One dentist's path into the field of dental sleep medicine
By Gary M. Radz, DDS
My journey into the field of dental sleep apnea has been an interesting one, largely started with the selfish desire to sleep in my own bed! Ten years ago, at my wife's insistence, I talked my physician into getting me in for a sleep study because my snoring was becoming a problem. The results of the test determined that I had severe sleep apnea, stopping breathing an average of 40 times per hour at night. I was promptly prescribed a CPAP machine, given a 15-minute demonstration on how to use it, and sent on my way with no follow-up appointment or phone call. After a week of miserable nights trying to sleep with my CPAP, I packed it up and placed it in the basement. The sleep center, the sleep physician, and my personal physician never called or followed up. For four years I gave up, and my wife and I continued to suffer.
Six years ago I read an article in a dental journal about the use of a dental sleep appliance for the treatment of snoring and sleep apnea. Seeing a potential solution for my own snoring issues, I took impressions on myself and made a wild guess at the correct bite registration. I sent this off to a dental lab that advertised "snoring" appliances.
While the appliance did reduce my snoring issue, it was uncomfortable and I'd wear it only when my wife woke me up and made me put it in so that she could sleep.
Knowing what I know now, I look back and laugh at myself. But today I also see myself then in my patients now. Only now I know how to properly help my patients in a manner that not only helps them with their problem but also working with physician partners ensures there is follow-up and a lifetime of continued care.
Sleep apnea is a serious problem that can be as big a silent killer as hypertension. While it may be funny and/or embarrassing to discuss issues related to snoring, the issue of stopping breathing multiple times every night is no laughing matter! The stress that apnea can create on the cardiac system is real and significant, and it can lead to a cascade of medical issues.
As I continued to learn more about sleep apnea and educated myself in search for my own personal solutions, I repeatedly saw apnea appear in dental literature. At the time, I was not looking to bring this into my practice for my patients. I had learned enough to know that a sleep appliance could not be fabricated without a written prescription from an MD and was unsure how to navigate that issue. I was concerned about potential liability questions.
The turning point for me was attending an Academy of Comprehensive Esthetics (www.acesthetics.com) meeting four years ago and listening to Kent Smith, DDS, (www.21stcenturydental.com) present an hour-and-a-half lecture on sleep apnea treatment in the dental office. I began to see how a dentist could bring this treatment successfully into his or her practice. After the lecture, I networked (more accurately, had beers) with other attendees and learned that they were starting to provide this treatment and that there were ways to do this and provide a great service for their patients.
One of the most important things I learned from talking at the meeting and continued discussions online (www.acedentalforum.com) was that there is a lot to learn and there is much more to learn than just how to take an impression and a correct bite registration. The consensus of those who have become my mentors was to spend time continuing to learn. So just as I did 20 years ago when I dove into cosmetic dentistry, I was now immersing myself in finding as much CE as I could on the subject of sleep apnea.
The best first step I took was attending a two-day course provided by Sleep Group Solutions (www.sleepgroupsolutions). The best decision I made about that course was to take my two clinical assistants with me. I have learned, as I'm sure many other dentists have, that it is critical with any new procedure, technology, or area of practice that the entire dental team has to understand and "buy in" to the introduction of a new aspect of the practice. The course was an excellent introduction to sleep apnea and I, and more importantly my assistants, could see how this would be a great addition to our practice and a huge health benefit to our patients.
Next came the hard part. As we are a general practice with a strong cosmetic focus, going into sleep apnea would require a significant adjustment within the practice. This introduction was made easier when the assistants were there backing me up with the rest of the team reinforcing the message that this is something we need to provide for our patients. We did have a unique opportunity to make a significant impact on our patients' quality of life and even possibly save the lives of some.
We began by including an Epworth Sleep Survey as part of the medical updates that we did on all of our recall patients. Our hygienists discussed sleep issues with patients who scored high on the survey and let me know when I needed to have a discussion with the patients. For patients who were interested in pursuing this, we made a copy of their Epworth Survey and instructed them to take it to their physician to discuss whether a sleep study was indicated. For patients without a primary care physician, we referred them to a board-certified sleep physician. Soon we started seeing our patients coming back with prescriptions from their physicians for oral sleep appliances.
The other way we began to promote our growing interest in providing sleep solutions was to start a new and different website solely dedicated to the treatment of sleep apnea. We focused the optimization of this site on finding patients who were not successful with CPAP therapy. The reasoning here was knowing that CPAP compliance is so low, it would be logical that people would be searching on the Internet for alternative treatments. With the assistance of our web design team (www.tntdental.com), we were soon on page one for many related words and phrases. For the past six months, we are averaging five patients per month who found out about us from our website.
The practice has now started to develop a steady stream of patients who are in need of sleep apnea appliances. The past six months we have averaged eight to 10 patients each month. The volume is growing at such a rate that I have now dedicated one of my dental assistants to the sleep apnea aspect of the practice.
While all of this was going on within the practice, there were continued efforts by all the team to participate in continuing education. All of the team has now completed the two-day program provided by Sleep Group Solutions. I have joined and attended the past two annual meetings of the Academy of Clinical Sleep Disorders Disciplines (www.acsdd.org), and this May attended the annual meeting of the Academy of Dental Sleep Medicine (www.aadsm.org) in Baltimore. Additionally, I have taken many hours of online CE courses as well as attended local and national meetings to learn more.
The formal education has certainly helped me quickly get up to speed on the important academic, clinical, and business aspects of treating patients with sleep apnea problems. But the other dimension to my learning has been finding a willing mentor who has been a great source of information and inspiration. Dr. Alan Gerbholz practices 20 miles south of me. I was introduced by a mutual friend a year ago. Alan has been providing dental sleep apnea therapy for more than eight years, and for the past four has limited his practice solely to the practice of sleep dentistry. Dr. Gerbholz has helped bring practical knowledge and experience to enhance and reinforce our didactic learning. His friendship and mentorship has been an important aspect of our growth within our sleep practice.
The incorporation of sleep apnea therapy into the dental practice is not necessarily easy, but it can be done and can be a huge benefit to your patients. Just as proper and continued education is required in implants, cosmetics, endodontics, etc., it is no different in the area of sleep. There is a lot to learn and most of us have had no exposure to it. The good news is that there are lots of places to start learning more and getting your knowledge base up to where it needs to be to successfully treat patients. The clinical aspects of dental solutions for sleep apnea are just the tip of the iceberg. There is much to learn about medical billing, proper communication with physicians, and marketing to new demographics. A weekend course will not make you an expert in this field, just like any other area of dentistry. But a clinician who is ready to make a serious commitment to learning, staff education/training, and adapting their practice to an additional patient flow treatment of sleep apnea will be rewarded!
Personally, I now have two oral sleep apnea appliances (SomnoDent [www.somnomed.com] and a Herbst (www.gergensortho.com). Both are very comfortable and I've worn an appliance religiously every night for two-and-a-half years. My AHI (number of times I stop breathing each hour) has gone from 40+ without an appliance to less than six when I wear my appliance! Most importantly, my wife allows me to sleep in my own bed now.
Recommended reading: Christensen GJ, Sleep and dentistry. Dental Economics, Aug. 2013; pp. 34-41.
Gary M. Radz, DDS, maintains a private practice in downtown Denver. He is on faculty of the University of Colorado School of Dental Medicine. Additionally, he is director of sleep studies at the Rocky Mountain Dental Institute (www.rockymountaindentalinstitute.com) where, along with his mentor Dr. Alan Gerbholz, he provides a two-day program on the "Successful Implementation of Dental Sleep Therapy into Today's General Practice."
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