it is very important to me that a referred patient does not come back for follow up in my clinic without an appliance because the dentist required an upfront fee that dramatically exceeded what their plan reimbursed.

And, finally, I want to make sure that adequate communication protocols are in place and the patient will be returned to my care for both efficacy testing and long term follow up. I also ensure that communication is bidirectional.

2. A non-starter is lack of proper training and experience in a dental provider who has clearly taken shortcuts on their path to the field.
3. I have been a major proponent of dental sleep medicine for many years and have always embraced a collaborative and multidisciplinary approach to the treatment of OSA patients. Sleep medicine is undergoing a paradigm shift toward a focus on the individual patient in an effort to provide the best possible care from a phenotype perspective. This has been fairly routine in the cardiology world and continues to evolve as the science dictates. It is exciting to see this begin to unfold in sleep medicine, and I am honored to be a part of it. It is very clear to me that sleep dentists are, and should be, a major healthcare provider. The ADA understands the critical importance of screening for OSA, and it is well known that most people see their dentists more frequently than their primary care provider. Dentists “live” where OSA exists and need to be part of the multidisciplinary healthcare Collaboration with the sleep physician is critical to achieving success and oral appliance therapy needs to take center stage along with PAP therapy as first line treatment options. Too many primary care providers and other specialists have little or no knowledge about this critical treatment option, so we have a lot of educating to do. As I have developed relationships with my local sleep dentists, I have seen significant improvement in the health of my patients being treated with oral appliance therapy. That is the most powerful point to make. Patients feel better and become healthier!

Ryan J. Soose, MD

1. My ideal dental sleep colleague exudes the 3 A’s: available, affable, and able. The availability to see high volume referrals and promptly initiate treatment as well as the availability to personally discuss and collaborate on complex cases. The affability that drives good bedside manner, healthy patient communication, and compassionate longitudinal care. And the ability, training, and expertise to deliver oral appliance therapy in a way that optimizes outcomes and minimizes risk.
2. One is the inability to take medical OSA is a chronic long-term medical condition with substantial implications on brain health, heart health, driving safety, and quality of life…not a cosmetic problem. The vast majority of patients need to manage this condition within the confines of their medical insurance and under the bigger umbrella of their overall health.
3. I simply couldn’t imagine sleep apnea treatment without oral appliance therIt’s such a core component of my patients’ care. Fortunately, the Pittsburgh region has been blessed with some of the best Sleep Dentists in the country. The many endotypes of OSA, the heterogenous nature of OSA anatomy and pathophysiology, necessitate a personalized multidisciplinary team approach for best outcomes – and Sleep Dentistry is a vital part of that team.

Madan Kandula, MD

1. Bottom line: I don’t care about your credentials. I care about your care of our patient. I refer patients to dentists who have simple, efficient, and effective techniques that deliver reliable and consistent results.

Good clinicians are optimists. They believe in their skillset and techniques, and their good results reflect this attitude. Bad clinicians are pessimists. They believe every patient is complicated and convoluted. Poor results are sure to follow. I refer patients to clinicians who deliver exceptional customer service and reliable results.

2. I have a few non-starters: Any dentist who doesn’t understand that they’re in the service industry first.

Someone who doesn’t treat their patients with humility and respect.

Someone who is constantly confusing patients, especially with an elitist attitude, unwilling to help them understand their care through layman’s terms.

Someone who is protecting their own ignorant facade by using medical jargon to hide the fact they don’t actually know what they’re doing or how to help.

And of course, poor quality work as evidenced by poor quality outcomes. If any of these are true, we aren’t meant to be.

3. You could say dentists own the teeth and jaws, and ENTs own the throat and sinuses. But, in actuality, we co-own the space where sleep apnea happens. Therefore, we must figure out a collaborative relationship to successfully treat this issue.

OSA is an issue that requires collaboration between ENTs and dentists to provide successful outcomes for patients whose lives are quite literally on the line.

I care more about my patients’ well-being and longevity than I care about crossing imaginary professional boundaries. All day, dentists are staring into airways – an ENT’s domain – so the more OSA awareness there is in the dental community, the better off patients will be.

Joe Ojile, MD, D.ABSM, FCCP

1. It’s important to me that dental sleep colleagues are committed to the patient experience and continual, ongoing sleep education or board accreditation. Patient experience best practices that reduce the friction for the patient include a free or low-cost initial consultation, in-network insurance options for patients, dedicated staff for oral appliances, written communication protocol to the sleep doctor, and planned follow-up sleep testing for efficacy. Another helpful programmatic consideration is notification to our practice of patients who have elected not to schedule or not to proceed so that we may follow up with the patient.
2. This is an interesting and insightful thought question. Acknowledging that the medical model and dental models are different in structure, flow, and communication. The dental model has traditionally been a more robust individual culture with some specialty referral. The economics more resemble the free market.

The medical model has a more regulated underlay due to the ubiquitous involvement of government and insurance agencies. Medicine tends to experience more inter-specialty communication and integration.

Given these two general observations the communications between our two specialties are a key aspect in the process. The non-starter situations are the model where dentists seek referrals without sensitivity to the collaborative process or the overall marketplace (for instance, we work with multiple excellent sleep dentists and a suggestion for a sudden abandonment of those relationships by one dentist can be off-putting) and the need to recognize that obstructive sleep apnea maybe only part of a much bigger medical intervention that is occurring.

3. The collaboration with sleep dentists has been an enrichment to our practice and our patients. To observe the effort and passion that the dentists we have been privileged to regularly collaborate with, their earnest efforts and caring for patients, staying in communication with us throughout the process and stratifying appropriate patients has only helped us to provide comprehensive approaches to management of OSA patients. We discuss oral appliances with a large percentage of our patients as part of their post-test review. It is important that every patient receives a thorough explanation of all treatment options that apply to them and their disease state. It’s essential that we have a confident solution for each modality. The relationship we have developed over the last decade with our dental colleagues has provided this.