Are You a "Provider"?

Doctor...Dentist...

Integrating sleep medicine into the delivery of care for most dental practices has been a challenge for dentists as well as medical professionals, payors and patients across the board! When considering the litany of difficulties the dentist faces when introducing sleep medicine into his/her practice, our recommendation is always that a multidisciplinary care delivery model is the only true successful pathway for oral appliance therapy. 

Although sleep science has advanced significantly in the last decade, the delivery of care for breathing disorders continues to remain fragmented. For the most part, oral appliances have historically been underutilized. And, while there seems to be a natural tendency to create separate “shops” for each specialty, a multidisciplinary care stressing the need to be able to play in the same “sandbox” (care-under-one-roof model) offers distinct advantages to improved patient care, continuity of treatment, and the central coordination of benefits, both insurance-related and clinical.

Past Challenges to Integrated Care

Reasons for dental sleep medicine failing to integrate fully with the delivery of sleep medicine care are many. First, the growth of dental sleep therapy has not kept pace with the exponential growth of sleep medicine in the treatment of obstructive sleep apnea (OSA). Dentists who provide appliance therapy for breathing disorders are seemingly few in number. And, many of those who do often tend to step into the world of the treating physician, further creating discord when attempting to align with a medical practitioner. The most frequently reported occurrence is when the dentist usurps the position of the medical doctor and begins participating in the diagnosis of sleep disorders.

While the dentist is well-positioned to "screen" patients for sleep - based on their time looking directly into the airway - moving into the diagnostic process quickly takes the dentist outside of their scope of practice. We know that most all private third party medical insurance payors adopt Medicare guidelines, and most haven't understood or enforced their own guidelines...until now!

ENFORCEMENT IS FORTHCOMING

Presently, dental boards in Colorado, Iowa, Nebraska, Oklahoma, Georgia and North Carolina are currently looking to adopt specific Medicare guidelines within their respective Dental Practice Act(s)...expressly prohibiting the dentist "DME" from participating in the sleep study, even as much as having the testing equipment picked-up or delivered in their office.

Development of these guidelines is the result of the numerous "programs" that encourage the dentist to diagnose sleep patients and bill cash for this service -again, outside their scope of licensure. Another example of the dentist approaching "scope" concerns would be the dentist titrating the appliance, here the jury is still out. However, the general consensus in the medical community is; the dentist "adjusting" the appliance is akin to their stepping into the "treatment" of this medical diagnosis. In fact, Medicare has recently confirmed that their designating the dentist as the "DME" is to prevent them from attempting to assume a role of "provider". 

education is key

Another limiting factor in dental sleep medicine is the lack of education in the specialized use of oral appliance therapy for sleep disordered breathing among dentists and sleep physicians. 40% of dentists know little or nothing about oral appliances for treatment of OSA. Moreover, 49 responding dental schools of the 58 US schools recently surveyed reported only 3 hours of total curriculum time devoted to sleep medicine. With the exception of short courses offered by such organizations such as AADSM, dentists have relied on training from marketing/retail groups often associated with hoping to sell specific appliances and products for sleep medicine, charging exorbitant fees for equipment for which use, the dentist is unable to receive direct insurance reimbursement - if you can't get paid, it is likely outside your scope of practice!

ever evolving

To date, the knowledge of new materials, techniques, procedures, and continuing education has been limited to dental journals, periodicals, and advertisements. Efforts are under way to formalize dental sleep medicine training in our dental schools. The University of North Carolina School of Dentistry has already hosted conferences for dental educators across the United States and Canada in conjunction with developing predoctoral DDS and clinical residency programs.

collaboration rather than competition

Education to sleep physicians and technologists about oral appliances has been virtually nonexistent. Indeed, there have been recent efforts to train physicians to practice oral appliance therapy at professional meetings. Although this practice raises awareness of oral appliance therapy, it can undermine recognition of the training dental sleep experts undergo to properly evaluate the integrity of the teeth, the surrounding bone, and temporomandibular joints; to obtain accurate impressions and fit removable oral appliances (such as dentures and bite guards) to the teeth; and to minimize negative side effects of their presence.

Most importantly, communications between sleep physicians and dentists have been suboptimal in most healthcare settings. Even in academic settings, interactions between medical and dental professionals have been limited by their separate and different clinics, patient record systems, administrative priorities, and business models. There has been little need to co-treat patients in the past; thus the infrastructure and administrative support to encourage good communication between medical and dental sleep providers are lacking.

The co-treatment of patients with dental clinicians has been viewed as vaguely competitive to some physicians who provide CPAP as the primary treatment modality. This is directly correlated to the dentist assuming the role of provider, which more often than not limits referral of patients for oral appliance therapy. However, a truly successful relationship between physicians and dentists can only be established by close communication and sharing the common goal of patient centered treatment.

reimbursement driven therapy

Routine referrals to dentists is also often discouraged by the lack of, or limited reimbursement for, oral appliances by insurance carriers. Although Medicare recognized oral appliance therapy as early as 2005 as a potential first-line therapy for mild and moderate OSA and for patients with severe OSA who fail positive airway pressure therapy, many medical insurance carriers have only recently began to provide benefits for oral appliance therapy. Progress on this front has been slow and severely challenged by claims processing centers that are not prepared administratively to negotiate contracts with, or process claims from, dentists who are treating a medical condition, dental practices that are unfamiliar with submission of medical insurance claims and the appeal process upon denial, and reduced reimbursement rates for appliances that may not meet the dentist's costs for high quality oral appliances and the chair time required for comprehensive follow-up care.

follow-up is essential 

Post-intervention care with oral appliances also has left much to be desired. Patients undergoing sleep therapy are often reluctant to return to the referring physician for follow-up evaluation of the efficacy of oral appliance therapy, often citing the costs of another sleep study or its inconvenience as reasons for their reluctance. One study revealed, only 18% of patients receiving oral appliances underwent follow-up testing after the initiation of therapy. For those patients who do return for a follow-up sleep study and for whom there is residual sleep disordered breathing, another sleep study with yet further costs and inconvenience may be indicated after adjustment of the appliance.

evidence-based therapy

With the lack of these necessary follow-up tests, outcome measures are not been well documented for oral appliance therapy. While some controlled trials have shown improvement in daytime sleepiness and blood pressure on a short-term basis, the impact of oral appliances on cardiovascular disease on a longterm basis remains largely unknown. Such data on robust outcomes measures are needed to substantiate the long-term benefit of oral appliance therapy when compared to those of nightly use of positive airway pressure.

These outcome measures form the backbone of the proposed model's care of patients with obstructive sleep apnea. Outcome measures would serve as benchmarks for quality assurance and improve our understanding of the natural history of the disease with different interventions. Several outcome measures would be evaluated for quality assurance including compliance (patient-reported until reliable low-cost objective measures can be obtained), post intervention reductions in the AHI and excessive daytime sleepiness (e.g., Epworth Sleepiness Scale) and improvements in scales of neurocognitive functioning (e.g., psychomotor vigilance testing). Recently, mouth temperature-sensing compliance-monitoring chips embedded in oral appliances have been shown to be useful in recording hours per night and nights per week of therapy. This technology provides oral appliance data similar to compliance monitoring of positive airway pressure therapy. Long-term followup and monitoring of blood pressure, cardiac and cerebrovascular events, and mortality should be undertaken, so that the benefits of oral appliance and positive airway pressure therapies can be compared. A concomitant surveillance of adverse effects (both short-term and long-term) should be documented.

enter the provider

Safety and compliance monitoring should be conducted by a Board certified sleep physician every 4-6 weeks after an appliance is delivered until treatment efficacy and patient adherence have been established. The importance of this monitoring being performed by a physician is not only to ensure compliance, but only the physician can evaluate and address any patient adverse effects. Noncompliance (compliance being defined as ≥ 4 h use for ≥ 70% the nights) or failure due to intolerance of oral appliance therapy would trigger an alternative treatment strategy ordered only by the sleep physician. Some alternatives might include hybrid therapy, PAP therapy, or surgical intervention in select cases. A sleep specialist would manage any concomitant sleep disorders, which a patient may have to avoid overlap of visits. Cardiovascular and cognitive markers would be recorded for outcome data analysis and quality control.

In the end, there are specific Medical and Dental Licensing Laws and Practice Acts, which dictate the scope of practice for physicians and dentists  As per individual state law, laws only a licensed physician can make a diagnosis and treatment plan for sleep disordered breathing. Similarly, a dentist's scope of practice includes, and is limited to evaluating the candidacy of patients for oral appliance therapy as well as construction and fitting of the appliances. If the “care-under-one-roof model” is considered, comprehensive care can be performed within the practice parameters established by the CMS guidelines. Additionally, updated practice parameters are currently being prepared by the AASM for publication.

Responsibilities of sleep physician specialist:

  1. Assess patients with sleep related complaints.

  2. Order appropriate diagnostic tests and diagnose obstructive sleep apnea.

  3. Discuss treatment options with the patient based on practice parameters and standard of care guidelines.

  4. Counsel on behavioral therapy, sleep hygiene, weight loss, and driving precautions.

  5. Manage concomitant sleep disorders which often accompany OSA, such as restless legs syndrome (RLS)/periodic limb movement disorder (PLMD), circadian rhythm disorders, and insomnia.

  6. Follow and document comorbid conditions and impact of treatment on hypertension, diabetes, heart failure, arrhythmia, and neurocognitive function.

  7. Engage in active consultation with staff dental sleep expert on treatment plan.

  8. Participate in periodic multidisciplinary rounds and conferences.

  9. Provide follow-up sleep testing after OSA therapy has been instituted.

  10. Provide ongoing and routine follow-up patient care.

  11. Review compliance and manage potential complications or adverse effects of therapy.

Responsibilities of staff dental sleep expert:

  1. Evaluate patients for dental sleep medicine therapies.

  2. Discuss treatment options (mandibular advancement splints, combination MAS/PAP therapy, tongue retaining device, maxillofacial surgery, etc.).

  3. Manage coexistent dental disorders, such as bruxism.

  4. Counsel on dental hygiene and daily maintenance of oral appliances.

  5. Maintain communication with sleep physician specialist for outcome measures monitoring.

  6. Participate in periodic multidisciplinary rounds and conferences.

  7. Provide ongoing and routine patient followup care.

successful treatment is the only success

Integrating oral appliance therapy into the delivery of care for obstructive sleep apnea syndrome has been a challenge and few effective models exist so far. It is imperative that the sleep medicine community develops a realistic and effective model of this underutilized but promising treatment modality. The best structure is to integrate dental sleep medicine with the sleep disorders program is via a care-under-one-roof concept. Training, communication, education, marketing, and evaluating outcome data are vital. Such centers of excellence at academic institutions are best suited to lay this foundation. These institutional centers can provide care in their community as well as serve as a model of integrated care delivery for sleep medicine throughout the country in non-academically based sleep centers.

Thinking of integrating a successful dental sleep program into your practice #weshouldtalk