Making the decision to branch out into dental sleep medicine, treating obstructive sleep apnea and airway issues with oral appliance therapy requires research, education, a large new learning curve, commitment, patience, and passion. The bad news, doing it well, doing it right, and doing it successfully is challenging. The good news, no one is better suited for this rewarding career move than you, a dentist.
By nature, dentists are “fix-it” people. We love the mechanics of repairing something broken and the immediate satisfaction of seeing the fruits of our labor deliver a “fix”. The incredible feeling of knowing you have helped a fellow human being better their life by relieving pain, restoring function or improving esthetics is our reward. Yet, with all we do as dentists it is rare that we have the opportunity to save a life. Oral appliance therapy and improving airway health has enabled dentists to jump into the world of saving lives. Quite frankly, I believe this is truly what all of dentistry has been heading toward without us knowing it.
Years ago (too many to admit) as a new dentist, I started to see how so many of the dental procedures I was doing were affecting more than just the patient’s teeth. We all have experienced restorative dentistry and prosthodontics and its improvement of neuromuscular health, digestion, and psychological well-being. Then, we learned of how important improved periodontal health crossed into so many co morbid medical problems such as heart disease and diseases like diabetes to make an impact.
The mouth has always been a vital component of our overall health. What we didn’t realize was how vital it was in providing air or perhaps blocking our ability to get air. The need to get oxygen is a very powerful force that will override all other developmental factors as we grow and age. Our tongue posture, occlusal schemes, swallowing issues, speech problems, skeletal growth, brain development, and so many systemic issues arise when our airway is compromised. So many of our patients are grinding their teeth, breaking restorations, loosing bone support, developing endodontic issues & periodontal problems as well as TMD issues secondary to a compromised airway.
I suggest that understanding the mouth, upper airway, and breathing, as a combination science is dentistry’s unknown true calling. We have seen that early intervention of orthodontics and some oral surgery procedures will help improve breathing and cranial facial development. Despite these interventions, many people still require more to provide optimal airway health. The longer I have practiced dentistry with an “airway centric” approach, the more I realize how so much of what we do is still more of an art than a science. We are on the right track, but more needs to be understood.
The mouth is our arena. No one understands the nuances of its development; maintenance, repair and long term care better than a well-trained dentist. The placement of an oral appliance to treat obstructive sleep apnea is a huge responsibility filled with unseen land minds as we use it to treat a life threatening disease. This is our challenge but we are the most qualified of all health care providers to provide this remarkable service.
Once you decide to practice dentistry with airway health as your most important goal, everything you have been taught traditionally in dental school and along your career will take a back seat in importance and priority when treatment planning. The decisions you make for your patients in evaluating, diagnosing, treating, and maintaining their oral health will be guided by their airway. Missing this component in modern dentistry will soon be considered archaic in thought. As an example, we have learned that simply fabricating a “night guard” for nighttime grinding without evaluating for the possibility of OSA may compromise an airway and worsen the symptoms of the OSA. The American College of Prosthodontics recently came out with a position paper stating this and advising understanding OSA in the decision tree of our patients’ treatment. How many of our patients are mouth breathers? We see the dental implications of this; dry mouth, increased caries and periodontal issues. We know that breathing through the nose is the proper and healthier way to breath. This is the kind of red flag that should send out an alarm that this patient’s airway is compromised and therefore not only is their mouth being affected but so is their overall health. As dentists we have the responsibility to understand this. The compromised airway patient may be a walking time bomb with underlying cardiovascular disease, risk of stroke, and excessive daytime sleepiness. Not only does this affect the health of the patient, but the population at large as the associated increase in sleepiness increases the occurrence of industrial accidents and transportation related accidents.
As dentists we are only a part of a larger team treating obstructive sleep apnea for our patients. The decision to make an oral appliance can only be based on a diagnosis of OSA made by a physician and with a prescription given to fabricate one. Once we are given the green light to proceed, the ball is in our hands and with proper training we can do some of the most rewarding treatment under the scope of our license… saving lives!
Although I believe that every dental school should be teaching dental sleep medicine and every dentist should practice with airway in mind, this is not yet the case. Although some universities have incorporated post grad or mini residencies for dental sleep medicine into their curriculums, the population is still vastly underserved. From diagnosis to treatment, we have only reached a small percent of patients that need to be treated. There is an ocean of patients that need our help.
So where does one begin? How do you make the leap into this field? Like any other part of dentistry the ultimate responsibility of your patient’s care will be up to you and in your hands. So just as if you were to incorporate the placement of implants into your practice, I suggest you learn as much as you can and get the best education you can about the field of dental sleep medicine. Oral appliances for treating OSA are a removable prosthesis, for breathing!! Like designing a complex restorative prosthesis, a complete dental evaluation is required. However, now you need to do this with an understanding of sleep medicine in order to have success with OAT. My suggestion would be to join any of the reputable organizations that support university researched educational courses as well as well established, unbiased, experienced practitioners who can share their knowledge. Start slow, learn well, and tread safely as you navigate through the vast amount of information that exists. Many of the manufactures of oral appliances also provide a lot practical information and can help to educate you. Go to meetings and mingle with colleagues. Find a mentor who has already made mistakes and learn from them.
Most dentists are skilled technically and learn quickly. The learning curve here is slow with so many appliances to choose from and so many complex dental factors involved in the decision making as to how to proceed and at what rate to adjust the oral appliance. This just takes time and experience is the best teacher. As long as you proceed with the motto of “do no harm”, and you monitor the progress of your patient’s care closely, you will have success.
Finding your first patients are easy, they are right under your nose in your own dental practice. Learning to screen for OSA should be part of every dentists initial exam. Once you think you have a potential patient, you need to get them into the medical loop. If you refer them to a local sleep center for a sleep study, these facilities and the physicians there will learn that you are available to help treat some of their patients. With time, your dental sleep practice will grow. Building relationships with our medical colleagues is key to practice building. The best you can do is learning as much as you can, become credentialed by organized dental sleep organizations, and deliver successful treatment. Patients will rave and physicians will refer.
You are making a medical device. A new and often difficult part of this will be learning how to bill medical insurance and navigate through the medical insurance guidelines. Like everything else, there is help out there for you provided by professional medical billers as well as courses you can attend that will teach you how to overcome this obstacle. Don’t despair; once you learn the ropes, it will be similar to dealing with dental insurance, just a part of doing business. Like dental insurance, there will be limits and rules and aggravation. It is a frustrating part of medicine to be “controlled” by insurance policies. Unfortunately, more so in medicine, than even in our dental practices, we need to learn to live and practice with this frustration. To say the least it is an eternal battle.
This field is dynamic and evolving even as I write this. Every day new technologies from diagnosis, to practice management, to innovative oral appliance designs are continuing to develop. The digital world has made its presence known and has infiltrated the world of OAT. From scanning images to fabricating appliances, the efficiency of digital technology is here and making an impact.
Incorporating airway health into our practices, treating obstructive sleep apnea, guiding the development of craniofacial development, and working with our medical colleagues to enhance the ability for our patients to breath properly, is the ultimate mission for us as dentists. No other thing we do as dentists has the impact that this has on the lives of our patients. We are guardians of the airway and we have the responsibility to maintain oral health and help provide our patients the ability to breath.
Neal Seltzer, DMD, FAGD, D ABDSM, D ACSDD, D ASBA
Neal Seltzer is a graduate of Tufts University, School of Dental Medicine. Has been in dental practice since 1982 and has been treating patients with oral appliances for obstructive asleep apnea since 1991.
His years of experience and extensive knowledge of oral appliances has enabled him , along with his partner, Jeffrey Rein DDS, and the outstanding staff at Long Island Dental Sleep Medicine, to build one of the largest and most successful dental sleep practices in the New York Metropolitan area.
With over 25 years of knowledge in dental sleep medicine, Dr Seltzer and the team at Long island Dental Sleep Medicine, is the official New York Pro Player Health Alliance office treating retired NFL players as well as the first and only office in New York State to be a Dental Sleep Medicine Accredited Facility by the Academy of Dental Sleep medicine.
Recently, Dr Seltzer, along with several other Diplomates of the ASBA had the honor and privilege, to be selected to speak in front of a congressional caucus in Washington D.C., on the dangers of undiagnosed and untreated OSA and its affect on public safety.