British Society of Dental Sleep Medicine members explain how to add dental sleep medicine to your practice
Snoring isn't just an embarrassing, annoying noise – it's documented to be a sign of obstructive sleep apnoea (OSA) or airway blockage and a potential killer. It's linked to long-term chronic disorders such as raised blood pressure, adult onset diabetes, carotid artery and increased risk of stroke.
OSA, resulting in serious sleep disruption, can produce greatly impaired performance at work, at home, and on the road; car accidents are statistically much more common in this group.
Snoring is caused by partial airway obstruction. The severity of the health effect varies widely. Dentists are perfectly positioned to screen for the signs and symptoms which may predict the presence of OSA and refer such patients to a respiratory physician for further diagnosis. If OSA is not suspected then the trained GDP is ideally placed to treat the snoring patient with a mandibular repositioning device (MRD).
In addition, dental sleep medicine is an interesting and rewarding skill to introduce into your practice. Kirsten Rogers introduced a dental sleep medicine (DSM) service into her practice at 53 Wimpole Street, London.
She says: "Starting a dental sleep medicine service in your practice is easy. Being a relatively new field in dentistry, it would be prudent to seek out non-commercial post-graduate courses. By attending a short course with the BSDSM you will gain a solid foundation of knowledge and be well on your way to successfully managing patients with snoring and sleep related disorders.
"Joining the Society gives you access to a complete clinical guide so that you are ethically covered and standardised for every case. It's a non-profit organisation run by genuinely caring dentists with years of experience in dental sleep medicine. The President, Dr Roy Dookun, has co-written (with Professor John Stradling, one of the most eminent respiratory physicians in the UK) a protocol for dentists which has been approved by Dental Protection and the Dental Defence Union. If you follow it you are not going to incorrectly diagnose and treat patients. This is how to remain ethical in a complex new specialty and it's the first and only dental sleep medicine pre treatment screening protocol for dentists in the world."
In the past years a number of patients of Oraprime Orthodontics in Whitley Bay asked if they could be fitted with devices to prevent or reduce their snoring. Leading on from this, Murray Waldron, an experienced consultant ENT surgeon, opened The Snoring Centre at Oraprime Orthodontics in May 2012.
At the first consultation, Murray Waldron provides patients with a detailed, individualised assessment including examination with a naso-endoscope. After this, a report is sent to the patient and their general practitioner with detailed findings and appropriate treatment options. If patients are found to have OSA, or a suspicion of it, The Snoring Centre can arrange overnight sleep studies for further diagnosis.
Granta Dental is a private practice in a residential area close to the centre of Cambridge and was established by Dr Helen Harrison in 1990. With her special interest in TMD and occlusal problems, Helen has always sought to give patients a much clearer understanding of the links between their dental experience and the function of their whole oral and cranial systems (including their breathing).
When Dr Thomas O'Connor joined the team in 2013 he brought his knowledge and training which he gained from the BSDSM with regard to sleep apnoea and provision of mandibular repositioning devices and Granta Dental began to provide home sleep studies with the ResMed ApneaLink monitoring system.
Helen Harrison says: "Together with some further training with the BSDSM for all three dentists on the team and the implementation of its clear protocols and pathways for assessing and managing the presentation of sleep disorder in our patients we can now offer a much more comprehensive and clearly understood approach to patient care.
"Many patients are totally unaware, or in denial of, the significance of the signs with which they present. For example, evidence of nocturnal bruxism, dental erosion and snoring. Often on further investigation they are found to have some degree of sleep disruption and they see immediate benefits with the oral appliances – which also benefits their dental health.
"In keeping with our ethos of evidence-based treatments and measurable outcomes, all the mandibular repositioning devices we use are adjustable and titratable. We provide follow-up with further home sleep studies and are delighted to find that the anecdotal improvements reported by patients and their partners are backed up with genuine improvements in measurable sleep function and a reduction in the Apnoea Hypopnea Index.
"The ability to offer a worthwhile service to patients with a home sleep study has introduced a new income stream to the practice, improved our communication with GPs, medical specialists and the hospital services, and is a welcome demonstration to our patients that our role as dentists in the health and wellbeing mix stretches well beyond the maintenance of good looking smiles."
One of the objectives of the BSDSM is to 'educate and support practitioner dentists' and in pursuit of this it runs regular one-day workshops which are virtually essential for dentists wishing to introduce DSM to their practice. Each workshop provides an overview of sleep-disordered breathing, shows how mandibular appliances work (with examples and the advantages and disadvantages of each) and how participants should assess and monitor their patients. Custom and non-custom devices are described as well as pre-treatment screening and medico-legal issues. Hands-on George Gauge™ sessions provide a quick, easy and reliable method of recording a protrusive registration.
The workshops includes tips on how to introduce a dental sleep medicine service into a practice and delegates receive a comprehensive course manual, as well as the BSDSM screening protocol – accepted by Dental Protection (UK) Ltd, the Dental Defence Union and the Association of Respiratory Physiology and Technology (Standards of Care doc relating to MRD therapy).
The next BSDSM course is on 18 October in central London and information about this and membership of the society is on: http://www.dentalsleepmed.org.uk/
Ten tips for introducing dental sleep medicine (DSM) to your practice:
1. Go to www.dentalsleepmed.org.uk for more information and details of BSDSM courses.
2. Educate yourself with non-commercial courses in DSM.
3. Explore a variety of custom-made mandibular repositioning devices (MRDs).
4. Introduce yourself to local medical practitioners and specialists in respiratory medicine and ENT.
5. Add a simple screening question to your patient medical history form: 'Do you snore?'
6. Decide on your fee scale – a standard initial assessment fee then an overall fee for providing an MRD (each device will have a different cost) and initial follow-up visits for adjustment.
7. Obtain a selection of tools such as a George Gauge™
9. Be primed with questions when speaking with patients and know the Epworth Sleepiness Score (ESS) inside out.
10. Allow at least an hour for a new patient's first visit for a snoring and OSA assessment and possibly impressions for an MRD.
George Gauge. Credit: Eurodontic