(Re)Defining Success in Dental Sleep Medicine by Barry Chase, DDS

In 1976, as I was graduating from Georgetown University Dental School, I received the most powerful nugget of wisdom that influenced the rest of my career. It came from Dr. Moore, a practicing dentist of many years who taught part-time at the dental school. He simply said, “Dr. Chase, never forget that there is a patient attached to that tooth.”

Although I knew what the words meant, I really did not fully comprehend the impact of that sage advice until many years after practicing general dentistry. What I now understand is Dr. Moore was telling me not to get caught up in the technical details of fixing teeth but remember that my purpose as a dentist is to restore dental and oral health to the patient. That may include restoring a tooth, doing a particular procedure, and paying attention to the micro-details of the technical protocols. But in the end, I must always ask myself if I improved the health, welfare and/or the quality of life of the patient.

Over the years I have come to realize Dr. Moore did not have the original thought. 2500 years ago, Hippocrates (yes, the same Hippocrates of the Hippocratic Oath) is credited with saying, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” Just a different way to express the same idea – don’t forget that there is a person attached to that disease.

I have combined what Dr. Moore and Hippocrates have said into our dental sleep medicine practice philosophy. Dental sleep medicine, in my opinion, is not about putting a piece of plastic in a patient’s mouth, it’s not about moving the mandible forward, it is not about what appliance I use. It is all about how I make the patient FEEL, treating the patient, not the disease. I do not treat Obstructive Sleep Apnea, or the apnea-hypopnea index (AHI). I treat people who happen to have a sleep breathing disorder. Along with hypertension, diabetes, obesity and overall misery because their quality of life is being disrupted by sleep apnea.

Toni Morrison, the Nobel Prize winning author is often quoted:

People will not remember what you said
People will not remember what you did
But people will always remember how you make them feel.

The “feeling” we want to create for our patients begins with the phone call requesting an initial appointment. My staff, trained in dental sleep medicine, take that call. It is not about just making the appointment. The call is an interview, a carefully scripted dialog of how we can best serve the patient and then sending the patient forms and literature about our office, our credentials and our philosophy of practice.

At the first visit, a dedicated patient care coordinator trained in sleep medicine welcomes them, gives them her card with her personal email and phone number and informs the patient that she will be following their case from the first visit through the insertion of the device, managing the medical insurance and all payments, setting up adjustment visits and coordinating post insertion care with their referring physician.

My consultation is 1 hour long, with the majority of the appointment getting to know the patient and reviewing the sleep study (which is very welcomed as most patients have no idea what the numbers mean and how they manifest into their physical disease).

My consultation is calculated and choreographed. It is structured with a specific flow of questions in an exact sequence including surveys, forms and semantically charged language to trigger certain emotional responses in the patient. Our objective is to clearly communicate that we are here to walk them through the difficult and long process of employing an oral appliance while following all the protocols demanded by our Academies. (In another article I can discuss the specifics of the consultation and how to get conversion and case acceptance).

(Re)Defining Success in Dental Sleep Medicine

Our industry standard definition of successful OSA therapy, whether with oral appliance therapy or another treatment option, is to reduce the AHI to stated Academy targets and relief of symptoms. However, I can tell you quite clearly that, after many years of experience, there is not always, or even often, a direct correlation between reducing AHI and relief of symptoms. Yes, the patient expects medical data in the form of improved AHI, oxygen saturation, and sleep staging. Most of the time, I can accomplish those objective medical goals by understanding and working with appliance selection, appliance titration, tongue position with minimal mandibular movement, using vertical relationships and managing the temporomandibular joint. But not always. I have non-responders and partial responders along with limitations of mandibular movement affecting or not affecting various sites of obstruction, and the ubiquitous issue of compliance.

It is also easy to forget that there is a person attached to the sleep study. As you treat more patients suffering from OSA, you will find as I do that there are patients with high, severe AHI, with few to no symptoms and other patients with low AHI, perhaps even with no diagnosed sleep apnea, just many arousals, and who are very symptomatic. We want a correlation between AHI and symptoms, but often that is not the case. We have to critically think about why that is, and not try to apply a statistical analysis that has little to do with managing the disorder.

But I can always make the patient feel better and cared for. I can get into discussions of sleep hygiene, talking to them about their sleep environment, what they eat before bedtime, the use of electronics and the influence of light on sleep. I can talk about sleep aids and the medications the patient is taking for comorbidities that may be affecting sleep quality. Positional therapy is sometimes a good adjunct to improving OSA symptoms. In other words, I have taken the time to understand more about the patient than just their AHI.

Therapy vs. treatment

In dentistry, we treat/fix teeth. If a clinical crown is fractured, we can place a full coverage restoration, with proper embrasures, balanced occlusion, well-fitting margins, and that tooth is fixed. In dental sleep medicine, we do not treat/fix anything – we manage a chronic, progressive sleep disorder that is negatively affecting people’s quality of life and is potentially life threatening.

I consult for an oral appliance manufacturing business that is owned by a parent company based in Tokyo. They comment that there is a big philosophical difference between their Eastern view of medicine and our Western view. We are criticized for having a mechanical, technical vision of health. They say the difference in our healthcare perspectives is that in the West we fix cars, in the East, they grow trees. What they mean is that in the West we think that if we replace a defective, diseased body part with a new replacement part, we have created health. Perhaps in certain aspects of medicine and dentistry that is true, but that approach to creating health does not translate to dental sleep medicine. We do not put in a piece of plastic into the patient’s mouth and they are magically and successfully treated for the malady of obstructive sleep apnea. We provide a lifelong therapy to manage a disorder that will continue to get worse, is influenced by the patient’s lifestyle, is multifactorial in origin, and often requires additional therapies by other healthcare practitioners.

Many years ago, when I first started in general dental practice, my wife I were in a restaurant and overheard someone at another table say they did not like their doctor. She felt he did not give her his time, his attention, and did not make her feel cared for. Another person at the table said they loved their doctor. He was interested in them as people, not just patients; they felt cared for. At no time did they say that either doctor was technically good or bad in medicine. It was all about being cared for; how the doctor made them feel.

Please do not misunderstand. I am not by any means advocating changing the definition of success for oral appliance therapy. Improving AHI and other parameters of sleep medicine, and meeting the standard medical targets, are important and required. The ideal, and we can reach it most of the time, is to both improve the objective data on the post insertion sleep study and at the same time provide a level of unsurpassed care for the patient.

Too often when I consult with or teach other dentists about dental sleep medicine, they perseverate on the type of appliance to order, how to take the impressions and make bite registrations, find proper mandibular protrusive positions, and, unfortunately, most of the time, forget that there is a person attached to that appliance.

Dental sleep medicine is rewarding, and challenging, and remember, in the echoes of Hippocrates and Dr. Moore, never forget that there is a person attached to that disease.

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