An MD's Perspective on Dental Sleep Medicine

Increased Awareness of Dental Sleep Medicine Shows Large Numbers Go Undiagnosed

In the last 5-10 years, there has been an increased awareness in the diagnosis and treatment of Sleep-Related Breathing Disorders and the associated co-morbidities associated with these disorders. Despite this increased awareness, 80-85% of the patients remain undiagnosed. In the past, the primary form of diagnosis has been the in-lab PSG followed by a subsequent CPAP titration. When the diagnosis was severe, if time permitted, a split night PSG was obtained to expedite the initiation of therapy. CPAP was considered the “gold standard” and the majority of patients were placed on CPAP, regardless of the severity of the OSA and Oral Appliance Therapy was a secondary recommended treatment.

Medicare & Medicaid Help Boost Testing With Reimbursement

In 2009 Centers for Medicare & Medicaid Services (CMS) approved Portable Monitoring (or Home Sleep testing) for reimbursement and a code was established as well. Over the next 10 years there has been a dramatic increase in the number of patients that have been tested in the home in lieu of the in-lab PSG. Additionally, there are many companies that provide home testing units to the dentist and primary care physicians, by-passing the sleep physician entirely. This trend has coincided with the rise in acceptance of Oral Appliance Therapy as a primary form of treatment for the patient with OSA as well as for patients who fail or refuse CPAP.

New Testing Protocols & American Dental Association Play A Critical Role In Getting More People Tested

It is clear that there are millions of American with OSA that go undiagnosed due to a reluctance to be tested in a sleep lab and the fear that they will be put on CPAP as the primary form of therapy. In October of 2017, the American Dental Association (ADA) adopted a policy on the role of dentistry in treating sleep-related breathing disorder, including the diagnosis and treatment of obstructive sleep apnea. This policy emphasizes the obligation and importance of dentists in screening their patients for OSA and outlines the importance of continuing education in this field as well as the need to collaborate with physicians. This collaboration is designed to optimize the skill sets of the two professions and reinforce that both dentists and physicians are practicing within the scope of their practice.

Dentists are in a unique position to impact the number of undiagnosed patients with SRBD (snoring, OSA, sleep-related bruxism) by screening all their patients as part of a comprehensive medical and dental history and as healthcare professionals they have the best expertise to evaluate the oral cavity and associated structures. Once adequately and appropriately screened, the patients should be referred to the sleep physician (via a face-to-face evaluation or a telemedicine consultation with a board -certified sleep physician) for a proper diagnosis. Thus, dentists play a critical and integral role in evaluating their patients with potential sleep-related breathing disorders but require the diagnosis to be made by the physician.

Home Sleep Testing Kits Simplify Diagnosis When Dentist and Physician Collaborate

The advent of home sleep testing (HST) or Portable Monitoring (PM) has created some confusion and ambiguity as to who should order, perform and or interpret both the diagnostic and the efficacy studies. While many dentists may choose to utilize HST’s to assess the objective interim results of Oral Appliance Therapy (OAT), the ultimate efficacy studies should be ordered, conducted, and interpreted by the sleep physician. It is critical that the sleep physician collaborate with the dentist regarding the timing of the follow-up efficacy study (PSG or HST) and provide efficient and timely reports and communicate them with the dentist. The complexity and comprehensive evaluation and treatment of SRBD’s is best achieved when there is open and frequent communication between the treating dentist (with the proper training and expertise) and the board-certified sleep physician.

Oral Appliance Therapy More Effective Than CPAP For Many Patients

It is clear that while CPAP is highly efficacious in the ideal world that is effectiveness is compromised by poor compliance. Due to higher compliance and acceptance of OAT by patients, with respect to treatment with CPAP, Oral Appliance Therapy may be a more effective treatment for many patients with OSA. This comparison and recommendation can only be made when dentists and physicians collaborate to provide the best care for their patients. Understanding the concept of mean disease alleviation, Effective AHI, the Sleep Adjusted Residual AHI (SARAH Index) is critical when comparing the relative effectiveness of these two forms of treatment.

The more dentists and physicians engage each other in this process the better the treatment will become in this age of precision medicine.

Edward T Sall MD DDS MBA

Board Certified Sleep Physician and Otolaryngologist