My First Dental Sleep Medicine Patient
How Dr. John Tucker’s quest for knowledge sparked a complete change in his practice.
(Published by Glidewell Dental in the Smile Bulletin)
For nearly 20 years, Dr. John Tucker has been focused on treating patients with sleep-related breathing disorders. His awareness and passion for the field was ignited early in his career — not once, but twice. Read on as he shares personal experiences that shaped his practice, as well as the successful approach he used to get started in dental sleep medicine.
Smile Bulletin: How did you get involved in dental sleep medicine?
Dr. John Tucker: Our son Chad was born six weeks prematurely. At the age of 3, he was on multiple medications for his respiratory system. He exhibited chronic snoring, parafunction, posterior cross bite, a high vaulted palate and dark circles under his eyes. When I questioned the pediatrician regarding his snoring and parafunction, the response was not to worry about it. I asked a pedodontist the same questions and got the same responses.
I was enrolled in a postgraduate program at the University at Buffalo School of Dental Medicine. One of the lectures was the importance of airway and sleep-related breathing disorders. An orthodontic resident presented his research regarding airway issues in children prior to starting treatment. I asked the orthodontic resident why our son snored and had parafunction. His response was, “Does he have a high-vaulted palate and posterior crossbite?”
I was overwhelmed with his questions, as he had never seen our son in person. The answer to his questions was, “Yes!” I asked for his guidance in treatment. His advice was to get him into rapid palatal expansion. Six months after initiating rapid palatal expansion, the snoring and parafunction had been successfully managed and he was off all medications. Our son had airway issues that impacted him daily, leading to unhealthy sleep. I think back to the day the orthodontic resident opened my eyes regarding the importance of a healthy airway. It was the most important concept I had ever been exposed to in my dental career.
That was in October 2002. I wonder how our son would have developed had his sleep-related breathing disorder not been addressed at an early age. He is now 21 years old and an amazing triathlete without airway issues.
Dr. John Tucker’s son Chad overcame his sleep-related breathing disorder at a young age. He is now a triathlete who competes in Spartan races.
SB: Can you tell readers about your first snoring and sleep apnea patient in the dental practice?
JT: Based on the experience with my son, I started shifting my awareness to patient airway health and quality of life. I was quickly humbled and realized this quote by D.H. Lawrence glaring at me: “What the eye doesn’t see and the mind doesn’t know, doesn’t exist.”
I changed my health history intake form and started asking patients if they snored, if they had their sleep evaluated, and if they were on a CPAP or unable to tolerate CPAP therapy. I started to see high-vaulted palates in patients and the correlation with sleep-related breathing disorders, as well as those who had four bicuspid extractions with orthodontic treatment. I was a sponge and wanted to know more about the airway, sleep and the impact of sleep-related breathing disorders on total body health.
I invited my lifelong friend Mark to join our family at our ski lodge for a weekend of fun. It turned out to be a miserable weekend for my family. Unfortunately, my friend was a horrific snorer and none of us got any sleep except him. My friend is an ER physician, and I started talking to him about his snoring issue and the related comorbidities. He had recently been diagnosed with hypertension and metabolic syndrome. He also complained of excessive daytime sleepiness, which would be logical for an ER physician. I started discussing airway health with him and recommended that he have his sleep evaluated.
I found it bizarre how little education he had on sleep and sleep-related breathing disorders. He took my advice and had an attended PSG [polysomnogram]. The results showed that he had severe obstructive sleep apnea with an apnea-hypopnea index, or AHI, of 55. I reviewed treatment options with him, including CPAP, surgery, oral appliance therapy and weight loss. His chief complaint was claustrophobia, and he stated that he would never be able to tolerate a CPAP. He expressed another interesting concern of not having the CPAP readily available with his erratic ER shifts. We fit him for an oral appliance and initiated therapy.
After three months of follow-up appointments and gradual titration of his oral appliance, we referred him back to his sleep physician for a follow-up attended PSG while wearing his appliance to document treatment efficacy. The sleep study results were incredible: The treatment had decreased his AHI from 55 to an AHI of 2. He reported feeling more alert with no snoring, and his hypertension and overall health significantly improved. He also started to exercise and watch his diet, netting a weight loss of over 50 pounds. All medications were either decreased or eliminated.
That was my first patient back in 2003. He continues to wear his oral appliance nightly, and he states that it significantly improved his quality of life.
Dr. Tucker’s first dental sleep medicine patient, Dr. Mark Van Dyke, attending a polysomnogram.
SB: Was it challenging to navigate dental sleep medicine at first?
JT: I made a commitment that I wanted to be highly involved in treating patients with sleep-related breathing disorders. When I began my journey in 2002, there were no textbooks focusing on the dentist’s role and the use of oral appliances. I understood that this was a medical issue and not a dental issue. I had no clue about medical billing or how to navigate through Medicare. I was fortunate to find a friend who authored textbooks regarding medical billing and knew the protocols for Medicare. I hired her immediately to assist me in setting up a new sleep practice that was a separate entity from my general dental practice. I followed her lead and directions to the letter. We started reaching out to the sleep physicians and medical community, informing them that we had a treatment alternative to CPAP for the 50% of the population that is nontolerant to CPAP therapy.
It was a very long road filled with major potholes, twists, bends and dead ends. Were there times when I wanted to throw in the towel? Of course, but I was extremely focused on making this work and becoming successful in providing treatment for those patients who wanted an alternative option to CPAP. Persistence was what kept me going. I remembered this quote from the legendary Babe Ruth: “It’s hard to beat a person who never gives up.”
SB: How did you make dental sleep medicine a bigger part of your practice?
JT: Through conversations with patients. Once you are aware of the importance of airway health as it relates to overall body health, it is easy to engage in a conversation with anyone who wants a better quality of life.
SB: Early in your career, what did you do to set yourself up for success?
JT: I started taking any CE program I could find related to sleep, the airway and oral appliance therapy. Every dentist realizes that if each team member is not on board with any new vertical integration he or she wants to implement into the practice, it is absolutely doomed to failure. Educating the team was critical to the success of adding airway health to the practice.
Of all the verticals I have attempted in my practice, airway health has been the most well received by my team, with 100% of the team being on board. Each staff member wears a button that says, “I’m an airway engineer.” That prompts an open-ended conversation with the patient. We also have a stop sign in the office, and it’s an attention-grabber. “Stop” represents these questions: Do you snore? Are you tired? Do you obstruct? And do you have high blood pressure? Every patient in the hygiene room says to the hygienist, “Why is that stop sign there?” And the hygienist says: “That’s a great question; thank you for asking. We’re looking at airway health. Do you snore?”
In Dr. Tucker’s practice, to start the conversation about sleep and airway health, staff members wear a button that says, “I’m an airway engineer.”
In addition, early in my career, I went to a local sleep lab and asked if I could shadow the RPSGTs [registered polysomnographic technologists] and have them educate me on what their profession involves, with the goal to learn all I could from them regarding sleep. I spent 40 hours at the sleep lab and quickly became enthralled with their profession. It was one of the most gratifying educational experiences for me.
I also read every textbook I could find regarding sleep and airway health. After that, my next step was to start the journey of becoming a Diplomate of the American Board of Dental Sleep Medicine. I successfully completed all the requirements and passed the board examination, and received my Diplomate status in September 2010.
SB: Looking back, what did that first DSM patient experience teach you?
JT: Since my first patients were my son and best friend, I am reminded on a daily basis of the importance of airway health and the positive benefits of dental sleep medicine on quality of life. I have yet to meet a person who doesn’t want a better quality of life, and it’s all about the airway!
Dr. Tucker (right) with Dr. Van Dyke.
SB: Is there any final information you think readers should know?
JT: Everybody used to say the 1970s was the golden era of dentistry — back then, all the restorations were full-cast type 3 or 4 gold. But I think the golden era of dentistry is right now because never before has dentistry had the opportunity to change someone’s quality of life. Airway health in the dental profession is the most rewarding and gratifying treatment we can provide for patients.