Sleeping Giant

Awaken the Production Potential of Sleep Dentistry.

People who suffer from obstructive sleep apnea (OSA) may have a longing to sleep just like the giant does in the above photo. However, this luxury isn’t an option for many OSA sufferers unless medical intervention is taken. Oral appliance therapy (OAT) from dental providers may offer relief, particularly in mild-to-moderate cases of OSA. Differentiating your practice from other dental practices is one of the most effective ways of growing your business. To enhance your value proposition and set yourself apart, you don’t need to look far.

Sleep Dentistry (a.k.a. Dental Sleep Medicine) has emerged as a promising growth sector within the broader dental industry. According to the American Academy of Dental Sleep Medicine (AADSM), dental sleep medicine is, “An area of dental practice that focuses on the use of oral appliance therapy to treat sleep-disordered breathing, including snoring and OSA. Dentists work together with sleep physicians to identify the best treatment for each patient.” OSA is classified as an obstruction of the airway, whereas central sleep apnea is a failure of the brain to signal the muscles to breathe.

Dr. B. Gail Demko of Sleep Apnea Dentists of New England in Weston, MA, focuses her practice solely on sleep dentistry. In 1997, Dr. Demko stopped practicing general dentistry in order to service patients with dental sleep disorders. In an interview with Dentistry IQ magazine, Dr. Demko said, “With more than 80 percent of the sleep-disordered breathing maladies undiagnosed, the vast majority of patients are not even seeking help. Most dentists do not even ask if a patient snores. For me, this simply highlights the great opportunity that exists for dentists interested in providing sleep solutions for their patients.”

When it comes to dental sleep medicine, dentists often assume that their patients won’t want to pay for treatment—their assumption is that patients will only want what insurance will cover. Keep in mind, that most insurance benefits will cover OAT for diagnosed OSA patients. Generally, insurance companies will not approve OAT for snoring only. Dentists shouldn’t underestimate what their patients may opt for, particularly when it comes to getting a good night’s sleep.

Benefits of Sleep Dentistry:

1. According to the American Sleep Apnea Association (ASAA), “An estimated 22 million Americans suffer from sleep apnea, with 80 percent of the cases of moderate and severe obstructive sleep apnea undiagnosed.” The sheer number of people suffering from some form of sleep apnea means that most dental practices already have a sizable patient population that may benefit from dental treatment.
2. ASAA further reports that, “approximately 90 million Americans suffer from snoring activity during sleep.” Again, most patients who suffer are simply unaware that help may be available with oral appliance therapy.
3. AADSM reports that more than 100 oral appliances have received clearance from the U.S. Food and Drug Administration (FDA). Custom appliances are available for dentists and patients who decide that oral appliance therapy may help.
4. In 2015, the global sleep apnea diagnostic and therapeutic devices market was $3.7 billion and is estimated to reach $5.3 billion in 2020, growing at a compound annual growth rate (CAGR) of 7.2 percent from 2015 to 2020 (according to a MarketsandMarkets report). The projected growth potential of the sleep dentistry market is similar to growth projections for more traditional dental treatments.
5. In an October 21, 2015, news release, Transparency Market Research reported that the dental prosthetics market (including bridges, crowns, veneers, dentures, and others) was $3.0 billion in 2014, and is expected to grow at a CAGR of 7.6 percent from 2015 to 2023 to reach an estimated value of $5.8 billion by 2023. Adding sleep dentistry to more traditional dental treatments increases revenue potential and capitalizes on two areas of growth.
6. The common treatment for those suffering from OSA, continuous positive airway pressure (CPAP), is onerous. A patient is required to use a mask, a tube, and a machine with a motor, which can be difficult to tolerate—therefore, longterm compliance is a major issue.
7. The AADSM and the American Academy of Sleep Medicine (AASM) consider OAT a first line of treatment for mild-to-moderate sleep apnea and as an alternative for patients who do not tolerate CPAP. Therefore, dental sleep medicine can dramatically increase the value proposition that dentists can offer their patients.
8. The appliance therapy options currently available allow chairside interactions that are quick and create a recurring interaction with the patient. OAT typically requires three to four appointments for the initial treatment, and then annual or semi-annual recall appointments.
9. Current continuing education (CE) offerings and the overall movement towards appliance therapy and away from invasive surgery have dramatically lowered the bar for dentists to add this type of dentistry to their practice.

Patient Potential
MayoClinic.org suggests that as many as 1 in 15 adults has moderate to severe OSA. Consider how many patients of record you currently have and divide that by fifteen. This becomes the number of potential patients for which a whole new series of treatment options can be offered just within your practice. The best part is that these treatments do not cannibalize any of your existing

services. Instead, they increase the perceived value that you bring to patients and create a new revenue stream. In addition, sleep dentistry allows dentists to deliver significant health and quality of life benefits to your patients.

Obstructive sleep apnea is often accompanied by severe health consequences (see sidebar on page 34, “Comorbidities of Sleep Apnea”). The upside for patients and the potential to provide solutions that differentiate your practice from other dental practices is significant.

Continued Growth

Not only does sleep dentistry provide dentists with an opportunity to differentiate themselves, it also offers a compelling growth potential. This growth is driven by a number of key factors, including:

• The large number of patients with sleep apnea and other sleep disorders.
• An increasing awareness by the general public of dental treatments for sleep disorders.
• The growing number and use of oral appliances.
• The availability and increased use of cone-beam imaging, which allows highly accurate imaging of a patient’s airway while he or she is in the dental office.
• Patient dissatisfaction and general non-compliance with traditional treatments like CPAP.
• Ancillary health problems associated with sleep apnea.

OSA Treatments
Today, typically only patients with severe OSA opt for surgery as a form of treatment. For sleep apnea patients, a surgical regimen is catered to the individual, based on his or her unique symptoms and the severity of the obstruction. Sometimes a combination of surgeries is recommended and success rates can vary widely. A New York Times report on sleep apnea entitled “Sleep Apnea In-Depth Report” found that, “Success rates for sleep apnea surgery are rarely higher than 65 percent and often deteriorate with time, averaging about 50 percent or less over the long term.”

Further, sleep apnea surgeries have a history of being excruciating for some patients. In April 2008, David Yu, a publishing director, told Health magazine that sleep apnea surgery (tightening the upper palate and removing scar tissue from a tonsillectomy) was “the most painful 14 days I’ve ever been through.”

The gold standard for severe OSA patients is the CPAP machine, with success ranging in various studies from 80 to 95 percent. As noted previously, however, the problem with CPAP is simply patient compliance. When people return home, there’s a good chance they just won’t use the CPAP machine.

Fortunately, the largest numbers of patients who suffer from sleep apnea are in the mild-to-moderate categories. (The severity is based on the number of times in an hour that an individual stops breathing, or that airflow to the lungs is reduced. The definition includes a reduced or stop in airflow for ten seconds or longer during sleep). According to WebMD, mild apnea is defined as “5 to 14 episodes of apnea or reduced airflow to the lungs every hour.” Moderate apnea is defined as “15 to 29 episodes of apnea or reduced airflow to the lungs every hour.” Severe apnea is defined as “30 or more episodes of apnea or reduced airflow to the lungs every hour.”

Based on an individual diagnosis, treatment may include OAT. Some of the advantages of OAT are that the appliance is comfortable, easy to wear (which increases compliance), easy to care for, non-invasive, easily adjustable, and can provide an increased air passageway. Understanding the importance of OAT is vital in the treatment of sleep apnea. According to the American Sleep Association, OAT is typically used for mild and moderate OSA, as well as for severe cases in which CPAP cannot be tolerated. By incorporating sleep apnea treatment into your practice, you can further enhance the services you offer and help improve your patients’ overall health.

The Sleep Dentistry–Cosmetic Connection
Another great feature of sleep dentistry is the natural synergy it has with large-case cosmetic and reconstructive dentistry. With much of the treatment modalities in sleep dentistry centered on appliance therapy, the changes that can result in the treatment of sleep apnea naturally lead to discussions of the benefits of full arch reconstruction and large cosmetic cases. Many of the sleep appliances on the market seek to modify the placement of the jaw while the patient sleeps. In certain cases, the suboptimal jaw position and the resulting constriction of airflow can be the primary factor in a patient’s sleep disorder. In such cases, optimization of the patient’s smile, including splint therapy and changing the occlusion, may offer a solution to the problem.

Some oral appliances seek to treat the underlying causes of sleep apnea by increasing the size of the airway via palatal expansion. One of the side effects of this approach can be the creation of gaps between the existing dentition. Here again, there is the opportunity of engaging patients in improving their smiles, once the treatment of the underlying sleep disorder has been completed. It is much easier to present a reconstructive or large cosmetic case to a patient who has already experienced the value and lifestyle enhancement obtained through the sleep dentistry treatments. Finding and using the synergistic relationship between sleep dentistry and cosmetics is a way that sleep dentistry can increase your production and perceived value to the patient.

Continuing Education
Today, more than at any other time, CE offers general and cosmetic dentists a clear path to adding sleep dentistry into their list of specialties. The movement towards more appliance-based approaches in lieu of surgery means that in a relatively short time period, sleep dentistry can become a strong contributor to your practice’s overall production. Regulations for dental sleep medicine may vary according to each state, so make sure to check with your state for any specific requirements. In addition, find a CE provider with an infrastructure in place to help you with technical support, and a lab that can produce and advise you on the different treatment options available for sleep dentistry cases.
The ultimate goal in dentistry is to provide optimal care for patients. Therefore, dentists should reach out to all their patients to ensure they are not suffering from sleep-disordered breathing, and if they are, take the necessary steps to help them alleviate the disorder. No one should ever look longingly at a statue of a sleeping giant and think, ‘I wish I could sleep as peacefully as him!’ Instead, help patients so that they confidently smile and say, ‘Yes! I get to sleep that way every night! And I feel fantastic because of it!’

COMORBIDITIES OF SLEEP APNEA

Since the comorbidities of sleep apnea can be very detrimental, it’s important to make the value proposition of sleep dentistry clear to your patients. These comorbidities have been shown to lead to a number of health problems. Here are five of the most serious:

1. High Blood Pressure (Hypertension)—Obstructive sleep apnea can contribute to high blood pressure in people who have it, due to the frequency of waking up at nighttime. Because of interrupted sleep, hormonal systems go into overdrive, which results in high blood pressure levels. The sudden drops in blood-oxygen levels that occur during sleep apnea episodes increase blood pressure and place a strain on the cardiovascular system. According to MayoClinic.org, “multiple episodes of low blood oxygen (hypoxia or hypoxemia) can lead to sudden death from an irregular heartbeat.”
2. Cardiovascular Disease—The links between sleep apnea and heart disease are strong. Donna Arnett, PhD and professor at the University of Alabama told the American Heart Association that “The evidence is very strong for the relationship between sleep apnea and hypertension and cardiovascular disease generally, so people really need to know that.”
3. Type 2 Diabetes—If a patient has type 2 diabetes, it is common to also suffer from sleep apnea. The International Diabetes Foundation suggests that up to 40 percent of people with OSA will have diabetes. The combination of type 2 diabetes and sleep apnea is often accompanied by another comorbidity of sleep apnea—obesity—as well as other potential complications.
4. Acid Reflux—Although research is inconclusive about the link between sleep apnea and acid reflux (a.k.a. persistent heartburn), many people with sleep apnea report symptoms of acid reflux. As a result, treatment of sleep apnea appears to improve some symptoms of acid reflux, and vice versa.
5. Obesity—An increase in weight raises the risk of sleep apnea, while losing weight can help ameliorate symptoms of sleep apnea. When people are severely overweight, they may fail to breathe rapidly enough or deep enough. When this occurs, low blood oxygen levels and high blood carbon dioxide levels result. And when that happens, breathing may cease altogether for short periods of time during sleep. This pattern places an extreme strain on the heart, which can lead to symptoms of heart failure.