How to Know: Is Now the Time to Add Sleep Medicine to Your Dental Practice?

This is a summary of the webinar, hosted by Henry Schein with featured speaker, Daniel Klauer, DDS. You may watch the webinar here.

Twenty-six percent of adults suffer from obstructive sleep apnea, and 80% are undiagnosed. Roughly one in four patients' dentists see today may have this potentially serious sleep disorder and many are unaware of it.

Practitioners like Dr. Daniel Klauer are working to change that.

Dr. Klauer runs and operates the TMJ and Sleep Therapy Center of Northern Indiana and the Myofunctional Therapy Center in South Bend, Indiana. His practice is 100% focused on TMJ (temporomandibular joint) and sleep therapy, assisting roughly 75 patients a month who are suffering from issues such as headaches, migraines, sleep apnea, snoring, sleep disorders, breathing issues, upper airway resistance syndrome and myofunctional disorders.

Dr. Klauer is also the author of Achieving your Victory:Solutions for TMJ and Sleep Apnea, which educates people about improving restless sleep and decreasing TMJ pain.

Understanding obstructive sleep apnea

Obstructive sleep apnea occurs when the soft tissue of the upper airway collapses, causing a blockage. This sleep disorder causes a person to stop breathing for 10 seconds or longer throughout the night. In 2017, the ADA issued guidelines that all dentists should be screening for sleep-disordered breathing because of all the risk indicators that are visible in their practices.

The financial case for providing sleep medicine

“We got into sleep medicine to advocate for our patients, but you also need to make sure there’s a cash flow so we can keep offering the service to our patients,” explains Dr. Klauer.

Dr. Klauer performs 16 hygiene checks a day. Statistically speaking, 4 of the 16 likely have  sleep-disordered breathing. He works 16 clinical days a month, enabling them to have 64 patients screened per month. If 50% of those follow through with a recommendation for a sleep study, that’s 32 patients. If 50% of those get diagnosed and move forward with treatment that’s 16 patients at $4,500 per case. That adds up to $864,000 of revenue generated a year.

They practice pays a little more than $2,546. a month for cone beam technology. Performing four scans a day for 16 days, they’re generating more than $17,000 a month in revenues.

Treating patient pain

In 2013, Dr. Klauer attended a conference and heard Dr. Olmos speak about craniofacial pain, TMD, and sleep. “It was like a light bulb went off,” he recalls. “I realized we had all these patients right in front of us that have these problems, and we weren't taught in school how to deal with them, but he had a system for that. That's why it really spoke to me.”

Dr. Olmos had a flow chart for treating these types of patients to get them healthy, whether they needed symptomatic palliative care, treatment of apnea with CPAP (continuous positive airway pressure, without CPAP or ortho needs. “He has a scientific model that is reproducible for other practitioners,” Dr. Klauer said. “He took someone like me, who didn’t know much about pain and sleep standpoint, so that I could deliver care like a seasoned professional.”

Exploring sleep medicine

If you’re considering adding sleep medicine to your practice, start by getting professional development. “Get out there and get exposed to the nomenclature, learn the way an exam goes, what goes into it, and the relationships you need to foster to succeed in sleep medicine,” advises Dr. Klauer. The first step to determining if sleep medicine is right for you is to take a course. This could be:

• Academic courses through the AACP, the AADSM, or AAPMD

• Lectures by a physician such as Dr. Olmos, Elliot, Spencer, Smith, Viviano, Tucker, or Patel

• Industry-sponsored courses such as through Sleep Group Solutions

• Vendor-sponsored courses from Henry Schein

Workflows for diagnosing and treating craniofacial pain and sleep disorders

In his practice, Dr. Klauer uses a screening form, asking patients questions such as:

• Do you take medications for headaches?

• Do you take medications to go to sleep?

• Do you feel rested in the morning?

• Have you ever been told to wear a CPAP?

He then applies the Epworth sleepiness scale to gauge the level of fatigue and tiredness of the patient. The practice uses cone beam technology to look at the patient’s jaw joint, the craniofacial development, as well as the nasal passages.

Capital investments

Dr. Klauer selected a 3Shape TRIOS system, an i-CAT CBCT system, as well as a joint vibration analysis system that measures the friction inside the jaw joint. He then bought a MediByte, a home sleep test unit for performing interim tests.

“I really enjoy having that 3D image and I find that tremendously valuable in evaluating these patients with TMD, craniofacial pain, and apnea,” he said. “It's so valuable to look at all three dimensions of the condyle. It gives you more information. Without a doubt, case conversion is also going to be higher with implants with a cone beam, where you can actually show a patient how to put the implant in, where it's going to go, you show them the precision and the guidance.”

Dr. Klauer also invested in building a team, working with nurse practitioners, myofunctional therapists, orthodontists, sleep and ENT rehab specialists, and musculoskeletal pain doctors. “If you're doing a ton of ortho, you really do want a myofunctional therapist because that'll be paramount in getting good results,” he said.

“Team training is huge. You need to spend money on professional development, including practice management help, leadership courses, and continuing education. I brought my team to a lot of sleep and TMJ courses over the years to get them trained. Once you have clinical training, you need to market to the community to attract new patients.”

Educating patients about sleep disorders

At Dr. Klauer’s practice, he shows patients scans of what a normal anatomy looks compared to what their anatomy looks like. He walks patients through the process of screening, diagnosis, and personalized treatment plans. He then shares the scans with patients so they understand what was diagnosed and what was performed.

Collaborating with physicians to help patients

Building a presence in the sleep disorder sector involves communicating with physicians, dentists, chiropractors, physical therapists, and psychologists in the area to let them know this type of practice is available to their patients.

“Once you start to accept patients as referrals and you get your name out there, you’ll start to build relationships with physicians, but the easiest way to get referrals is to send referrals out and they come back,” Dr. Klauer said.

Incorporating to sleep medicine

Practitioners who are new to sleep disorders may choose to screen patients and advise them to participate in a sleep study or talk to a physician, or they may screen patients, refer some out, and then start to offer treatment. “Once you’ve had ample training, you can have patients come back to discuss what an oral therapy appliance looks like, discuss the risk indications, and get an order from the physician or sleep physician to fabricate the oral appliance,” advises Dr. Klauer.

“Once you start dabbling in sleep disorders, what we most commonly see is practitioners starting to offer more of this in their practice. It’s a good idea to dedicate half days or particular days to this, because it’s such a dynamic mental shift to go from performing general dentistry to the types of conversations we have around sleep and pain. It’s hard to go back and forth.”

Some practitioners create a different entity within their practice, so that patients have a bit of a different experience than when they come in to get their teeth cleaned or to get a filling. “You might consider creating a separate brand,” Dr. Klauer advises. “It can be under the same roof and share overhead but typically has different staff, its own phone system, and so forth. At some point you may form a separate, independent practice with a different location that’s 100% focused on craniofacial pain and dental sleep medicine or just dental sleep medicine if you choose.”

“One of the most profound things I remember hearing was Dr. Jameson Spencer saying that dental sleep medicine is easy if you're an expert of the TMJ. I think there's a lot of truth to that because of the overlap of those two branches. We're seeing more and more of that. Dental sleep medicine courses are in fact talking about craniofacial pain, TMD, and the relationship between these.”

Clinical case examples

Below are some recent case examples:

Ivan was a dental patient who presented complaining that his teeth were grinding off. The scan showed a mild obstructive sleep apnea. Ivan got his nose fixed, and the ENT sleep physician provided an order to fabricate new oral clients. Dr. Klauer then performed a follow up sleep study to see how Ivan was doing. He is now in a stable position with no TMJ issues and is sleeping well. Five years later, Ivan has lost weight and his master hypertrophy is decreasing as well.

Rocco is a healthy 37-year old who presented with TMJ problems. He wanted to be able to relax his mouth and jaw and not feel so tense all the time. He had been through multiple orthotics with multiple different dentists and seven different appliances over the years. He had dizziness, anxiety, muscle spasms, and was tired.

What bothered him most was that he had an open bite, so he didn’t know where to bite. Dr. Klauer performed an evaluation and recommended that Rocco receive a diagnostic sleep study and see an ear, nose and throat physician for his nasal valve issues and his deviated nasal septum. The treatment plan involved starting with myofunctional therapy to help keep the tongue in the roof of the mouth and help treat that lateral open bite.

Dr. Klauer was able to get the jaw pain under control and Rocco then went ahead and got braces. After discovering that Rocco had mild sleep apnea, Dr. Klauer started treating the jaw joint dysfunction using myobrace and myofunctional therapy. In eight weeks, Rocco started to see his bite closing and within roughly three months, the bite was reestablished as normal.

After Rocco got his nose fixed, he still had some sleep apnea, so Dr. Klauer devised an oral appliance for him. This helped Rocco’s bite feel better, and actually improved his posture, which also alleviated his neck pain.

Conclusion

“Our goal is to offer a stellar patient experience,” said Dr. Klauer. “These are the type of results you can get with patients – taking away significant pain and improving their breathing. You can see pretty significant changes.”