ADA, Airway and the Team

by Glennine Varga, AAS, RDA, CTA
In October of 2017 the American Dental Association released a policy statement that impacts every dental office in the US. This policy statement was the first step toward identifying the role of the dentist and dental team regarding sleep-related breathing disorder treatment. Let’s break down the policy statement and identify how we can integrate these concepts into practice and promote this very important message from the ADA.

First, become familiar with this policy statement:

Read it multiple times, post it in your office and share on social media. For the first time in history, the ADA is getting involved with advising dentists to screen for sleep-related breathing. Take advantage of this endorsement with your patients. Patients will ask, “Why are you asking about snoring or why are you assessing my airway?” Part of your answer can be, “Because it’s our role to do so.” According to the ADA House of Delegates of 2017, dentists are the only health care provider with the knowledge and expertise to provide oral appliance therapy. Since dentists and dental team are often the first to identify symptoms and discuss medical and dental history with the patient, The Council on Dental Practice developed the policy. The policy is intended to help dentists on the front lines help their patients through proper recognition and treatment. Here is our first task as team! Identify what sleep-related breathing questions are currently on your medical and dental history that can be used to have a discussion with your patients. Specifically, snoring, waking up choking or gasping, cardiovascular, respiratory, dental and other systematic diseases should be identified with patients. It may be necessary to customize your history intake to include airway compromised questions. I’m a true believer the more we get to know our patients, the better we can communicate, educate and influence them to make educated decisions toward therapy. Take the time for this critical step and let your patients do the talking. It is imperative to link signs, symptoms and risk factors as many patients are clueless how sleep-related breathing could contribute to overall health and wellness.

Now that we understand our profession plays a major role in screening and treating sleep related breathing disorders, what exactly is this policy directing us to do? Perhaps the most important directive in the policy addresses children. Screening through history and clinical examination may identify signs and symptoms of deficient growth and development or other risk factors that may lead to airway issues. You might have heard Margaret Mead’s quote about “Small groups of committed citizens can change the world.” There are eight task forces of dedicated dentists, physicians, and medical professionals working right now to provide guidance in this area for the dental profession, including you and your office team, so stay tuned! In the meantime, look for mouth breathing, tongue-tie (attachment), thumb or finger sucking, noisy breathers, chronic runny noses, large tonsils, earaches, high palatal vault, crowded or no spacing in primary dentition, overbite, overjet, retrognathic jaw, speech impairment, hyperactivity, developmental delay, poor concentration and bed wedding as a start. Create two different patient intake questionnaires – one for adults and one for children. ADA’s policy statement says if risk is determined, intervention through medical or dental referral or treatment may be appropriate to help treat the disorder and/or develop an optimal physiologic airway and breathing pattern. In the dental office I was in we did not have a great office to refer these kids, so we became the source. We took continuing education to learn how to treat these types of patients. As team, it is vital to take the extra step to learn these concepts or find a provider in your community that can. If you can’t travel with your doctor to courses, ask if they will support online learning for you. There are some wonderful programs that focus on children’s airway like the ADA’s CE courses, The Healthy Start System, MyoResearch training or Rondeau Seminars which all provide online courses for convenience.

Next, the policy says oral appliance therapy is an appropriate treatment for mild to moderate sleep apnea, and for severe sleep apnea when CPAP is not tolerated by the patient. As team we can help by making sure to administer protocol and get copies of baseline sleep test reports as part of our room set up before diagnosed patients are seen. Use this baseline report to confirm diagnosis and severity and whether there is the right detailed information to be used for the patient’s medical insurance claims. Most policies base benefit on severity of OSA. The policy will state what other documentation is needed to prove medical necessity. We can also create literature for our physician referral entities that outline the referral relationship. Make sure and work with your dentist to solidify your communication. The policy statement also indicates obtaining a written or electronic prescription order for an adult patient with OSA. We team can help facilitate this by gathering physician contact information from our patients and faxing requests for written prescriptions. You can continue to nurture the relationship no different from any other referring entity.

Once patients commit to oral appliance therapy, the policy statement says dentists should obtain appropriate patient consent for treatment that reviews the treatment plan, all available options, and potential side effects of using oral appliances. You see, most of what the ADA has in the policy, team can facilitate. A signed informed consent from your patient is vital – make sure and get a great one, preferably from an attorney. Give your patients time to read it and have them sign with a witness from the team. Ideally, doctors explain what’s in the informed consent to the patient. Team can make sure it gets done and patients have a copy to take home. As patients progress with oral appliance therapy the policy states dentists should monitor and adjust the appliance for treatment efficacy as needed, or at least annually. Let’s help with this process by checking into your dental practice management system to find a way to flag your sleep patients to evaluate annually. If you have a DSM specific system, get training on how to set this up so you can monitor annual visits and financial responsibility discussions.

The policy indicates that dentists should consider surgical procedures as a secondary treatment when CPAP or oral appliances are inadequate or not tolerated. In selected cases surgical intervention may be considered as a primary treatment. Schedule time as a team, order in some yummy local food and do some research. Find physicians you would like to reach out to establish a referring relationship. Decide as a team which offices you would like to approach and role play what you would say if you called or visited their practices. Make it happen – the more your office is out in the community the more referrals you will get.

The last point the policy statement reflects is that dentists treating sleep-related breathing disorders should continually update their knowledge and training of dental sleep medicine with related continuing education. If your office allows for team CE, ask to go with your doctors – the more education you can get the better. I know when I’m leading a group of learners in a sleep/airway course, I love it when team are in the audience! Focus on educating your patients, they will appreciate it when the time comes to make a decision. At the end of the day, it’s the patient’s decision – let’s help them make a good one!

Besides exploring the ADA policy statement for dentists on sleep related breathing disorders, read another article by Glennine Varga regarding team engagement with functional oral appliances here.

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