Earning OAT referrals is key to expanding your sleep practice. See how ProSomnus Sleep Technologies offers the information and results that sleep physicians can relate to.
“Without tradition, art is a flock of sheep without a shepherd. Without innovation it is a corpse.” – Sir Winston Churchill
by Mark T. Murphy, DDS, D.ABDSM, and Len Liptak, MBA
The Churchill War Rooms museum in London is a network of dank, subterranean bunkers where Sir Winston Churchill led Britain’s defense against the Nazis. Not only do the War Rooms pay homage to Churchill, the museum is a glorious tribute to crisis management. The fact that such a vast percentage of an otherwise modest area is allocated to collecting, analyzing, and funneling information to Churchill’s team is profound. Churchill understood that timely, accurate information, good news or bad, is essential for designing and optimizing war plans.
Though not on the same level as World War II, obstructive sleep apnea (OSA) is a public health calamity that requires expert crisis management. Everyone associated with Dental Sleep Medicine (DSM) can recite the key public health and economic statistics that characterize the urgent need for treating more OSA patients.
Facts, figures, and policy abound; DSM continues to struggle with the myriad reasons many physicians remain cautious about oral appliance therapy (OAT). Policy statements on OSA treatment encourage patient preference.1 Multiple studies agree that 81% of patients prefer OAT.2 So why do sleep physicians only refer one out of ten patients for OAT?
Earning OAT Referrals
Finding resolution to this question is the next herculean quest for ProSomnus Sleep Technologies. Over the past few years ProSomnus has aggregated hundreds of data points from physicians boarded in sleep medicine. What have we learned? In the spirit of the Churchill War Rooms, ProSomnus is funneling this information to the DSM community.
First and foremost, DSM must accept that physicians have legitimate reservations about traditional OAT. Acknowledgement is the first step in change management. “Firsthand clinical experience,” is cited as the primary source of reservations about OAT. Sleep physicians state that better scientific data and studies would be helpful, but their reservations about OAT are predominantly based upon what they experience with OAT patients during follow-up appointments.
Across multiple surveys, 85% of the reservations cited by sleep physicians fall into one of four categories. These four categories are: efficacy, adherence, insurance coverage, and side effects. Let’s dig deeper.
Over 50% of respondents identify efficacy as their primary reservation about OAT. However, reliable disease alleviation, not single night in-lab AHI score, is the most common way respondents describe efficacy. In one survey of sleep physicians, just 9% thought OAT offered reliable disease alleviation.
The underlying qualitative feedback on efficacious, reliable disease alleviation points to mechanical issues with traditional OAT devices. Physicians report that many traditional OAT devices have critical failures (activation screw slippage, devices not maintaining therapeutic position, device straps stretch, adjustable arms break, mechanisms malfunction, liners delaminate, etc.) by the follow-up visit with the physician. An abstract published at the 2014 AADSM indirectly shines some light on this issue, reporting that 21% of 309 patients treated with traditional OAT devices, ranging from 15% to 57% of patients depending on OAT device type, required some form of device intervention.3 This is not good enough. Imagine if a heart stent failed 21% of the time!
Adherence is the second most significant barrier facing OAT. This may be surprising as most DSM practitioners assume that adherence is better with OAT than PAP therapy. There is a litany of research that demonstrates adherence with OAT,4 but many physicians have a different point of view. Another survey reports that 69% of sleep physicians cited patient discomfort as a key concern.5 Sleep physicians explain that patients report a level of discomfort that ultimately leads to the discontinuation of OAT. Once again, traditional OAT devices are a root cause issue. Devices are too big, too bulky, irritate the soft tissue, stain and smell, and may require over-protrusion to correct for design and manufacturing limitations.
Insurance coverage is the third biggest reservation about OAT. There are two aspects to understanding this reservation: physician education and dental office billing capabilities. Most physicians are poorly educated about whether private insurance and Medicare cover OAT. 83% of respondents were not aware that OAT is covered by Medicare and most medical insurance plans.
The second dimension to the insurance coverage reservation is that many dentists receiving referrals from physicians may not be enrolled in Medicare or may not know how to bill medical insurance. This could result in potentially avoidable out of pocket payment for the patient. If you are discussing OAT with a physician, educate them about insurance coverage. Inform them that your practice has experience billing insurance or utilizes a professional medical billing service. This will help reduce or eliminate this reservation.
Side effects are the last of the four key reservations. The most frequently reported examples of side effects are tooth movement, long term bite changes, and jaw pain. Although the side effects associated with traditional OAT are considered less severe than those associated with CPAP and should be disclosed in informed consent, they are nonetheless a main concern of sleep physicians.6 Further, recent studies have reported that modern OAT devices may be more capable of mitigating side effects.7
A Path Forward
Based upon this analysis, the dental sleep medicine community can earn more OAT referrals from sleep physicians by taking the following three actions:
- Utilize Better Devices
- Demonstrate Better Outcomes
- Enhance Communication and Collaboration
Utilize Better Devices
The AADSM definition of an effective device, not PDAC lists, should guide OAT device selection.8 Today, modern, precision-engineered OAT devices exist that have better efficacy, are designed for patient comfort and side effect mitigation, and they offer more reliable performance post-delivery. Dentists can address physicians’ reservations by selecting devices not by price or habit, but rather by choosing devices that yield the best performance for your patient and from the perspective of the referring physician.
When physicians feel confident patients will wear oral appliances causing fewer side effects and enjoy more comfort without hygiene or maintenance issues, they will embrace OAT more. When patients return to their sleep doctors with sore jaw joints or muscles, teeth movement, altered bite relationships or gunky looking appliances made from suck down, soft, or heat-sensitive porous materials we do ourselves no favors. We can and must do better today. Options exist today. Use them.
Demonstrate Better Outcomes
Oral appliance efficacy has been on a slow but steady upward slope for the past two decades. Devices like ProSomnus with precision bite transfer, lingual-less designs, and prescription posts with positive stops that ensure the therapeutic position, have pushed OAT even further toward desirable PAP results. When combined with higher compliance, the effectiveness and Mean Disease Alleviation have been demonstrated to be comparable or even superior to PAP therapy.9
As stated earlier, it is not just about the AHI score. Many physicians lament the poor quality of life experience that patients have when side effects appear and comfort wanes. Bands and straps need to be rigid enough to hold the therapeutic position or the device may fall short of the AADSM definition of an effective appliance.10 Non-hygienic appliances can also lead to discontinued use. Most of us would be challenged to place an appliance like the one pictured in Figure 1 in our own mouth or a loved one’s mouth versus a clear, hygienic device as shown in Figure 2.
We cannot accept poor outcomes because of ease of use or slight cost differentials. The outcomes Case Registry that I use from ProSomnus has been instrumental in demonstrating the effectiveness of my OAT with physicians.
Enhance Communication and Collaboration
Communication is not limited to SOAP notes, faxing referring practitioners, and sending follow-up letters. It also means making sure that we let our medical counterparts know we are following the AASM/AADSM joint guidelines, using devices that meet the AADSM’s standards for an effective appliance, following standard procedures that mirror medicine, and that we are a qualified to practice dental sleep. Working with medicine and not counter to it, demonstrates our willingness to be part of the solution and NOT create unnecessary, avoidable friction. Whether you like it or not, physicians drive the sleep segment of health care. We will NOT increase the number of oral appliances prescribed by working around them, taking short cuts, or ignoring joint guidelines. Cooperation and collaboration can help medicine experience a paradigm shift in how they look at the OSA epidemic.
The future of DSM and Sleep Medicine is bright. A recent third-party survey of over 100 sleep physicians reports that if we do these things physicians are likely to increase their OAT referrals by 30-40% over the next few years.11 Let’s create a better environment for our patients, practices, healthcare stakeholders, and payers. Let’s give physicians more reasons to trust Dental Sleep Medicine providers. There are enough headwinds gathering in the distance to shake up the space and create economic anxiety. Collaboration toward an efficacious, effective, comfortable solution with fewer side effects is the common goal. Following these steps will help redefine the gold standard for treating OSA to include Oral Appliance Therapy.
ProSomnus Sleep Technologies published a 2-year clinical study regarding tooth movement and OAT devices. Read about the findings here: https://dentalsleeppractice.com/industry-news/prosomnus-sleep-technologies-announces-publication-of-a-2-year-clinical-study-assessment-of-potential-tooth-movement-and-bite-changes-with-a-hard-acrylic-sleep-appliance/
- Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 2015;11(7):773–827.
- Tan YK, L’Estrange PR, Luo YM, et al. Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: A randomized cross-over trial. Eur J Orthod. 2002;24(3):239-249. doi:10.1093/ejo/24.3.239.
- Scott Craig’s abstract from the 2014 AADSM published in the JDSM. Note sure how to cite this. This is the poster title. POSTER #010Practice Management Implications of Leading Custom Mandibular Advancement Devices Scott Craig, James Hogg, Katherine Phillips, Richard A. Craig Midwest Dental Sleep Center, Chicago, IL, USA and this is the link to the JDSM page. https://aadsm.org/journal/abstracts_issue_12.php
- Hu J, Liptak L. Evaluation of a new oral appliance with objective compliance recording capability: a feasibility study. Journal of Dental Sleep Medicine. 2018;5(2):47–50.
- Medpanel Sleep Physician Survey, 2016.
- Sheats RD, Schell TG, Blanton AO, Braga PM, Demko BG, Dort LC, Farquhar D, Katz SG, Masse JF, Rogers RR, Scherr SC, Schwartz DB, Spencer J. Management of side effects of oral appliance therapy for sleep-disordered breathing. Journal of Dental Sleep Medicine. 2017;4(4):111–125.
- Vranjes N, Santucci G, Schulze K, Kuhns D, Khai A. Assessment of potential tooth movement and bite changes with a hardacrylic sleep appliance: A 2-year clinical study. J Dent Sleep Med. 2019;6(2).
- Mogell K, Blumenstock N, Mason E, Rohatgi R, Shah S, Schwartz D. Definition of an Effective Oral Appliance for the Treatment of Obstructive Sleep Apnea and Snoring: An Update for 2019. J Dent Sleep Med. 2019;6(3).
- Poster #016 Effectiveness and Efficiency of the ProSomnus® [IA] Sleep Device for the Treatment of Obstructive Sleep Apnea – The Effects Study, Stern J, Kuhns D. Blue Sleep, New York, 2Technology, ProSomnus Sleep Technologies, Pleasanton, United States, https://aadsm.org/journal/abstracts_issue_53.php
- AADSM device definition, https://aadsm.org/docs/definitionoforalappliance.pdf
- Fletcher Spaight International Sleep Physician Survey, 2020