Incorporating Dental Sleep Medicine into a Practice: Avoiding the “7 Deadly Sins”
It seems that dentists are increasingly being urged to treat patients who snore or have obstructive sleep apnea (OSA) with mandibular advancement appliances. These appliances, which are based on the “jaw thrust maneuver” used by anesthesiologists to open the oropharynx and ease intubation, open the upper airway and improve the patient’s breathing at night. Borrowing from the orthodontic world, where the Herbst device was developed in 1910 to permanently advance retrognathic mandibles, nighttime use of this style of device has been found to be exceptionally effective in the treatment of snoring and OSA.1 The Food and Drug Administration (FDA) has now certified around 100 appliances for the treatment of snoring and OSA. But why should dentists be interested in treating patients with these conditions?
While clinicians routinely care for the hard structures of the oral cavity, a patient’s overall well being should also be a consideration. Interestingly, the incidence of OSA in the adult population of the United States is higher than the incidence of asthma.2,3 Also, patients over 65 have a 60% probability of having OSA.4,5 Many of these patients, of course, are treated by their physicians with positive airway pressure (PAP); however, dentists can return more than half of them to normal breathing by placing a mandibular advancement appliance. This puts dentists in a prime position to effectively treat many of these patients within the scope of dental licensure.
Within most general dental practices lie all of the equipment, materials, and training needed to make mandibular advancement appliances, except for two things: a gauge to measure the patient’s mandibular protrusive range, and knowledge. There are various gauges on the market, most costing around $50. The costliest part of implementing this type of treatment into a practice is learning about the pathophysiology and medical sequelae of obstructive sleep apnea.
Learning about sleep-disordered breathing—a topic that is not typically offered in dental school—requires a dentist to seek training courses, textbooks, and published literature. The American Academy of Dental Sleep Medicine (AADSM) is the only nonprofit organization that specializes in training dentists to treat patients with snoring and OSA. AADSM offers a variety of courses and lectures and also provides access to a network of some 3,000 dentists who are interested in the field. Providers must be strongly self-motivated and willing to spend time and effort learning about the disease itself. Dentists must be aware that OSA is not a dental disease; it is a medical disease, and each dentist is part of an overall medical team working to improve both the mental and physical status of the patient.
In recent years dentistry has been progressively returning to its medical roots. Periodontal disease is now known to be tied to cardiac health.6 Changes in the oral cavity may lead to a diagnosis of gastroesophageal reflux disease (GERD), human immunodeficiency virus (HIV), or autoimmune diseases, and while dentists do not treat these diseases, they are on the forefront of ensuring that these patients get properly diagnosed. With OSA, dentists may not only screen for a disease but also be a partner with physicians in the appropriate treatment. As professionals, dentists should be aware of all areas of health that are manifest through changes in the oral cavity and oropharynx. As caries becomes less prevalent through the public health efforts of fluoridation, dentists can expand their areas of treatment and expertise more into a medical arena; however, it must be understood that recordkeeping, reimbursement, and communication must be at the level of a medical provider.
Adding the treatment of snoring and OSA to a practice can give clinicians a viable option in moving toward a medically oriented area of treatment. However, in doing so there are hazards that must be avoided; the author refers to them as “seven deadly sins.”
1. Treating a Patient without a Medical Diagnosis
For any sleep-disordered breathing, it must be a physician who diagnoses the patient. While 40% of the US adult population does snore intermittently, only 16% have obstructive sleep apnea.7 Many women with OSA do not snore. No one can discriminate the difference between “primary snoring” and “obstructive sleep apnea” without some sort of sleep testing. In most instances, this requires an in-laboratory polysomnogram, but insurance companies are pushing for patients to be diagnosed with out-of-center sleep tests (OCST) (also known as a home sleep tests). Most dentists are unaware that OCST underscores breathing events, and, while it accurately diagnoses patients with moderate to severe sleep apnea, it is poor at ruling out mild sleep apnea. Patients who complain of daytime sleepiness, insomnia, depression, and other symptoms often equated with sleep apnea and who undergo an OCST that reports a lack of OSA must then undergo a full lab polysomnography to verify the findings of the OCST. These patients must also have a full history and physical done by a physician. A dentist is unable to diagnose a patient with depression, hypertension, or other cardiac and metabolic diseases that are highly correlated to OSA. A dentist who treats a patient complaining only of snoring with an oral appliance that is FDA-accepted to treat snoring and OSA may be considered criminally responsible if that patient goes on to have significant medical problems because of undiagnosed OSA.
2. Being Ignorant of the Disease Process and Possible Medical Outcomes
OSA is related to a narrowing of the upper airway from the posterior nasal spine to the base of the epiglottis. The true cause of the disease can be related to the central nervous system, lung volume, chemoreceptor sensitivity, neuromuscular abnormalities, or the patient’s facial and airway anatomy.8 Patients with severe OSA undergo significant oxidative stress on a nightly basis, which can lead to heart failure, stroke, arrhythmias, depression, excessive daytime sleepiness, loss of executive function, and endocrine changes that can result in impotence, type II diabetes, and weight gain.
3. Being Unaware of Standards of Practice and Treatment Protocols
The American Academy of Sleep Medicine has issued standards of practice for the treatment of OSA and snoring with oral appliance therapy, published in 2006 and presently under revision. These standards are used to guide physicians and dentists in the appropriate manner of treating patients and to provide patients the best possible treatment with the least amount of harm. In a court of law, all dentists would be held to the standards of practice published by specialists in that field.
4. Failing to Fully Inform the Patient about Treatment
The patient must be made aware of all side effects of treatment, most of which have minimal impact on function. Because the mandibular condyle is being held forward, often out of the glenoid fossa for the entire sleep time, joint edema and stretching of the joint ligaments is the most common morning complaint. Appliances used to treat OSA are based on appliances used in orthodontics, so tooth movement is also possible. Because these appliances need to be retentive on the dentition, ill-fitting crowns and restorations could become dislodged. Patients must also be informed that these appliances may control snoring in 80% of patients, but only 56% of patients who receive an oral appliance and are properly titrated during polysomnography will completely control their OSA.9,10
5. Forgetting an Informed Consent
As with any major medical treatment, the dentist must have the patient sign a well-written informed consent, informing the patient of all treatment options, realistic outcomes, and side effects.
6. Neglecting to Communicate with the Medical Team
Obstructive sleep apnea is a medical disease. Any dentist treating a patient diagnosed by a physician must periodically inform the medical team about the patient’s status. If the patient has been diagnosed with primary snoring, it is the dentist’s responsibility to contact the medical team if symptoms recur. OSA increases in severity with age, weight gain, and, for women, at menopause.11 Primary snoring can become mild OSA at any point in time. The dentist is expected to communicate with the physician after initial consultation with the patient, after placement of the oral appliance, and whenever there are alterations in symptoms or the patient discontinues treatment. Patients with OSA must return to their physician for follow-up testing to verify the effectiveness of the oral appliance.
7. Ignoring Necessary Follow-Up
Since oral appliances are known to have a side-effect rate greater than 50%,12 published protocol by the AADSM suggests 90 days of follow-up immediately after placement of the appliance, 6-month re-evaluation for the first 2 years after placement, and annual re-evaluation thereafter as long as the patient wears the oral appliance. Side effects should be identified as quickly as possible to prevent significant dental changes.
By educating themselves in dental sleep medicine and purchasing a mandibular protrusion gauge, clinicians can offer their patients another option to improve their overall health, well-being, and emotional status. They can take the skills learned in the area of removable prosthodontics and apply them to the more than 20% of their patient population who may benefit from oral appliance therapy. The investment in knowledge will allow them to educate their patients and staff on how dentists can change people’s lives and find significant gratification using techniques and materials already present in the dental office.
ABOUT THE AUTHOR
B. Gail Demko, DMD
Dental Director, Sleep Apnea Dentists of New England, Weston, Massachusetts
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