Surprising misperceptions a Diplomate has come across when talking to sleep physicians, sleep technologists, and CPAP providers.
As a dental sleep medicine practitioner, I have had conversations with myriad sleep physicians that have gone something like this:
Me: Doctor, do you refer patients for oral appliances sometimes?
Physician: Yes, I do. I work with [insert dentist’s name].
Me: Great! Have you noticed that sometimes patients you refer either don’t go to the dentist or you’re not sure if they went or not?
Physician: I have noticed that.
Me: Let me ask you, doctor, when you refer your patient to the dentist, do you say something like this? “Mrs Johnson, I’m sorry you’re having trouble using your CPAP, but I have good news. I work with [insert dentist’s name] and she makes oral appliances for sleep apnea. She does a great job and is very nice. Heads up though: The appliances are super expensive and are not covered very well by insurance.”
Physician: That’s pretty much exactly what we tell people.
The result is the patient never even calls the dentist’s office…but the doctor thinks he’s made a referral.
What I’ve Learned
I’ve had the great opportunity over the past decade to be able to speak with literally hundreds of sleep physicians, sleep technologists, and CPAP providers. Some of this contact has been through lecturing at medical sleep meetings, some through my consulting work with a sleep lab equipment company, and many through direct one-on-one conversations. And I have seen and heard quite a few things that are worrisome, including the following.
Sleep physicians, sleep technologists, and CPAP providers are typically not aware that:
- Oral appliance therapy is covered by medical insurance (based on the same criteria as CPAP).
- Oral appliance therapy is covered by Medicare (based on the same criteria as CPAP).
- Oral appliances can be effective in more than just mild OSA (at my practice, we have successfully treated patients with AHIs over 100).
- Oral appliances may be adjusted live in the sleep lab, resulting in significantly improved outcomes (key to our success in treating severe OSA).
- Oral appliances do not typically cause temporomandibular joint (TMJ) problems. (In my experience, they virtually never do. Dentists who don’t understand TMJ problems and make the wrong decisions do…but that’s a topic for another article.)
In addition, many, or perhaps even most, sleep physicians think:
- Oral appliance therapy is extremely expensive. (Dentists: This usually means any amount above $500 in patient out-of-pocket expense.)
- If they do refer a patient to a dentist, they will never hear from the dentist or see the patient again for follow-up.
- Referring a patient for a boil-and-bite appliance from the Internet is ok.
Setting the Record Straight
Sleep Review published the results of an excellent survey in the January 2016 issue titled “Oral Appliance Therapy Awareness and Perceptions Survey.” The survey was filled out by sleep center directors, sleep medicine physicians, and other physicians who work in some degree with sleep apnea.
According to the survey, the #1 reason “non-adherent CPAP patients” aren’t referred for oral appliance therapy (OAT) was that they “want to try other strategies to get the patient CPAP adherent,” which seems completely reasonable to me. But the #2 reason was “the patient won’t be able to afford the oral appliance,” which does not seem reasonable.
In my practices, we work with medical insurance. Most of our patients pay very little (less than a few hundred dollars)—and often nothing—out of pocket. Of course, they have deductibles to meet, but often these have been met through the preceding sleep study and CPAP trial (if there was one). If the patient could afford CPAP, they should be able to afford oral appliance therapy.
We are in-network with medical insurance and Medicare (just like CPAP providers). The insurance-related difference between OAT and CPAP is that oral appliances typically must be preauthorized (except with Medicare). Also, patients almost always know how much OAT will cost them out of pocket before they commit. Typically with CPAP, they do not know this (but usually CPAP is initially rented, so the initial costs are minimal to the patient).
The #3 reason cited per the survey was “the oral appliance may not be efficacious.” In response, I point out these are CPAP failures we’re talking about. OAT may not always be as effective as CPAP, but it sure beats doing nothing for those that have already failed CPAP!
So the real concern is likely: The appliance may not be efficacious, and the patient had to pay a bunch of money out of pocket for it. When I explain to physicians, sleep techs, and DME providers how we adjust the appliances live in the sleep lab and have an over 85% success rate at reducing the AHI to below 10 (most often in patients who failed CPAP for whatever reason), they are blown away. And this AHI reduction isn’t just my experience, but the experience of all of those I know who are “fine-tuning” their appliance position via a follow-up PSG.
The #4 reason was “the oral appliance won’t record the patient’s adherence with the therapy.” Dentists know that we can record adherence, but medical colleagues likely do not know this or have not yet experienced it. Braebon’s DentiTrac is available right now and works great.
Reason #5 was “the patient may develop side effects from using the oral appliance.” In my experience, sleep physicians are often concerned specifically about the patient developing TMJ problems. I strongly believe that if a dentist has a reasonable understanding and training in basic principles of craniofacial pain problems, most jaw problems can be avoided or easily dealt with. Out of over 6,000 patients that we have treated in our Idaho practice, we have had very few discontinue oral appliance therapy due to jaw pain.
Reason #7 on the survey was “patients ‘disappear’ when I refer them to a dentist.” We dentists are not doing a good job at communicating with the referring physician. Most of us also do not do a good enough job getting the patient back to the sleep physician for follow-up. I tell patients (every one of them) that once we have them snoring less and feeling better, we will be referring them back to their physician for consideration of a follow-up sleep study with titration of the oral appliance in the sleep lab. I tell them this will be the only way that we will know for certain that the appliance is in the most efficacious position, or if it’s working at all.
Finally, reason #8 was “I don’t know a local dentist who I trust with my patients.” The keyword here is trust. Charging ridiculous fees out-of-network does not build trust. Not referring your patients back for follow-up because the HST you did looks fine does not build trust.
Better Bidirectional Communication
To my dental colleagues: Get out there and talk to your local medical sleep professionals, specifically sleep physicians, lab managers, lab technicians, and CPAP providers. Inform them about what’s really true regarding OAT. Let them know you can help their patients use their CPAPs better through combination therapy or adjunctive therapy. Communicate that oral appliance therapy is covered by medical insurance (including Medicare!) and that most patients do not have to pay more than a few hundred dollars out of pocket, plus you have ways to help make paying their portion affordable (such as payment plans). Let them know you can monitor adherence if necessary, and that they don’t need to worry about the appliance causing TMJ problems (as long as you know something about TMJ). And most of all, let them know that you are NOT anti-CPAP, and that as a dentist if you can avoid “strapping a piece of plastic to someone’s teeth for the rest of their life,” you think that’s a good thing.
To my medical colleagues: Many dentists practicing dental sleep medicine are excellent and trustworthy. Go to aadsm.org and find a dentist near you…or call or e-mail me and I’ll help you find someone. As medicine and dentistry come together, we are able to find more people who need our help, provide an incredible service for our patients, increase successful outcomes dramatically, and, literally, save lives.
In conclusion, I cite a quote frequently attributed to George Bernard Shaw: “The biggest problem in communication is the illusion that it has taken place” (emphasis mine). In my experience, good communication between the medical sleep professionals and the dental professionals is not difficult; it just isn’t being done very well. Together, we can change that. You can change that.
Jamison Spencer, DMD, MS, is the director of the Center for Sleep Apnea and TMJ in Boise, Idaho, and the director of Dental Sleep Medicine for Lane and Associates Family Dentistry in North Carolina. He is a Diplomate of the Board of Dental Sleep Medicine and a Diplomate of the Board of Craniofacial Pain. Spencer is adjunct faculty at Tufts, UNC Chapel Hill, and Pacific Dugoni School of Dentistry. Spencer lectures around the world on dental sleep medicine and TMD, and recently launched the “Spencer Study Club” for dentists who want to increase their knowledge and skill in DSM and TMD without leaving the comfort of their home. For more information, go to www.jamisonspencer.com or e-mail him at jamison[at]jamisonspencer.com.