Sleep Service Levels – Which One is Right for You?
Steve Carstensen, DDS

Dentists can provide support for airway health in many different ways, each a key component in service of community health. This talk will outline those levels of service through discussion between Dr. Hindin and Dr. Carstensen about Steve’s decision to start a new practice at age 68. The story will highlight the choices each dentist can make to improve the patient’s health and fulfill individual commitments to practice values and goals. Listen in to see if you are a Level 1, 2, 3, or 4 provider and whether you are comfortable where you are or want to change levels to satisfy personal, professional, or business goals.

Dr. L.D. Pankey taught dentists for decades that a key to success is to identify what is important to the dentist – he labeled it “Know Yourself.”  Once that bedrock is established, taking the time to understand the patient, or, “Know Your Patient,” showed  the problems the patient felt and began to reveal treatment choices that might be acceptable. Most options require learning more about dentistry – materials, techniques, talking points, that drives professional growth through education – “Know Your Work.’”  Only when all these three fundamentals are in place can “Apply Your Knowledge” find its full expression.
Improving people’s health with sleep services requires awareness of these vital steps, the first being ‘Know Yourself.’
There are four levels of sleep services available to every dentist.

Level One is screening and information. After the ADA endorsed the dentists’ role in sleep related breathing disorders in 2017, every dentist is encouraged to screen for these problems and refer when risk is found. A couple of simple questionnaires and a list of resources is all that is needed for Level One. The biggest impact on typical dental practices is encouraging curiosity around signs of pathology such as sleep bruxism or refractory periodontal disease.

Level Two services include providing mandibular advancement devices for diagnosed patients referred by physicians. Management of these custom devices and the side effects falls to educated dentists. Pre and post treatment testing and referrals to other providers are done by the medical doctor. One impact on practice is the need to choose to participate in medical insurance billing for the benefit of patients.

Level Three dentists are more hands-on managers of airway function. These dentists will ensure the mandible is titrated to the most effective position possible, typically using objective measurement to evaluate physiologic response. The dentist will consider additional means of improving outcomes, such as combination therapy, referral to a rhinologist, and establishing proper nasal function as fundamental paths to success. To avoid unproductive use of the doctor’s time, the practice will need to establish a ’sleep champion’ to guide patients through a more involved treatment flow.

Level Four practices embrace the Primary Care Dentist model where the dentist is a key leader in helping people maximize respiratory function. Sleep related breathing disorders are one of the diagnoses, but poor respiratory function, nutrition, and comorbid conditions such as insomnia influence the care pathway. The dentist is not responsible for treating outside their licensure, but their scope of practice expands greatly as more education and clinical insight provide therapies and techniques to address individual patient needs. Special equipment can identify areas of focus and give feedback to therapeutic strategies. The primary care dentist gathers a network of providers to collaborate with to address individual patient needs, often including myofunctional therapy, rhinology, physical therapy, dentofacial orthopedics, sleep physicians, and cognitive behavioral specialists. The patient’s medical history and provider team play a big part in guiding therapy. Deciding which type of objective measurement will be valid often depends on timing and medications the patient is taking for comorbid conditions. Several medications require PPG- and PAT-derived signals to be interpreted carefully, for example,

These levels do not represent a scale of professionalism or a grade of intent to improve the health of people in a practice. Each level is vital to the medical system, and each role moves population health forward. I see these levels as a launching point for dentists to identify where they want to be, how they can achieve the knowledge to fulfill the requirements, and how they can identify patients who want the services that align with these descriptions.

At the end of this discussion, participants should be able to: