DENTISTS - Frequently Asked Questions
The recently published update of the Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea by the American Academy of Sleep Medicine specify certain requirements.
www.aasmnet.org/PDF/PracParam_OralAppliance05.pdf
"3.2.1 Oral appliances should be fitted by qualified dental personnel who are trained and experienced in the overall care of oral health, the temporo-mandibular joint, dental occlusion and associated oral structures. Dental management of patients with OAs should be overseen by practitioners 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". (Option Level)
SMN provides regular, AGD / Pace qualified continuing dental education to help any interested dentists to meet these requirements.
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Not only are SMN Affiliate Dentists trained to practice in accordance with AASM guidelines, but the protocols they are taught meet all of the areas for future research as advocated by the Standards and Practice Committee of the AASM which was responsible for the research to develop the practice parameters for Oral Appliance Therapy.
Refer to 4.0 - page 4 - www.aasmnet.org/PDF/PracParam_OralAppliance05.pdf
Areas for Future Research
| a) |
Future studies should determine and emphasize use of accepted endpoints for OA therapy of OSA.
The SMN protocols utilize therapeutic home monitoring to determine physiology data on every patient.
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| b) |
Adherence data for OAs mostly relies on subjective reports. CPAP adherence can now be routinely monitored in an objective fashion. Development of similar capabilities for OA therapy should be pursued for both therapeutic and clinical purposes.
SMN has access to covert monitors for appliances offered. These monitors have yet to be shown to be effective in improving patient outcomes, but the hardware exists now to begin clinical trials should funding be available.
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| c) |
Research to define more clearly patient characteristics of OA acceptance, success and adherence is needed.
The SMN protocols require stringent work up and follow up. Data collection is thorough and standardized. Future retrospective studies on the standardized SMN protocols will be invaluable in meeting this stated need.
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| d) |
Economic assessment, focusing on both short- and long- range costs (inclusive of needed follow-up and indirect costs of OA therapy) is needed so that OA therapy can be compared with alternate therapies through cost and effectiveness analysis.
The standardized insurance reimbursement protocols developed and managed by SMN on behalf of SMN Affiliate Dentists has generated sufficient data to propose that OA therapy is comparable to CPAP therapy. The long-term data collection by the Sleep Medicine Network will provide large data sets for this kind of precise future analysis.
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| e) |
Research is needed to clarify design characteristics most beneficial in given patient groups, so that device selection is driven by data that are more precise.
Again, SMN's standardized protocols with a growing network of dentists will provide specific data envisioned here and will lead the way in the development of this field.
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The short answer is yes. SMN Affiliate Dentists are not only up to date, but will lead the way for the field in this dynamic, evolving field.
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Approximately 1/3 of your patients have some level of snoring or obstructive sleep apnea. 17% of your patients have obstructive sleep apnea. For those patients over 60 years old, the rate of incidence of OSA doubles. In your new and recall patient examinations, be aware of the incidence of OSA in the following cardio-vascular diseases:
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Uncontrolled hypertension - 2+ medications | 80% |
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Stroke | 60% | |
Congestive Heart Failure | 50% | |
Myocardial Infarction | 40% | |
Systemic Hypertension | 30% |
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Several peer-reviewed research articles have examined the relationship between patient medical history and sleep testing for the presence of OSA.
If you answer "yes" to two questions:
1 - "Do you snore regularly?" and
2 - "Do you sometimes gasp for air?"
there is an 88% chance of accurately diagnosing OSA at a severity level of 10 collapses per hour. This is significant and requires treatment.
Adjusted Neck Circumference Survey for OSA
New England Journal of Medicine 347:498-504, 2002
The adjusted neck circumference survey uses 4 predictors of OSA to screen patients for the likelihood and possible severity of the disorder.
| 1. |
Neck circumference in cm (2.5 X inches)
| ENTER
MEASUREMENT |  | | 2. |
History of high blood pressure
(treated or not)
| ADD 4 | |
| 3. | Snoring
| ADD 3 | |
| 4. | Gasping or choking in sleep
(observed or awakened)
| ADD 3 | |
| | TOTAL
SCORE | |
Probability of Obstructive Sleep Apnea
Less than 44 = LOW
44 - 48 = MODERATE
Greater than 49 = HIGH
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5. Does a patient need a sleep study before I treat them with an Oral Appliance?
The Practice Parameters of the American Academy of Sleep Medicine, which provide the Standards of Practice for the management of sleep disorders, specifically require diagnosis by Polysomnography (PSG - the overnight sleep laboratory test). Currently, virtually all medical insurance carriers require diagnosis by PSG in order to provide reimbursement. SMN Affiliate Dentists are trained to comply with all provisions of the AASM Practice Parameters.
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Trained to practice only within AASM guidelines, SMN Affiliate Dentists understand well the processes that limit risk management in the treatment of these patients. Since guidelines require diagnosis by polysomnography, the training includes the proper relationships with local sleep laboratories and sleep specialists.
OSA is a medical disorder that can lead to diminished longevity and quality of life. Now that the disorder has been proven and accepted as a risk factor for cardio-vascular disease, the dental office needs to practice within the medical model. An SMN Affiliate Dentist is thoroughly trained in all aspects of that model, including:
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appropriate examinations |
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proper informed consent |
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medical documentation to support EM insurance coding |
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proper communications with medical colleagues |
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proper follow up patient management systems in accordance with guidelines |
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medical chart requirements |
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HIPPA protocols |
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medical insurance chart requirements to avoid unintentional fraud |
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continuing education to be aware of changes in procedures and techniques in this dynamic field |
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SMN Affiliate Dentists benefit from the training and ongoing support by experts in the field of medical insurance. Contracted exclusively by SMN, our insurance experts will provide assistance to our network of affiliate dentists in:
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Credentialing |
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Pre-verification / Pre-authorization services |
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Optional Billing Services |
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Billing Software Training and Management |
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Claim Denial / Appeals Management |
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Practice Management Services to assure "Clean Claims" |
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Ongoing Education of Insurance Staff at the Dental Office as Relevant Changes in the Insurance Industry Occur |
SMN assists affiliate dentists in the all-important trust relationship with the insurance carriers. When they are assured that the office is practicing within the medical model, reimbursements are virtually always assured, subject to the limits of the patients' policies.
Using SMN's proprietary treatment algorithm, coding, documentation, ongoing support and network, reimbursement for oral appliance services is generally rapid and dependable. Denials will be minimized, patient out-of-pocket fees are minimized and patient acceptance rates become virtually 100%.
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Yes. SMN provides all the necessary staff training and documentation services to assure an efficient and effective integration. On-site training or monthly courses at SMN's education facility in Portland, Oregon is available. Contact SMN for details.
An SMN Affiliate Dentist can capitalize all training fees and capitalization costs by treating only 2 patients per month for three months. If you survey your practice properly, you will find at least several patients per day that require your care to avoid loss of lifespan and diminished quality of life. Sleepy people are also a risk and a threat on the highway. The patient you save may save your life.
The revenue of managing OSA patients is now comparable to virtually any procedures done in the general practice of dentistry. Auxiliary staff can be effectively used for much of OSA therapy. The management of OSA commonly makes remarkable improvements in patients' quality of life. The outcomes can be overwhelmingly successful creating remarkable professional rewards. Often, office staff members become intensely interested and invigorated in their work.
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Yes. There are a growing number of dentists who decide to use dental sleep medicine as a vehicle to taper out of the rigors of a career in restorative dentistry. Having sold equity in the practice to an associate, the dentist is generally required to participate in the practice to introduce the new associate for a period of time. The agreement can allow a full or part time practice of dental sleep medicine by the original practice owner. This is an excellent way to stay in practice at a very controllable level and significantly augment retirement income.
Dental sleep medicine is a very low overhead, highly manageable and focused practice of medicine. Dentists generally report a reinvigoration of their view of practice.
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Considering the fact that oral appliance therapy has now been approved for the first line management of OSA though moderate sleep apnea, and since mandibular position is the fundamental principle of airway management, the need for dentists to treat this disorder is no longer speculative. 85% of the disorder is undiagnosed. The dentist is an essential part of not only the identification of patients, but also essential to their management.
Dentists will be more involved in sleep monitoring for therapeutic reasons, in accordance with AASM Practice Parameters.
Dentists will be instrumental in managing CPAP failure patients, using innovative customized interfaces utilizing the dentition to support nasal or oro-nasal CPAP. Dentists will get training in CPAP management.
Dentists may begin to have equity in sleep laboratories. There are many synergistic relationships between medicine and dentistry, including patient identification, polysomnography, patient treatment, home monitoring, follow up management, etc.
The future of dental sleep medicine as "the next thing dentistry does" is at the doorstep.
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