Dr. John Viviano was going about his day — just like any other day in his practice — when an unexpected complaint from a patient launched his career into a new and exciting direction. In this Q&A, Dr. Viviano shares the story of his first dental sleep medicine patient, as well as the surprising reasons dental sleep medicine benefited his practice in ways that had nothing to do with sleep.

Smile Bulletin: How did you get involved in dental sleep medicine?

Dr. John Viviano: It was the fall of 1996, a typically busy Tuesday evening in my general dental practice. I was working alongside four hygienists, with an anesthetic syringe in my hand. My patient lamented that her husband’s snoring had her contemplating divorce, and all I could quietly think in my mind was: “Can you please stop talking and open your mouth so I can freeze your tooth? I am behind, my hygienists are buzzing for me, and I was just told an emergency patient was on their way.” That, in fact, represented the level of interest I had in her problem. After all, I was a dentist. How could I possibly help with either her marriage or her husband’s snoring?

That same week I attended a cosmetic dental meeting where I observed a “Snoring” sign over one of the laboratory exhibits. I approached the booth and was shown a variety of appliances used to manage snoring along with some supporting literature, including the landmark Schmidt-Nowara paper that solidified the validity of oral appliance therapy. That weekend, I read those papers and many more that were sourced on the internet. On Monday, I showed up at my office with a newly created homemade brochure, alerting patients of an evening course I provided where they would learn about the management of snoring and sleep apnea through oral appliance therapy. That weekend, I experienced my “aha!” moment and started my journey.

SB: Can you tell readers about your first patient?

JV: The patient I mentioned above did attend for a consultation and proceeded with oral appliance therapy after obtaining a sleep physician prescription. I recall having reasonable success with his snoring, although this therapy took place very early on, when I only had a basic understanding of the process. As to be expected, the more I learned, and the more experience I obtained, the better my results became.

Initially, I was literally overwhelmed by the important role I could be playing in my patients’ lives — not only improving quality, but also extending lifespan. My desire to learn more was instantaneous. I haven’t stopped learning since, and those who know me will attest to the fact that I haven’t stopped talking about it since! Who knows if I would have even noticed the “Snoring” sign over the lab exhibit if my patient hadn’t inquired about it just a few days before. That week changed the course of my entire dental career.

Oral appliance therapy was still thought of as witchcraft in the 1990s, so I felt it was important to practice at the highest evidence-based level available. In 1999, I became a Diplomate of the American Board of Dental Sleep Medicine, the first year this was offered, and proceeded to build a Sleep Disorders Dentistry practice within my general dental practice. I am very fortunate that, after all these years, my current dream sleep team still includes Callie and Elaine — both of whom were part of my practice in 1999!

SB: Was it challenging to navigate dental sleep medicine at first? Were there any surprises?

JV: Yes, the physician resistance and nonacceptance took me very much by surprise. Keep in mind, we are talking about the 1990s and oral appliance therapy effectiveness had yet to fully establish itself in the literature. This created a need for me to establish a “patient advocate” approach. Realizing that patients were unlikely to start off with an oral appliance, I spent my time rescuing non-adherent CPAP (continuous positive airway pressure) patients, many of whom were simply being ignored. Of course, through increased awareness and a mountain of literature evidence regarding oral appliance therapy effectiveness, today many more patients start their treatment journey with oral appliance therapy, making entry into this field much easier for the general dentist.

SB: What was the biggest hurdle clinically?

JV: Clinically, the biggest hurdle was the lack of physician cooperation. I handled this by working within the published guidelines and helping patients exercise their rights to obtain a prescription for treatment. When one physician didn’t cooperate, I would refer them to another who did. Although this is much less of an issue today, this resistance still surfaces on occasion. The remedy remains the same: Find a physician who is willing to follow the current guidelines.

SB: How about for your business?

JV: Perhaps the biggest business hurdle was team buy-in. I’ve learned that it is absolutely mandatory for the dental team to be well educated regarding how impactful their participation can be in a patient’s life. The first step to building a dental sleep medicine component in your general dental practice is to ensure that each and every team member experiences his or her own “aha!” moment.

SB: Were there challenges to achieving overall success?

JV: If one defines overall success as patients following through with therapy, I find it is critical to take the time to help them experience their own “aha!” moment. They all know that they have a problem when they are first consulting with you. However, regardless of insurance coverage or how expensive the therapy is, they also need to truly understand the nature of their medical problem and the ramifications of leaving it unmanaged. I find that creating an “aha!” moment in their mind — that stays with them long after the consultation — helps patients proceed with therapy.

SB: How much of your practice is devoted to snoring and sleep apnea now?

JV: In 2013, I opened an office dedicated to dental sleep medicine and then had it accredited by the American Academy of Dental Sleep Medicine. In 2017, I sold my general dental practice and moved the small sleep office into a brand-new 3,200-square-foot facility, which included the Sleep Disorders Dentistry Research and Learning Centre — the only brick-and-mortar facility in Canada dedicated to teaching dental sleep medicine. I am living the dream, and it all started when a patient asked if I knew anything about snoring!

In addition to our live, onsite CE programs, our online learning platform sddacademy.com hosts an online study club, zSleepClub, that provides unlimited access to prerecorded, on-demand CE as well as livestream webinars and study club sessions that review all aspects of dental sleep medicine.

SB: Early in your career, what did you do to set yourself up for success?

JV: I introduced sleep therapy into my general dental practice and found it was a great practice builder that benefited my practice in ways that had nothing to do with sleep. It attracted new patients and referrals for sleep services that were eventually added to the general practice, and it also established a special bond with patients — which served to strengthen their relationship with the office, aiding in patient retention. I believe that in the future, every dental patient will be screened for breathing-related sleep disorders. This has been recommended by the American Dental Association and should happen routinely as a minimum contribution to help battle this epidemic-level problem. Those dentists who wish to also participate in patient care will be served well for this decision.

I highly recommend finding a mentor, obtaining training and practicing in an evidence-based manner. In a recent webinar that I participated in, sponsored by the Sleep Research Society, a prominent physician pointed out that the elephant in the room is physicians’ distrust of dentists. This, in fact, is our largest obstacle going forward. You can never go wrong by practicing evidence-based guidelines and putting patients’ interest first. In this way, you can respectfully stand up to resistance when encountered and help patients get the care they need — and hopefully earn the physician’s trust as well.

My career going forward includes continued learning, researching, writing, teaching and treating breathing-related sleep disorders. Every time I teach, one of my main objectives is to help the attendees experience the same “aha!” moment I experienced 25 years ago. I remain eternally grateful for that patient’s question. By asking me about something I had no idea I could help her with, she opened my eyes to an entire change in career, which has fulfilled my professional life beyond words can describe. Aha!