Dental Sleep Medicine's Flawed Priorities - The Secret To Waking Up Refreshed

By John L. Bouzis, DDS

Dental sleep medicine has its priorities all wrong, and people with undiagnosed and untreated obstructive sleep apnea (OSA) are suffering as a result.

Despite the American Dental Association telling dentists to screen for OSA in 2017, as recently as January 2024 59% of dentists reported not screening. As a dentist who has exclusively practiced dental medicine for five years, I can’t say I blame them. With the complex, disparate processes dentists need to navigate to screen, refer, treat, monitor, and bill for sleep apnea-related services and devices, sleep isn’t worth the hassle for too many.

And the newer the dental practice, the more likely it is to embrace a dental support organization, which makes it likely (with a few exceptions) to not embrace sleep.

Limited pods of success continue to prevent us from addressing the real issue: people whose sleep apnea is undiagnosed and those who fail CPAP or who use it only for the bare minimum of four hours a night.

If we continue this way, dental practices that are willing to identify patients at risk for OSA, as well as those that deliver custom oral appliances for OSA, will not grow in number but will diminish.

Numerous Priority Problems in Dental Sleep Medicine

I see several big problems with dental sleep medicine’s list of priorities.

Dental sleep is too product-driven. This can be seen at any dental sleep conference where the exhibit hall aisles are flush with companies marketing their particular product—be it a cone beam CT scanner, a pharyngometer, or another widget—as the “solution.” Sure, some technologies are useful, but none are standalone solutions. I think players are stuck on their own success, while patients have been moved down the priority list.

Even dental sleep education is product-focused. And the unbiased education, such as earning Diplomate status, costs a whopping $8,000, and the requirements have been dumbed down so much (with fewer case studies required and fewer outcomes reported) that the credentials mean much less than they did even a few years ago.

What’s more, in an administratively burdened restorative practice, it does not take long to realize that juggling sleep takes the practice away from its primary niche.

Then there are the payor-related problems: Waiving your rights to reimbursement to appeal a denied network gap exception claim is one example. Another is that dentists are sometimes designated by the payor as “in-network providers” upon submitting a claim—even when we are not—forcing us to abide by the payor’s in-network terms for the allowable and preventing us from balance billing.

Seamless Workflows Are Needed

In my opinion, there are too many moving parts for the average dentist to be expected to play any role in dental sleep medicine.

So instead of trying to bring more of our dental peers to the dental sleep medicine table by either shaming them or continuing to teach an unworkable process, patients would be better served if we research why so many dentists choose not to screen their patients—and then design a simplified system that works.

Oral appliance brands come and go. It’s the process that sticks. And our processes need to be fixed. Dental sleep medicine needs a simple and device-agnostic process to improve efficiency and reduce the costs of delivering care.

I have noticed a few dental sleep companies headed in the right direction. I am not paid by any of these companies, nor do I even use all of these potential solutions in my practice. But I like that they are attempting to deliver seamless ways for dentists to screen, refer, treat, monitor, and/or get paid for caring for patients with OSA.

Screening for OSA

For general dentistry practices, Daphne Sleep could be a screening solution. The software allows administrative staff to send recall patients a digital screener with custom messaging before their visit. Upon completion, patients are directed toward an educational video that warms them up to the conversation to be had at their appointment. Should further identification of risk be indicated, the patient can use a high-resolution pulse oximeter by the software’s parent company (Patient Safety Inc), SatScreen, which yields a pattern-based report including respiratory disturbance index, which I have found to be physician-friendly. Other tracking features reside within the software.

OSA Diagnosis

VirtuOx is also involved in this improved workflow effort. It provides home sleep testing (HST) with more than one brand of HST available to be mailed to a patient’s home. The company is also looking into integrating at least one brand of oral appliance into its updated HSATPRO software platform and other possible integrations that would result in a large data set and perhaps lead to a better understanding of phenotyping.

Monitoring Therapy Longitudinally

Australia-based Good Sleep Co is new to the United States, but I’ve been trying out their services (without compensation from the company) for about seven months. Good Sleep Co markets and manufactures its own oral appliances, but what I like is that its SleepCare App allows for any oral appliance to be tracked longitudinally via integrating metrics from the SleepImage ring.

Also, Good Sleep Co does direct marketing that allows consumers, should they choose, to begin treatment with a temporary trial appliance, then coaches them toward a custom-fitted one. What’s more, through the app consumers can schedule with a trained dental provider for their care.

We need more oral appliance longitudinal monitoring options that are not embedded in an oral appliance like Braebon’s sensor is. Those single-oral appliance sensors also tend to add around $300 to an appliance’s cost.

Better Billing for Oral Appliances

As reported in Dentaltown, dentists consistently identify billing and insurance as their most challenging issues. Here, too, we need simple solutions.

I like the work of Dental Sleep Solutions (DSS) and Comprehensive Sleep Services as they are integrating medical billing options into their workflows. Comprehensive Sleep Services provides medical supervision with predictable reimbursement by the 15th of the month after the delivery of the device.

Essentially, dentists get an immediate profit center and a protocol that fills the void between identifying a patient at risk, all the way through device delivery. Comprehensive Sleep Services even handles portions of the consultation and all of the financial arrangements directly with the patient, leaving the dentist and their staff free to tend to other aspects of their practice. So for a dentist, you only need to get the clinical part right, and Comprehensive Sleep Services takes care of the rest.

Meanwhile, DSS has been asked to identify a small group of high-achieving providers to integrate the process if Good Sleep Co’s appliances receive PDAC approval. DSS users will be able to select either 4 Pillar Billing or Comprehensive Sleep Services on a patient-by-patient basis, and inexperienced users will be offered an educational process, staff coaching, and a bimonthly study club to advance their skills and troubleshoot cases.

Take Action to Support People with Untreated OSA

With patients suffering from this disorder at an epidemic level, the dental profession can no longer remain on the sidelines.

For educators in the field, I hope rather than only focusing on what works for you that you join an effort to find solutions for the many moving parts of dental sleep medicine that clearly don’t work for anyone, whether it be patients, providers, or the industry itself.

Perhaps removing insurance barriers, providing a learning platform, and offering appliance availability through one imaginative integrated source will make it more desirable for dentists to get involved in screening and care for patients with OSA.