|I want to bring some reality to the economics of dental sleep
medicine, an area for dentists that is being promoted by many as a
new profit center in the den tal practice. There is no question that
adding this service to your armamentarium has the potential not
only to improve the quality of life for many of your patients, but
also provide increased income.
Along with the ability to increase services and income, dental
sleep medicine provides many new challenges to the dentist, which
are often ignored or underestimated. The dentist will only be in a
position to provide a therapy that could be essential to the patient's
quality of life if the challenges are recognized and conquered.
What is Sleep Medicine?
Sleep medicine is a relatively new specialty of medicine. In a
2005 article, Shepard, et al. stated "the history of the development
of sleep medicine in the United States is relatively short and most
of the individuals involved with its development are still living."1 They go on to state: "Until 1975 sleep medicine was deemed
'experimental' and medical insurance companies routinely denied
reimbursement claims." In discussing the development of the specialty
of sleep medicine, they conclude that "sleep is viewed as a
basic biologic process that affects all individuals and has significant
impact on the function of all organ systems."
The International Classification of Sleep Disorders is a 400-
page, stand-alone document that was written in 1990 and revised
in 2005.2 Sleep medicine deals with sleep and arousal disorders
that include all conditions encountered clinically. It deals with
dyssomnias, which are those disorders that involve initiating
and maintaining sleep, as well as with parasomnias, which are
movements and behaviors that occur during sleep.3 Obstructive
sleep disorders are classified as dyssomnias and represent those
disorders resulting from airway obstructions that occur during
sleep. They are relatively common syndromes and by conservative
estimates affect five percent of the Western world,4 but they are
often under-recognized despite having substantial morbidity and
mortality rates associated with them. Treatment for obstructive
sleep disorders ranges from the extremely conservative measures of
weight loss and sleep position training to variations of continuous
positive airway pressure (CPAP), oral appliance therapy and surgery.
Many patients prefer the concept of oral appliance therapy
to either the use of CPAP or surgery.5 A dentist should then be
involved with patient evaluation, insertion and appliance maintenance
as well as managing post-appliance insertion complications.6 Consequently, one might think that oral appliance therapy
would be a considerable portion of many dentists' general practices.
But this is not the case.
The Carrot of Economic Success
It isn't unusual to see an advertisement refer to the potential
economic boom that a course will provide for the participant.
Silber states that 30 to 50 percent of the population older than
50 snores.7 This is often interpolated to 40 percent. So, if 40 percent
of your adult population snores, and you have a practice with
2,000 active adult patients, 800 of your patients snore. If you treat
only 25 percent of them, and you bundle the workup and appliance fee to a moderate charge of $3,000, then your gross income
should increase by $600,000 the first year.
Unfortunately, that is an unrealistic computation. The literature
ignores the many challenges that face dentistry. Let's examine some
of those challenges.
The Physician's Bias
The past few decades have seen the line between dentistry and
medicine continually blur, as dentists have made significant contributions
to the care of patients with chronic daily headache,
migraine and facial pain. There was a bias among sleep physicians
against early attempts at oral appliance therapy. Pantino reports
that when he began treating with oral appliances it was not
only considered experimental, but with limited data, research, no
consideration of coverage from the insurance industry and with
limited physician support, he may as well have been "practicing
witchcraft."8 The 1995 landmark study by Schmidt-Norwara9
opened the door to the need for dentistry and medicine to work
synergistically and pointed out that as health-care providers, we are challenged to acknowledge the necessity for interdisciplinary communication.10 This early bias is complicated by the fact that
obstructive sleep disorders are indeed a medical disorder.
Obstructive disorders are a continuum of disorders that start with
snoring. Therefore, snoring should not be treated without a medical
diagnosis, and that diagnosis should be done by a physician.6
In spite of the tremendous improvements in oral appliance therapy,
the fact that oral appliances are usually preferred by patients over
the alternatives of CPAP or surgery, and the fact that the Academy
of Sleep Medicine has mandated by policy that some patients
not only can, but in some cases should, be treated or given oral
appliance therapy, physician bias against oral appliances still exists.
It isn't enough for dentists to know just the basics of sleep
medicine and oral appliances. Dr. Schmidt-Norwara wrote that
"dentists who offer this service need to become acquainted with the
multifactorial nature of sleep medicine to serve their patients
better and to facilitate their interaction with other sleep medicine
clinicians."11 A high level of mutual respect and open communication
is required for the medical and dental professions to properly
triage and treat patients. In a position paper on practice parameters
by Kushida, et al., it is stated that oral appliances should be
delivered and followed by qualified dental personnel "who have
undertaken serious training in sleep medicine and/or sleep-related
breathing disorders with focused emphasis on the proper protocol
for diagnosis, treatment, and follow up."6
Challenges Beyond the Science
In order to be successful in incorporating dental sleep medicine
into your practice, understanding the science of sleep medicine and
possessing the ability to insert oral appliances is not enough. The
art of implementing the science requires a different skill set than
was required to develop a general dental practice.
In order to be successful, dentists must have strong communication skills. For the most part, general dentists can work
within their own office walls and choose those specialists with whom
they would like to work. In sleep medicine, dentists must immediately
work to develop relationships of trust and mutual respect with
physicians with whom they might have no past relationship and
with whom they have had limited contact. Furthermore, because
many physicians hold the bias discussed earlier in this paper, they
will often have to be educated and motivated to refer patients for
oral appliance therapy.
There is also the matter of "management" and the potential for
failure. The dental model of practice doesn't usually involve "managing"
disease; we treat it and cure it. Obstructive disorders can't be
"cured," a concept I have found not readily accepted by some dentists.
Dentists need to develop a new mindset and a new definition
of success for the practice of dental sleep medicine. They must learn
that success cannot be determined with an explorer or depend totally
on the polysomnogram results. They must also realize that some
patients will be unable to wear their appliances. Dentists must quell
their disappointment and acknowledge that although they have rendered
the best possible care, there are factors beyond their control that
impact the success of oral appliance therapy. This potential for failure
should not dampen their enthusiasm. Fear of failure should not prevent
them from helping many other patients. Making this realization
and sharing this information with the patient prior to treatment is a
total change in the model that dentistry routinely utilizes.
There is also the obstacle of post-insertion management. The oral
appliance helps maintain the airway during sleep by creating an external
splint, resulting in an increased tonic tone to the relaxing pharyngeal
musculature.12 In order to do this, there is a strain placed on the
muscles of mastication, as well as the temporomandibular joint
itself.13 General dentists are not well trained in joint anatomy, physiology
or in the treatment of joint dysfunction.14 These common complications will sometimes frustrate the dentist who might not be
trained in the ability to diagnose, treat or manage these adverse effects
on the joints or muscles. This frustration has the potential to cause
the dentist to stop treating with oral appliances. Training in these
areas of treatment is readily available, and will allow the dentist to
manage these complications and make wise risk/benefit decisions
concerning the continued use of the oral appliance.
The most common adverse effect is occlusal changes.13
Dentistry has long emphasized the role of occlusion, and it is difficult
for the dentist to make an informed risk/benefit decision if
that role is considered more important than the resolution of the
patient's obstructive disorder. Ferguson states, "This presents a clinical
dilemma when the patient is unconcerned about the occlusal
changes and refuses to abandon the appliance citing that the perceived
benefit of treatment outweighs the dentist's concern with the
altered occlusion."13 Dental malocclusions created by oral appliance
therapy might have limited or no effect on the patient's aesthetics
or function, and it might be much more beneficial for the patient
to continue to wear his or her appliance despite the occlusal
changes. It is counterintuitive for the dentist to do anything that
creates a malocclusion, and yet this might be in the patient's best
interest. This is a difficult concept for dentistry.
Why the Hidden Agenda?
This is, no doubt, an exciting and new field. We are all aware
of today's economics, and the need for general dentistry to find new
income potential. On the surface, an argument can be made about
how successful dentists can be by adding dental sleep medicine to
their regimen. It is clear that challenges exist, and that we are more
likely to be successful and conquer the challenges if we are aware of
them from the beginning. The rosy picture that is often painted
isn't real, and many dentists who take their initial course in dental
sleep medicine are soon disenchanted by the unexpected roadblocks
Is the promise of economic gain, then, a conspiracy? The
answer is simple. Yes, it is a conspiracy if there is some implication
that implementing dental sleep medicine is as simple as finding patients in your office who snore and treating them with oral
appliances that you fabricate easily with impressions and bite registrations
sent to a lab.
There are real challenges that face dentistry in the field of
dental sleep medicine. These challenges include:
unique place in our health-care system, it has the responsibility to
screen patients for OSA.16 Ninety percent of OSA remains undiagnosed.17,18 Our patient load would be well served if all dentists had
a better understanding of sleep disorders. Our profession and our
patients would benefit if all dentists were taught the basics of sleep
medicine and consequently screened their patients. But more
intensive study on many levels and a commitment to consider the
model changes discussed are required before the dentist can provide
oral appliance therapy and create an other income source in his or
- Becoming a serious student of sleep medicine
- Educating your medical colleagues about the potential service
you can provide their patients who might benefit from
oral appliance therapy
- Understanding the need to manage your patients and understanding
their role as key players on the treatment team
- Learning how to communicate with local sleep labs and
physicians by keeping them in the loop and referring patients
back to them for post-treatment evaluations
- Establishing reasonable fee structures and understanding the
need to process claims through medical insurance in order to
get the most coverage for your patients
- Learning more about the craniomandibular structures that
you are compromising in order to support a compliant airway
- Carefully reconsidering some of your occlusal concepts that
will prevent your potential bias from keeping patients from
treatment for this serious disorder that is associated with substantial
morbidity and mortality rates15
The conspiracy is on the part of those who might gain economically
in the short run by having dentists construct snoring appliances
for those patients who snore (even if it means without proper
diagnosis) or by encouraging dentists to take courses be cause of the
perceived economic gain without recognizing the obstacles to that
end. Furthermore, the conspiracy often encourages the front-end
purchase of equipment that is not required to perform dental sleep
medicine; again, in the long run, this frustrates the general dentist
who is not aware of the obstacles that prevent the successful
implementation of dental sleep medicine in his or her practice.
Many well-done studies have now been completed to demonstrate
over and over again the potential of oral appliance therapy to
be successful in mild, moderate and even severe sleep apnea.13
Certainly, oral appliance therapy has been implemented into many
dental practices success fully. Some dentists around the country
have actually limited their practices to dental sleep medicine. The
obstacles can be overcome. But before they can be overcome, they
have to be recognized and acknowledged.
It is essential, then, that the "conspiracy" not result in frustration
and the dentist deciding not to pursue dental sleep medicine.
Those who have accepted the challenges and overcome the obstacles
have placed themselves in a position to provide a potentially
life-altering and life-saving treatment modality. The diligent dentist
has the opportunity to add not only a new stream of income for his
practice, but also a new quality of life for his or her patients.
- Shepard, J.W., Jr., et al., History of the development of sleep medicine in the United States. J Clin Sleep
Med, 2005. 1(1): p. 61-82.
- American Sleep Disorders Association, D.C.S.C., ed. International Classification of Sleep Disorders:
Diagnostic and Coding Manual. 2005, American Academy of Sleep Medicine: Westchester, IL.
- Kryger, M.H., T. Roth, and W.C. Dement, Principles and practice of sleep medicine. 4th ed. 2005,
Philadelphia, PA: Elsevier/Saunders. xxxiii, 1517 p.
- Young, T., P.E. Peppard, and D.J. Gottlieb, Epidemiology of obstructive sleep apnea: a population health perspective.
Am J Respir Crit Care Med, 2002. 165(9): p. 1217-39.
- Ferguson, K.A., et al., A randomized crossover study of an oral appliance vs nasal-continuous positive airway
pressure in the treatment of mild-moderate obstructive sleep apnea. Chest, 1996. 109(5): p. 1269-75.
- Kushida, C.A., Morgenthaler, T.I., Littner, M.R.,etal, Practice Parameters for the treatment of snoring and
obstructive sleep apnea with oral appliances:an update for 2005. SLEEP, 2006. 29(2): p. 240-243.
- Silber, M.H., Krahn, Lois E., Morgenthaler, Tomothy I., Sleep Medicine in Clinical Practice. 2004, Boca
Raton: Taylor & Francis.
- Pantino, D.A., Joining Forces. Sleep Review, 2008. 9(3): p. 34-5.
- Schmidt-Nowara, W., et al., Oral appliances for the treatment of snoring and obstructive sleep apnea: a
review. Sleep,1995. 18(6): p. 501-10.
- Glassman, B.H., Multidiciplinary Is Not a Dirty Word. Cranio, 2004. 22(2): p. 87-89.
- Schmidt-Nowara, W., A review of sleep disorders. The history and diagnosis of sleep disorders related to the
dentist. Dent Clin North Am, 2001. 45(4): p. 631-42.
- Hoekema, A., B. Stegenga, and L.G. De Bont, Efficacy and co-morbidity of oral appliances in the treatment
of obstructive sleep apnea-hypopnea: a systematic review. Crit Rev Oral Biol Med, 2004. 15(3): p. 137-55.
- Ferguson, K.A., et al., Oral appliances for snoring and obstructive sleep apnea: a review. Sleep, 2006. 29(2):
- Klasser, G.D. and C.S. Greene, Predoctoral teaching of temporomandibular disorders: a survey of U.S. and
Canadian dental schools. J Am Dent Assoc, 2007. 138(2): p. 231-7.
- Eckert, D.J. and A. Malhotra, Pathophysiology of adult obstructive sleep apnea. Proc Am Thorac Soc, 2008.
5(2): p. 144-53.
- Barsh, L.I., The recognition and management of sleep-breathing disorders: a mandate for dentistry. Sleep
- Young, T., et al., Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged
men and women. Sleep,1997. 20(9): p. 705-6.
- Baumel, M.J., G. Maislin, and A.I. Pack, Population and occupational screening for obstructive sleep apnea:
are we there yet? Am J Respir Crit Care Med, 1997. 155(1): p. 9-14.