Struggle of the Juggle: Managing More Sleep in a Busy Restorative Practice

by Teresa Power

There are nearly 200,000 dentists in the United States today, but the American Academy of Dental Sleep Medicine (AADSM) boasts of fewer than 5,000 members. Surveys of the dental industry continuously rank dental sleep medicine (DSM) and implants as the top two subjects of interest for continuing education. Implants are booming and have certainly reached a tipping point among clinicians and the public. DSM hasn’t reached that inflection point yet. We’re not even close. Why?

When asked this question, many dentists reply that their general practice demands too much time, with little to no time for screening for sleep disordered breathing (SDB) or implementing DSM. They’re aware of the labyrinthine steps required to meaningfully incorporate DSM – steps such as screening, patient education, obtaining a diagnosis, coordinating with physicians, and medical billing.

Many of these same clinicians fervently proclaim their desire to implement DSM because they care about their patients. They believe looking at the airway is within their scope of practice, and they want to abide by the ADA’s standard of care. Unfortunately, the obstacle course inherent to DSM and the dynamic time constraints are non-starters for many.

These hurdles are real, but they can be overcome. Great sleep dentists overcome them every day. Adding DSM to a busy restorative practice is possible, and the following three stories feature three dentists from three different time zones. They’ll tell you how they dance with the struggle of the juggle.

Brandon Hedgecock, DDS, D.ABDSM

When dentists say they don’t implement sleep into their dental practices because they’re way too busy, it takes too much time, or they tried it and it didn’t take off, I tell them, “Those are 100% excuses – not reasons.”

DSM has a lot of hoops, and the process can be long and convoluted, but it’s definitely not insurmountable. You can’t do it alone. You can’t do it without a solid team. You wouldn’t open a general practice with no assistants, hygienists, or marketing plan and expect it to work. That’s ridiculous. DSM is no different. In a restorative practice, you hire RDHs to do prophys and treatment coordinators to talk about money. The dentist can’t do it all and shouldn’t do it all.

You develop a plan, put the right people in the right places, don’t give up, then it becomes easier, and then it becomes sustainable.

If You Build It, They Will Come

When dentists complain they don’t have time to screen their patients, my response is that it takes 10 seconds to mention that there are signs they brux at night or they were snoring during a procedure, and then simply hand them off to the right person in the office.

Then comes the excuse about team resistance. The team won’t get on board with sleep implementation. That’s a leadership and management issue. They probably pushed back when you brought in a scanner, Invisalign, a new software, whatever it is. People are generally resistant to change – any change, good, bad, or indifferent. Remember though, they are in healthcare, so they care about people and their jobs. If they don’t, you have to look at the team and decide if these are the right people.

You wouldn’t open a general practice with no assistants, hygienists, or marketing plan and expect it to work. That’s ridiculous. DSM is no different.

Next, take an assistant or another team member and develop them into your sleep champ. It’s kind of like the Field of Dreams. “If you build it, they will come.” This is not an expense. That’s flawed thinking. This is an investment in your practice, in your team, in your patients’ health, and in your career. Invest the money into getting the right person. As sleep started to gain momentum in our office, I Initially I had someone from the restorative side help, but issues arose on the dental side because everyone’s focus was too fragmented.

In short time, we realized we had to dedicate someone full-time to properly manage sleep patients, the workflow, the documentation, and prevent anyone or anything from falling through the cracks. I remember Jessica, who now runs sleep in our office, telling me that we needed another team member. I told her we could hire that person after we hit our number. A month went by, and we didn’t hit it. She passionately explained that we’d never hit the number if we didn’t have enough people to do the work. We hired the person, and 1 month later we exceeded the goal by 30%. Have a growth mindset, not a scarcity mindset. Do more, be more, and you’ll see more patients. Build it. They will come.

Physician Referrals and Maximizing Your Time

A recurring question I get during lectures is about whether I see sleep and restorative patients on the same days or if I have days dedicated to sleep. I do see them on the same days, but I have 1 chair that’s dedicated entirely to sleep. This allows me to do a crown prep in one op and then while the assistant packs cord or takes a scan, I can go into the sleep room to do an appliance delivery. With this type of schedule, the most productive use of my time is when we have sleep and implant cases scheduled simultaneously.

Another common question is about generating physician referrals. It’d be disingenuous to deny that many physicians lack education about sleep, see some stigma associated with oral appliances, or have a heavy bias toward CPAP. Sometimes it’s all three. This is really the biggest friction point for our office, but again, it is an issue that can be overcome. It just requires constant contact. Don’t let patients fall through the cracks. Take physicians to dinner to discuss how your practice functions, learn about theirs, and identify commonalities. We had a physician liaison and actually just added a second one. This is all they do all day. They keep us top of mind with existing referral sources and continually generate new ones, too.

If nothing else, please remember first the impact you can have on your patients’ quality of life, their health, and their happiness. You will fall – know that. Pick yourself up and do it again. The only ones that fail are those that quit.

Jason Doucette, DMD, D.ABDSM

We’re busy. Our sleep patients are booked out over two months right now. There’s just so much massive growth in this area. I wish it wasn’t needed, but I’m glad we’re trained and available to provide these patients with the help they need. Managing general dentistry and DSM wasn’t easy at first. I try to keep the restorative dental side less complex, so I can focus on the high volume of sleep patients. We must balance family, too, which is most important. This is the struggle of the juggle.

Ugly teeth don’t kill people. Collapsed airways do.

Time Management and the Patient Journey

Saying you don’t have enough time to talk to patients just isn’t true. On the subject of time, I provide fantastic care for all our sleep patients. I care about them so much. That doesn’t mean I have to spend hours with them. Between the 5-minute initial discussion with them during the hygiene check, the 10 minutes I spend with them during the consult, 5 minutes during the HST review, and the 10 minutes I spend during the 90-minute records appointment, I have 30 – 45 minutes dedicated to each case. And again, I pride myself on our level of patient care.

If you’re doing a hygiene check or the patient is there for a toothache, you just note that they have a Mallampatti of 4 or a scalloped tongue. Ask if they have trouble going to sleep, staying asleep, or snore. Do they have headaches or get up to go to the bathroom during the night? Yeah, it’s true, if you try to have a full sleep consult appointment during a hygiene check, it is going to set you back, and your patient back, and your hygienist, too. Don’t do that. Don’t talk too much. Instead, tell them you want to get them scheduled on another day for a 45 minute no charge sleep consultation. Don’t schedule it for that same day!

The hook is that initial screening to get them to come back for the consultation. You help them recognize they have a problem they’ve been dealing with privately. Our patients trust us. They trust that we are here to help them.

When they come in for the consultation, we use the pharyngometer (to evaluate the collapsibility of the pharynx) and rhinometer  (to evaluate nasal patency) as a visual to help them tie their airway issues to their chief complaints. Most patients actually get somewhat excited at this point, because they’re thankful there may be a solution to the issues they’ve been silently suffering through. Tanya gives them a WatchPAT to take home and manages the majority of the consult. She used to sit in the room with me while I did them. After watching me do dozens of them, she was able to take what she observed, and now, with the exception of the 10 minutes I’m present, Tanya does this on her own. I can’t stress enough the importance of investing in an all-star sleep champion. They also schedule the 1-hour HST review before leaving.

90% of my patients come from MD referrals now, but we still test some of our own patients. During the HST review, we focus on the treatment and avoiding bad health outcomes. We talk about how PAP and OAT can help eliminate the signs and symptoms. At this point, there’s still no talk of money. We want to build value, illuminate how sick they are, and what a healthier future can look like.

After this, Tanya hands the patient to the sleep care coordinator who connects with GoGo Billing to work out the insurance and financial details.

Then, they come in for the records appointment. Like I said, most of my sleep patients are referred by physicians. This means I’m not their regular dentist. Still, we take a pano, probe, and chart everything. If they’re our own dental patients, this has already been done. Tanya uses the pharyngometer again, I palpate the joint and muscles, check the range of motion, and help determine which device we’re going to prescribe. Tanya scans and sends the case off. All of this is driven by Tanya, our sleep coordinator, except for the parts that legally require the dentist to do them.

The Importance of a Sleep Champion

Tanya has been an assistant for 25 years. It’s true – you don’t have the time to do all this yourself. Shut down the entire office for a day or take everyone to a 2-day course. Get them educated, trained, and coached. If the dentist is the quarterback, you’ll lose the game before it even starts. Find a team member that wants to learn, that gets passionate, and invest in them to lead sleep in your practice.

Don’t think about the cost. It’s an investment that’s pretty much guaranteed to pay dividends, but way more important, it’ll save your patients’ lives. You’ve helped patients get out of pain from an abscess, you’ve turned black teeth into white teeth, but nothing is more rewarding than this. Ugly teeth don’t kill people. Collapsed airways do. Saying you have to go get more and more CE or more information is BS. Get to a course. Take what you learn and go. Start screening, consult with your patients, invest in your team, and keep learning. Repeat.

Success is not an accident; success is at the intersection of hard work and opportunity.

Marc Newman, DDS

I don’t want to throw our profession under the bus, but I’ve heard a lot of our colleagues say they don’t have the time to treat sleep patients. Fine. Don’t treat them, but you should absolutely follow the ADA’s guidelines to identify patients. Then, just make a referral to another provider.

I’m a sleep champion. That means my assistant is one, too. Sleep champions breed sleep champions.

New Patients and Neck Measurements

In our practice, every single new patient we have gets their neck measured. This is an excellent icebreaker. The patients almost always ask why we’re measuring their necks. We tell them we’re doing it to comply with the ADA’s position that all patients should be screened for sleep disordered breathing. This kicks the door open, and many patients begin volunteering information about their sleep.

Challenges, Opportunities, and HST

DSM workflow is complicated due to the amount of documentation. You must allot enough time to properly document cases and remember, MDs are dealing with the same issues – cumbersome EMRs, patients running late, payor records requests. No two cases are the same.

We don’t have separate days for sleep only. If a patient can’t come in during an available window, we try to get them in a bit earlier in the morning or schedule a telehealth visit during non-production time. We really try to be available for them.

One gamechanger we’ve recently benefited from is the use of the NightOwl HST technology. Our front office people no longer have to manage all the HST units. In the throes of Covid, they were uncomfortable cleaning and maintaining the units. The NightOwl is great, turnaround is less than 10 days, and it really simplifies the HST process in our practice.

It Takes a Team

My most significant obstacle has been standardizing a high level of DSM care into a full team approach. However, in combating that obstacle, I must say – one thing I’ve learned in my career, not just as a dentist, but as a leader, is that some challenges are good challenges to have. We have 5 front office admins, 6 assistants, and 4 hygienists dispersed across two locations. Although it can be a task to implement every single protocol from the wish list, I am certainly blessed to be surrounded by a support staff willing and able to multitask the day-to-day of our busy practice. More than anything, I have the best job in the world, because I get to work alongside some pretty great dentists, who happen to be my brothers – Dr. Mikel Newman and Dr. Don Newman.

With that said, I’m a sleep champion. That means my assistant is one, too. Sleep champions breed sleep champions. Just don’t give up. Don’t ever give up. If you’re passionate about helping others, you’ll make it happen. DSM is on the cusp of changing things. I want to be a part of it.