Three Big Questions

The president of the American Academy of Craniofacial Pain tackles cost, efficacy, and results.

Dentists with experience in sleep medicine hear the same three questions over and over again: 1) Why are oral appliances so expensive?; 2) Are oral appliances ever covered by insurance?; and 3) How do I know if oral appliances are effective? As a fol- low-up to number three, physicians usually want to know why patients they refer for oral appliance therapy rarely, if ever, come back for follow-up.

Cost
The fee that most dentists charge—and that most insurance companies pay—usually takes into account everything that dentists do for patients. These services often include x-rays, examinations, treatment planning, dental impressions, and model fabrications. Factor in a laboratory bill for custom appliances (which can be as high as $600), plus fitting and 90-day follow-up, and the typical fee by a dentist who knows what he is doing can be about $2,000 to $3,000.

Jamison Spencer, DMD, MS, president of the American Academy of Craniofacial Pains, knows that sleep physicians don’t always refer to dentists who have extensive experience with oral appliance therapy. “An assumption is often made that all dentists are equally proficient in dental sleep medicine and oral appliances,” says Spencer, a dentist with practices limited to dental sleep medicine and craniofacial pain in Boise, Idaho. “This is absolutely not the case. Dentists receive virtually no education regarding dental sleep medicine in dental school, and many dentists will choose appliances based on dental magazine advertisements rather than education or training.”

Spencer concedes that less experienced dentists may charge a few hundred dollars less than clinicians with hundreds of hours of continuing education, but outcomes will often be less than satisfactory. “I have had many patients referred to my office after being fit with an inferior appliance by a well-meaning dentist who didn’t really understand oral appliance therapy,” laments Spencer. “In the end, the patient pays more than if he had been referred to my office in the first place.”

Coverage
Sleep physicians are often surprised to learn that oral appli- ance therapy is generally covered by medical insurance, as long as the patient meets criteria for treatment—and Spencer confirms that this criteria is the same as CPAP. While insur- ance coverage usually exists, including through Medicare, most dentists are not aware of how to work with medical in- surance companies or Medicare.

It usually ends up that only dentists who are serious about oral appliance therapy to acquire the knowledge and resourc- es necessary to work with third party payers, Medicare, and Tri- care. Spencer is contracted with many insurance companies, including Medicare and Tricare. He acknowledges that it took years to make it happen.

Efficacy
Sleep docs know the literature regarding oral appliance ther- apy and AASM guidelines. Most are also aware that oral appliances are effective, particularly in mild to moderate OSA. The problem is that patients often do not receive appropriate and objective follow-up.

Once again, this may have to do with whom the sleep doc- tor is sending his patients . Most dentists have their patients’ best interests in mind, but good intentions are not enough. “They usually will not even be aware that their patient should be evaluated in the sleep lab to confirm that the oral appliance is effectively treating the patient’s sleep apnea,” says Spencer. “The only way to know if the oral appliance therapy is work- ing is for the patient is to get back to the sleep lab. While this often requires some patient education, to convince them to go in for yet another sleep study, most patients understand the importance of confirming that the appliance is helping.”

Most insurance companies and Medicare will pay for these follow-up studies, but what about those who don’t have insur- ance coverage, or those who have high deductibles? For these patients, Spencer has developed an oral appliance called the Silent Sleep that is non-custom, but fits in a unique way.

Typical “boil and bite” appliances are difficult to fit, lack retention, are bulky, uncomfortable, and often ineffective. The Silent Sleep is fit using an impression-type material that is odorless, tasteless and durable. “The time for the dentist to fit the appliance is less than 10 minutes, and the complete cost to the dentist is low,” says Spencer. “This is opening up treatment to those who can’t afford CPAP or custom appliances, and is also a great option for those diagnosed as primary snorers.”

Spencer believes that sleep professionals owe it to their pa- tients to coordinate care with dentists who are trained and ex- perienced in dental sleep medicine. A good way to ensure this is for sleep physicians to look for dentists credentialed by the American Academy of Dental Sleep Medicine and the Ameri- can Academy of Craniofacial Pain (AADSM.org and AACFP. org). These dentists will understand dental sleep medicine, TMJ, and facial pain issues, which is crucial to avoiding and treating possible side effects of oral appliance therapy.

Ultimately, sleep physicians and trained dentists working together can provide effective and affordable treatment op- tions for patients suffering with OSA—including combination therapy where oral appliances are used to help patients to bet- ter tolerate CPAP. Many patients may benefit from oral appli- ance therapy, and the three common concerns can be easily resolved by working with knowledgeable dentists.

“Knowing the facts and seeking answers is the first step,” adds Spencer. “The fact is that oral appliances are reasonably priced considering everything that is included. Medical in- surance will typically cover the therapy, and trained dentists will encourage patients to return to the sleep lab for objective follow up. Knowing these facts will hopefully motivate sleep professionals to find trained dentists to work with.”

In addition to his role as president of the American Academy of Craniofacial Pain, Jamison Spencer, DMD, MS, is a dentist with practices limited to dental sleep medicine and craniofacial pain in Boise, Idaho. He also serves as chief technical officer for Cadwell Therapeutics,Inc., a company that manufacturers the Silent Sleep appliance and helps connect sleep physicians and sleep labs with trained dentists, including helping with the challenges of billing third party payers for payment of oral appliance therapy (www.ctisleep.com).

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