treating sleep disordersIn a previous article, I went over some of the chief concerns to be aware of when treating a patient with a sleep disorder. Effectively treating these patients requires enhancing our perspective and for us to think like a physician.

This exciting challenge stretches our knowledge and requires better systems and team training. We must adapt to new terminology and pay attention to details previously unconsidered. E&M medical coding requires proper documentation of details not normally noted in dentistry.

History and comorbid conditions In our practices, we’re used to screening for things like blood pressure, oral cancer and other various issues. Even though we don’t treat these ailments, we do need the ability to understand the impact treatments may have on some of those conditions. This includes current medications the patient is currently on and how they can be affected by your treatment. My grasp of pharmacology has blossomed since I started learning about many medications.

Review of systems This means you go through their whole body systems similar to what you experience at your physician’s office during a physical. This can be done by questionnaire, and you don’t need to ask about every positive answer; getting a sense of your patient's total health picture will help you understand how best to coordinate with their medical providers and set expectations for therapy outcomes. For example, a person who has battled chronic pain for a decade is probably not sleeping well; you would not want to “overpromise” on sleep quality with your oral appliance therapy.

What treatments have they already tried? This one is critical. It may not occur to you to ask questions in this area, because with dental problems, it’s rare they have tried other remedies before sitting in our chair. In medicine, a lot of patients will try different things for treatment – including sleep disorders. By inviting patients to share what they have tried, you create the culture of safety and collaboration that will form the foundation for the cooperative care behavioral therapy such as appliance use requires. Don’t laugh when they talk about using an “anti-snoring spray,” thank them for being honest and ask how it worked for them. This goes a long way toward getting to know your patient.

Nasal airway exam There are parts in the nose that affect the way air flows through. Dentists can look in the nasal passages and see how much restriction is present which can directly affect the expectations you set. Someone with severely crowded nasal airway may need an appliance that easily allows mouth breathing, and you may want to set the stage for an ENT referral as therapy proceeds.

Throat evaluation This means you are able to look past the teeth and back of the tongue to get a look at the uvula and tonsils. This can help you make a determination of what is going on in their throat so you can talk intelligently to your patient about issues that may be present. This can also reveal if they have had any throat surgery to help open up the airways.

Steve Carstensen, DDS


Commenter's Profile Image Will Baker
January 29th, 2013
A mallampati photo, and a depressed tongue photo at the new patient exam have been good conservation starters about apnea and its cause/effects. We also use these photos in pedo pts for ENT consults/ behavior/ bed wetting/ ADHD etc...
Commenter's Profile Image Muna Strasser
January 31st, 2013
When I begin this discussion with a patient with positive signs and symptoms, in addition to the appropriate documentation of nasal airway , pharyngeal airway, Epworth Scale,and Thornton Scale, I register the patient's height, weight, BMI and neck size in inches and ANC. I give the patient a pulse oximeter to wear overnight and return to me, such as one made by Virtuox. I upload the results, and get a summary report of SpO2 and heart rate which I send to the physician with a letter to support a preauthorization for a sleep test. It's simple, non-invasive, and takes just a few minutes. I have been surprised by how many patients have been helped by this simple monitor, and some physicians are simply resistant to request tests unless they see the proof...
Commenter's Profile Image Steve Carstensen
February 1st, 2013
Muna, you are serving your patients very well with the documentation you provide. Pulse Oximetry has some controversial use as a population screener because many people with SDB do not desaturate so false negatives are a bit troublesome. What if you have all the other signs of high risk but the oximeter shows no desaturations? Might you give a skeptical patient a reason to not see the sleep MD? This is not a deal killer but be careful with the conversation you have with the undiagnosed patient. STOP-BANG is pretty great for sensitivity and sensitivity and can motivate a great number of people to seek diagnosis. I'm in favor of the simplest possible way to get folks in to the lab/HST to establish their diagnosis. I use pulse-ox just like you do if I need to motivate someone, but not everyone. After diagnosis, pulse oximetry is well proven as a way to measure MAD effect, but only if the patient shows desats on the diagnostic study - people with flow limitation/no desat need a monitor that measures flow or heart rate variability to see if there is any therapeutic benefit, and interpreting sophisticated heart signals is out of the scope of most dentists. The device you cite, VirtuOx, has capability found in few other devices. By connecting with the sleep MDs in the area and gaining common understanding of how the data can be used, you can provide them with excellent information and become a valuable contributor to the treatment team. It's not simple to practice at this high level - it's a ton of fun, but not simple - so setting yourself apart with this level of distinction is certainly a commitment. Good for you!