CE Expiration Date: November 20, 2022
CEU (Continuing Education Unit):2 Credit(s)
AGD Code: 010
The ADA’s Policy Statement on the Role of Dentists on treating Sleep Related Breathing disorders arguably triggers more changes in dentist behavior as it relates to the health of their patient than any other policy statement published by the ADA. Dentists who understand the implications found within the statement will impact community health beyond any expectations they might have made during professional training or practice. The purpose of these essays are to bring together the opinions of the nation’s leading experts so every practicing dentist can recognize areas where mastery exists and where further study is necessary.
At the end of this reading, the participant will be able to
- Discuss with their team and peers the implications of the policy statement for their practice
- Lead their teams to develop communication skills so the changes can be introduced to patient communication
- Have confidence their practice is working towards the highest ideals of collaborative medical/dental services.
Editor’s intro: Part 2 of our special CE section includes interpretations of the ADA recommendations for treatment based on its Policy Statement of long-term treatment of sleep-related breathing disorders. From defining successful therapy, to surgical management, to communicating with other professionals, these six articles cover what is known, what is practiced, and what to do after symptoms are resolved.
An Ounce of Prevention: Avoiding Oral Appliance Therapy Related Side Effects
by Jamison Spencer, DMD, MS
With serious systemic health consequences being clearly linked with not treating SRBD, any potential dental side effects related to treatment of such disorders are a small price to pay. After all, tooth movement and occlusal changes rarely result in heart attack, stroke or death. Still, the caring dentist wants to minimize problems for their patients.
The keys to avoiding these troubles are:
- Recognizing in advance if the patient may be at greater risk for any specific side effects.
- Proper appliance choice and fabrication.
- Utilization of methods to help the patient re-align their habitual occlusion and regularly check for tooth movement and bite changes.
- Proper follow-up.
To be clear, the most common side effects related to oral appliance therapy are transient and typically of little concern to the patient. Localized discomfort in a single tooth or a few teeth, increased salivation, disrupted sleep as they get used to wearing the appliance, localized muscle soreness and occasionally discomfort in one or both temporomandibular joints are relatively common and tend to improve quickly without any modification to the appliance or intervention. Patients should be educated that such temporary effects are to be expected and are part of the normal accommodation process
- Recognizing in advance what side effects for which the patient may be at greater risk.
I strongly support the statement in the ADA’s policy directing dentists to continually update their knowledge and training of dental sleep medicine with continuing education.
This knowledge and training MUST include understanding temporomandibular disorders and principles of muscle pain. While a complete list of all potential OAT risk factors is beyond the scope of this article, here are several conditions I believe are important.
Periodontal disease: Patients with periodontal disease are at higher risk of tooth movement or loss of teeth. The dentist should decide if OAT is the best option or if CPAP, in combination with comprehensive periodontal therapy, might be necessary until acute conditions are managed.
Internal Derangements: Reducing and non-reducing disc displacements and degenerative arthritis may make a patient more likely to develop occlusal changes and/or discomfort in one or both jaw joints.
Reducing Disc Displacement (RDD): The articular disc is off the condyle when the teeth are together and on top of it when the mandible is forward, such as with OAT. Until the tissues adapt, the patient feels a ‘pop’ when the disc moves off and on the condyle. We discuss this carefully with every patient, including the rare occurrence of a permanently repositioned disc which can create a posterior open bite.
Non-Reducing Disc Displacement (NRDD): When the disc is chronically displaced or dislocated anterior to the head of the condyle in all mandibular movements. Usually a history reveals popping that ‘went away.’
As with RDD, oral appliance therapy is not contraindicated. Patients need to be educated on what is likely going on and that OAT may exacerbate a condition that has not bothered them in a long time, including a return of the ‘clicking.’
Unlike RDD, the most likely side effect with NRDD is joint pain and retrodiscitis (which may result in a transient posterior open bite, but due to swelling related to inflammation, not changes to disc position). These patients are treated and encouraged in the same way as any minor injury with inflammation.
2. Proper appliance choice and fabrication.
While there are many considerations in choosing the best appliance design for overall efficacy, patient comfort, and compliance, it has not been shown that specific appliance designs are more or less likely to result in side effects such as pain, tooth movement or bite changes.
Patients with tooth wear may have a reduction of their bruxism with treatment of their SRBD. I choose an appliance that will allow the patient to move their mandible in the same way that they had to in order to create the wear. They may continue to brux and be at higher risk of damaging or prematurely wearing out appliances. This should be explained so that the patient knows that these are side effects of their bruxism rather than the appliance.
A common error is not “wrapping” the distal of the most posterior mandibular teeth. Whenever possible the lab should wrap the distal, which will make it less likely that the other teeth in the arch will be pulled forward, resulting in open contacts.
3. Utilization of methods to help the patient re-align their habitual occlusion and regularly check for tooth movement and bite changes.
It has become common to provide some sort of “morning occlusal guide” to help the patient recover their normal bite. I strongly encourage you to provide every patient with such a device and verify they understand how and why to use it.
We explain to the patient that if they notice their previously tight contacts are now easier to floss or they now seem to be hitting harder on the front teeth, they are to contact us immediately. When we catch things early it is much easier to deal with the issues.
In my experience, patients who develop tooth movement or bite changes are usually either not doing what you asked them to do or they are doing it wrong. This is why regular follow-up is vital.
4. Proper Follow-up
Regular visits confirm the therapy is still effective and allow the dentist to recognize and manage changes, many of which are unnoticed by the patient. With oversight, it is much less likely that a patient will develop significant dental side effects.
Even though many medical problems associated with not treating OSA are far more serious, the patient must understand the potential side effects of OAT and their role in avoiding them, their responsibility in keeping follow-up appointments, and decide to move forward with therapy. The dentist must be able to recognize and manage common side effects or refer to those who have the necessary expertise.
Jamison Spencer, DMD, MS, is the director of Dental Sleep Medicine for the Center for Sleep Apnea and TMJ, in Boise, Idaho and Salt Lake City, Utah. Dr. Spencer is the Past-President of the American Academy of Craniofacial Pain (AACP), a Diplomate of the American Board of Craniofacial Pain, a Diplomate of the American Board of Dental Sleep Medicine, a Diplomate of the American Board of Craniofacial Dental Sleep Medicine and has a Masters in Craniofacial Pain from Tufts University. He taught head and neck anatomy at Boise State University, is adjunct faculty at the University of the Pacific School of Dentistry, and the University of North Carolina at Chapel Hill. Dr. Spencer created Spencer Study Club, an online education, mentoring and implementation program to help dentists and their teams help more of their patients with sleep apnea and TMJ disorders.
Dr. Spencer now lives in Pleasant View, Utah with his wife, Jennifer, and their 3 children of 6 who are still at home. Dr. Spencer can be reached at Jamison@JamisonSpencer.com, 208.861.5687 or www.JamisonSpencer.com.
Defining Successful Therapy
by W. Keith Thornton, DDS
A discussion of the ADA Policy Statement and recommendations for long term treatment (disease management) must be predicated on the definition of sleep related breathing disorders (SRBD), the various treatments, the severity of the condition, and the understanding of the patient’s desires and objectives. Only then can a cogent algorithm for management be proposed to apply precision medicine to the individual.
The term describes the behavior of the passive pharynx during sleep: a continuum from snoring, flow limitation, Upper Airway Resistance Syndrome (UARS), to obstructive sleep apnea. The continuum is called pharyngeal instability. Only when it reaches the end stage of significant under-breathing and oxygen desaturation (hypopnea) or cessation of breathing (apnea) does it rise to the level of a medical disease called obstructive sleep apnea (OSA) and defined by the Apnea-Hypopnea Index (AHI). Most people with SRBD do not have OSA. All breathing is controlled by a central, chemical controlled, feedback loop (Fig.1).
Dr. Magdne Younes in 1989 found that both the pharynx and ventilation were unstable (loop gain) instead of just the pharynx. This understanding has been applied more recently to SRBD and OSA (White 2005). A better term for SRBD should be Sleep Pharyngeal-Ventilatory Instability (SPVI). It is interesting that the ADA Policy states that SRBD is “caused by anatomical airway collapse and respiratory control mechanism.” Thus, treatment efficacy must include titrating the mandibular position, affecting pharyngeal stability, but also by addressing loop gain.
Ventilatory instability can be improved by eliminating mouth breathing, taping the lips or using a mouth shield with an oral appliance. Even daytime breathing exercises can improve loop gain. The dentist is in the unique position of being able to manage all levels of SRBD including severe OSA, complex OSA, and even some central sleep apnea (CSA), utilizing a systems approach.
Most physicians are aware that CPAP therapy is problematic due to compliance. Studies are showing that CPAP does not
improve cardiovascular outcomes. Approximately 75% of patients fail a minimum CPAP use of 4 hours per night 5 days per week. It would seem logical that oral appliance therapy would be tried first. A barrier to this approach is the lack of standard of care in dentistry, including screening, appliance selection, titration, and follow up. The complaint of sleep physicians is that most devices are not predictable, fail to reach the success criteria (an AHI<10, a reduction by at least 50% and the elimination of symptoms), and are very expensive. A great advantage of CPAP is that a trial is always done before a purchase. Studies show that the only consistently successful appliances are titrated objectively, while even the best fail without titration. A key trait is the ease of patient titration.
Screening and Monitoring
Whether a patient with suspected SRBD is a patient of record, referred for treatment, or has failed PAP, standardized objective and subjective screening should be done prior to any therapy to determine need for referral or as a baseline for titration, monitoring and clinical decisions. Examples of subjective tests are Epworth Sleepiness Scale and Thornton Snoring Scale. Consumer sleep technologies, such as smartphone apps, may also be helpful. Objective tests include oximetry, cardiopulmonary coupling, and even home sleep apnea tests (HST). Tests should be simple, inexpensive, and reliable. With a failed CPAP patient or with a patient who prefers an oral appliance, the goal of titration would be to achieve a high negative predictive level that would assure the patient doesn’t have OSA while wearing the device. Pulse oximetry meets these criteria well and has been used by the author for 26 years. If time below 90% oxygen saturation is less than 1% of the night, there is less than a 2% chance of having OSA, particularly with elimination of the patient’s symptoms (Series 1993). Traditional oximetry and HST measure only pharyngeal instability and only for OSA, not all SRBD. However, high-resolution pulse oximetry appears to be able to measure both pharyngeal and ventilatory instability and can detect everything from flow limitation to OSA, and even CSA. It also classifies the severity of the SRBD including cycling time and depth (Figs. 1-3). The analysis includes all of the traditional parameters, providing doctors the greatest amount of information to make clinical decisions.
Oral Appliance Therapy
The greatest weakness in treating SRBD by oral appliances is the inconsistency of the outcomes with the various appliances. With over 120 cleared appliances, there is a need to determine which ones have the capability of managing all levels of OSA including severe and then titrate them appropriately. The best source for evidence comes from the 2015 AASM/AADSM Guidelines on Oral Appliance Therapy – every dentist should study those guidelines and choose devices that demonstrate the best outcomes on the 40 RCT that were included.
Standard of Care in the Dental Office
Once the decision has been made to provide OAT, both a before and after objective screening to measure the efficacy of the appliance for OSA is required. A sleep physician is almost always involved with pre-treatment testing and provides baseline data that the dentist can use during therapy to gauge success of the OA. The dentist should be well-trained on any testing device that is employed and collaborate with the patient’s physician on how the data is interpreted. Increasingly, trial MADs are being used to evaluate patient response even prior to formal sleep testing; the dentist must be well trained and alert for subtle signs of ongoing problems. For example, cessation of snoring should not be assumed to be the end point of therapy.
Yearly appointments with objective monitoring are mandatory. Devices may need to be re-titrated due to changes in weight, medical conditions, or medications. Critical to success is both the efficacy and effectiveness of the device – does it work and are they using it. If not efficacious, another appliance should be tried or other treatment options discussed. Communicating and collaborating with the patient’s physician(s) is an integral part of the process.
Keith Thornton, DDS, is a third generation dentist who practiced restorative dentistry for 40 years in Dallas. His practice is limited to the treatment of airway and breathing disorders. He is a member of nine different dental and medical organizations and has had numerous leadership positions. He has been a member of the American Academy of Dental Sleep Medicine since 1993 and was an original Diplomate of the American Board of Dental Sleep Medicine. He is a visiting faculty member at A&M College of Dentistry, and is a consultant to the Army, Navy, Air Force and the VA. He has developed a number of medical devices that treat snoring and obstructive sleep apnea and has 72 issued patents. He is the founder, owner, CEO and chief technical officer for Airway Technologies, Inc.
Surgical Management of Sleep Related Breathing Disorders
by Edward Zebovitz, DDS
Airway surgery is a viable option when alternative treatments have been deemed intolerable, ineffective, or if the patient desires correction instead of management of the disease. Dentists are uniquely positioned with a varied skill set to address SRDB in the growing child to develop a normal airway and to manage adults with anatomic airflow restriction. Indications for surgical management include: targeting subjective and objective signs and symptoms, correcting underlying dentofacial deformities, addressing anatomic airflow restrictions, and redirecting airway-related compensations, such as forward head posture and jaw protrusion.
Addressing the airway restriction in the OSA patient requires careful diagnosis by means of direct clinical visualization of airway anatomy while awake or asleep (by drug induced sleep endoscopy) and imaging: CT, CBCT, MRI static and dynamic. Airway restriction can be the results of anatomic issues in any part of the upper airway and oral cavity – the craniofacial respiratory complex.
Airflow restrictions can be located anywhere between the nares and the larynx – including structures bounded by bone such as the piriform aperture and nasal airway, and soft-tissue-defined areas like the naso-, velo-, and oropharynx. If the palate is elongated or the lymphoid tissues (adenoids and tonsils) are hypertrophied, the airway may be narrowed.
Oral cavity airflow restrictions can be related to constriction in available 3D volume for the tongue and the subsequent effects on the oropharynx. The size of the tongue is variable; while it can accommodate the surrounding structures, the available space for the tongue can be restricted by deformity of anatomic oral structures (e.g. palatal or lingual tori, ankyloglossia), narrow maxillary and/or mandibular arches, and deficiencies in the antero-posterior position of the mandible, maxilla, or combination of both.
Intranasal or oropharyngeal soft tissue airflow restrictions are typically referred to our otolaryngologist colleagues to address. Their typical procedures include: adenoidectomy, tonsillectomy and, less often, uvulopalatopharyngoplasty (UPPP). Other
options include tongue base or epiglottal surgery, septoplasty, inferior nasal turbinoplasty, nasal valve stenting and palate-stiffening procedures.
Addressing the specific areas of oral airflow restriction related to width or transverse deficiencies can be addressed by techniques to expand the arches: there are three primary approaches for the adult SDB patient. First, expansion orthodontic mechanics by means of traditional orthodontics or clear aligners. The magnitude of expansion is 1-5mm and limited by maintaining the roots within the alveolar housing. When the roots are close to the buccal or facial cortical plate, root dehiscence and gingival recession are potential complications. The second option, Surgical Facilitated Orthodontics (SFOT) or Periodontally Accelerated Osteogenic Orthodontics (PAOO), is ideal for expansion requirements of 5-8 mm. These involve surgical exposure of the alveolar process and cortical bone scoring of the alveolus, outlining the roots on buccal/facial or palatal/lingual aspect, or both, depending on the proposed vector of tooth movement desired, followed by augmentation with allogenic bone graft material and meticulous soft tissue closure. Early and forceful application of well controlled force vectors is required. A 12-week window of opportunity exists, labeled “regionally accelerated phenomena” (RAP). This procedure also allows for simultaneous connective tissue grafting for root coverage and addressing mucogingival issues. The 3rd option, micro-implant rapid maxillary expansion (MARPE), is indicated for expansion requirements in excess of 8mm and in cases with intact periodontal support. This approach utilizes 1.7mm diameter implants placed to engage palatal bone on both sides of the suture. Additional procedures include surgically assisted rapid palatal expansion (SARPE) which add palatal osteotomy, lateral maxillary wall osteotomies and pterygoid plate release to allow more 3D expansion of the maxilla.
The goal and results of these procedures allow for a more forward and relaxed tongue posture, less restricted nasal airflow and increased oropharyngeal size.
Surgical management of antero-posterior deficiencies are focused on anterior repositioning of the posterior nasal spine, which positions the velum, and the genial tubercle, which directly applies tension on the genioglossus muscle. This tension results in antero-inferiorly positioning of the hyoid bone and advancement of the tongue base, which increases the posterior pharyngeal space in both antero-posterior and transverse dimensions – a true 3-dimensional enlargement. Decisions of the magnitude of genial tubercle advancement is based upon cephalometric and clinical evaluations to idealize facial proportions and maximize airflow. These decisions are based on careful, detailed and educationally focused pre-operative consultations with the patient and the oral and maxillofacial surgeon. Additional decision making is influenced by idealizing the occlusion and determining if maxillary repositioning surgery is required to bring the palate forward, away from the posterior pharyngeal wall. If indicated, intranasal issues can be addressed simultaneously (e.g. septoplasty, turbinate reduction or piriform rim widening). This is advantageous in reducing the number of surgeries and recoveries. Maxillomandibular advancement (MMA) surgery differs from traditional two-jaw orthognathic surgery in magnitude and focus, with MMA surgery primarily focused on addressing airway related issues with a goal typically in excess of 10 mm of advancement.
Additional adjunctive airway procedures are available and can be utilized in isolation and in combination with MMA, genial tubercle, or hyoid suspension procedures. Precise assessment of structures, possible with CBCT, MRI and clinical measurements, allows the airway surgeon to maximize increases in posterior pharyngeal space.
In summary, surgical options can be performed with predictable results and should be considered for patients with anatomic
issues who are younger, or any who wish to attempt correction of their airway and/or have failed conservative therapies to address OSA. Dentists and surgeons work together to help patients avoid the medical implications of untreated sleep related breathing disorders.
Edward Zebovitz, DDS, an accomplished oral surgeon by day, and generous humanitarian, dedicated husband, father and international citizen after hours. Making the most of his gifts and talents, Dr. Zebovitz is as comfortable practicing in his state-of-the-art office as he is in rural primitive facilities, serving the needy across the globe, and across the street. Since 2006, Dr. Zebovitz has served as Chief of Oral and Maxillofacial Surgery at Anne Arundel Medical Center in Annapolis, Maryland. He is certified by the American Board of Oral and Maxillofacial Surgery (ABOMS) and is a Fellow of the American Association of Oral and Maxillofacial Surgeons (AAOMS). Dr. Zebovitz’ thriving practice, established in 2000, is located in Bowie, Maryland. He is quick to share his success with his loyal, gentle and patient centered staff.
Narrowing the Gap Between What is Known and What is Practiced
by Chelsea Erickson, DDS
Sleep is such an essential part of health that humans spend a third of our lives doing it. 1 in every 5 Americans have Sleep Apnea (one of the most common sleep disorders) and nearly 40% of Americans suffer from some type of sleep disorder in their lives. As vital as sleep is to our overall health and wellbeing, its an area of health, that has been vastly overlooked for centuries in Western Medicine. A survey in 2002 of 500 medical doctors showed that none of them felt they had an excellent understanding of sleep and 90% of them rated their knowledge as fair to poor. In 2011 a nationwide survey done by Goh found that medical students are getting about 3 hours of sleep education in their curriculum. In comparison, they receive about 2 hours on dentistry and oral health. Sleep medicine wasn’t recognized as a specialty in medicine until 2003 and it’s still not recognized in dentistry. This demonstrates that we know very little about such an important aspect of every day life.
As our knowledge and understanding of sleep has grown over the last 20 years so has the field of sleep and dental sleep medicine. We as dentists have distinct advantages when it comes to helping people who suffer from these disorders. Many of the symptoms of SDB either originate or manifest in the oral cavity. Not only are we highly trained to recognize poor oral health patterns as a part of disease, but we also can relate it to skeletal issues that many other professionals cannot identify. Few, if any other medical providers can make these assessments and correlations. This knowledge makes us a vital part of a team of providers necessary to comprehensively treat a patient who suffers from airway related sleep issues. Once they are properly diagnosed, dentistry may be called upon again to help with treatment.
We are fortunate in dentistry that even though many of us practice by ourselves, we are still very much a collaborative community. We have study clubs, private and public education institutes, large group organized learning, and small group learning. We have blogs, Facebook pages and Instagram feeds. We can do week long focus courses or we can sign up for weeknight meetings. We have an abundance of information sharing but what we truly need as a dental community is more providers who are seeking out this information.
When we focus on sleep as a part of overall health and comprehensive care, we all win. We are healthier, happier and safer in a community that is well rested. I personally feel that we have a double standard when it comes to medicine and our desired role. We want to be involved and regarded well in the medical community as a valuable resource, but we also want nothing to do with the current medical structure of patient care. From billing and coding to the time we get to spend with our patients, we have tried to insulate ourselves from the main stream medicine world. Sleep and airway form a large bridge between medicine and dentistry and the overall health of our patients, and dentists are the gatekeeper. It is an important role which is vital to the health of our community.
We are still early in our learning and understanding of sleep and treatment for sleep disorders. We are one of the primary providers of therapy to deal with the consequences of airway issues whether it be a MAD, orthodontics, or another type of therapy that address the airway directly. Because of the incredible growth of sleep knowledge and its importance to our patients and their care we must continue to learn from the growing research. It simply isn’t enough to take a week long course or even to become a Diplomate of the ABDSM. It isn’t enough to rely on the same appliances, approaches and research day after day. These are great accomplishments but a continued interest and commitment to keeping up with current research and education is essential. Dental sleep medicine is rewarding and completely life changing for both the provider and the patient and we owe it to ourselves, our profession and our patients to provide the best possible care with the most current standards.
Chelsea Erickson, DDS is a North Dakota native and attended the University of North Dakota and graduated with Bachelor of Science in Chemistry in 2006. She then attended Creighton University in Nebraska where she graduated with her degree as a Doctor of Dental Surgery in 2010. She practices full time in East Grand Forks, MN. She has a passion for continuing education and travels often to learn the most update information especially regarding comprehensive care including airway, TMD and sleep. She is a member of 5 study clubs, is a visiting faculty member at the Pankey Institute in Key Biscayne, Florida and loves to help educate as well.
We’re Not in This by Ourselves – Communicating with Other Medical Professionals
by Ronald S. Prehn, ThM, DDS
Excellent care is separated from standard care by the quality of communication between providers. The dentist treating SRBD with excellence does more than is required by policy and law. The ADA policy statement addresses communication to both the patient’s referring physician and to other healthcare providers. The content of this communication concerns treatment progress and recommended follow-up treatment recommendations.
The recommended follow-up reports are to all the other members of the sleep treatment team. After the history and examination of a patient identified as having risk factors for a sleep related sleep breathing disorder, a referral to another healthcare provider may be indicated as either monotherapy (such as to an ENT for tonsillectomy) or adjunct therapy in combination with oral appliance therapy (myofunctional therapy or weight loss). There are many professionals with therapy expertise that can help resolve SRBD – and all deserve complete communication.
The referring provider could be a PCP, ARNP, specialist physician or a board-certified sleep physician. The foundation of all communication lies within the diagnosis by the physician. During the process of a diagnosis, the physician considers the history and examination, the objective findings (testing), and the subjective symptoms (patient’s complaint). The sleep dentist should determine and record similar subjective symptoms as did the physician. If there are discrepancies in the subjective symptoms, then communication with the physician is essential to determine the patient’s chief complaint. The objective findings of the testing done by the physician should be well understood by the sleep dentist. The diagnosis is the foundation of all medical judgments for each patient. Therefore, the clarity of communication at this level is critical to making good treatment decisions.
After diagnosis by the physician, the essential communication begins when we inform them the patient has been examined and a treatment plan has been recommended. It is critical to keep the physician informed about the patient’s treatment decisions. Did the patient accept treatment? Has therapy been initiated, delayed, or rejected? Send a letter with your clinical notes, including your intention to have the patient return to the physician for final determination of the resolution of the sleep related breathing disorder. The depth of communication with the diagnosing provider and others on the health care team depends on the role each has in the diagnosis and treatment.
During the titration phase of Oral Appliance Therapy, the effectiveness of the oral appliance in stabilizing the airway is being determined by subjective symptoms (e.g. written questionnaires and verbal inquiry) and objective testing (e.g. wrist pulse oximetry). Once your therapeutic goals have been reached, the patient is to return to the physician for confirmation of efficacy of the oral appliance – resolution of the sleep related breathing disorder. At this point communication should include your objective and subjective records of the appliance titration, as well as your protocol for long term monitoring of the oral appliance therapy. State clearly in your cover letter that you feel the patient is ready for therapy confirmation testing. Yearly communication and update of your patient’s condition should be sent to the patient’s providers.
If you are unable to meet therapeutic goals with the oral appliance, enhanced communication to the boarded sleep physician becomes essential in order to help resolve the patient’s sleep related breathing disorder.
For example, if you are able to reach objective goals with your oral appliance (blood oxygen levels above 90% more than 99% of the night and low heart rate variability), but unable to resolve subjective symptoms (e.g. fatigue), then a referral back to the sleep physician would be essential for additional medical workup.
Another example would be if the subjective symptoms were resolved (patient is happy with sleep), but the objective testing indicates too much time spent (>1% of the night) under 90% blood oxygen. A referral back to the sleep physician to determine further treatment would be essential to success.
In both of these cases, one would be looking for, as one choice, combination therapy to achieve therapeutic goals. Combination therapy has great communication as its foundation. There are many combinations to be considered; the most common is to use an oral appliance concurrently with PAP therapy. The physician would be prescribing PAP therapy and you as the treating sleep dentist would be managing oral appliance therapy at the same time.
A dentist cannot treat sleep related breathing disorders without a foundation of good communication with a physician. Beyond that, some challenging cases can only be successfully treated with close, frequent exchange of information between providers. Reinforcement from everyone on the health care team may be essential to help the patient remain in oral appliance therapy as either monotherapy or in combination therapy. Good communication is what is best for the patient and builds professional satisfaction in all providers. It is also what will help to keep a collaborative relationship between our two professions…Medicine and Dentistry.
Ronald S. Prehn, ThM, DDS, is a third generation dentist who focuses his practice on complex medical management of Facial Pain conditions (TMD and Headache) and Sleep Disordered Breathing. He received his degree at Marquette School of Dentistry in 1981 and post graduate education at the Parker Mahan Facial Pain Center at the University of Florida and the LD Pankey Institute in the years to follow. He is a Board-Certified Diplomat of both the American Board of Orofacial Pain and American Board of Dental Sleep Medicine, of which he is president-elect. While being an adjunct professor at the University of Texas Dental School in Houston, he is published in several journals on the subject of combination therapy for the treatment of obstructive sleep apnea. He is a sought-after speaker on this subject at the national level. He currently limits his practice to management of complex sleep breathing disorders at the Koala Sleep Center in Wausau, Wisconsin while enjoying with his wife, Linda, the outdoor life style and people of North Central Wisconsin. He can be contacted at email@example.com.
After the Symptoms are Resolved
by Mark Murphy, DDS, and Eddie Sall, DDS, MD
When we would embark on a trip, my kids used to wonder, and my grandchildren still ask, “are we there yet”? Honestly, sometimes I felt the same way. As you arrive at the gates of Disney or the hotel/resort you chose, there is a sense of relief, celebration and the satisfaction that you have safely completed the mission. So, too it is with treating obstructive sleep apnea for our patients. Are we “there” yet? Defining “there” is more gray than black and white. An AHI of 5 or less may be ideal but when a CPAP failure patient who started their journey with an AHI of 60 has been improved to 12, that may an incredible success. They may have more energy, less dependence on medications, reduced morbidities and a higher quality of life, but we are certainly not in a position as their dentist to determine if that is an acceptable treatment outcome. We should let the diagnosing provider make that call.
After periodontal therapy, many patients can maintain their teeth in acceptable comfort, function and esthetics even if they have some residual pocket depths greater than 3 millimeters. Many clinically acceptable endpoints are not black and white, yet someone must make the call. As dentists, we are well trained to work interdependently with the periodontist to determine the survivability of the dentition in less than perfect outcomes, but we have far less expertise in medicine. The evaluation of the effectiveness of the outcome and the follow up responsibility for disease management is and should be in the realm of medicine. We should participate, but not direct or be responsible for the treatment efficacy or follow up for the development or recurring OSA, relevant symptoms or comorbidities. Nor should our partner in health care, the physician, direct the follow up care with regards to the fitting, adjustment, titration or replacement of the precision oral medical device that is driving
This policy emphasizes the obligation and importance of dentists in screening patients for OSA and outlines the importance of continued 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 the scope of practice in dentistry and medicine. Dentists are in a unique position to screen patients for SRBD as part of the comprehensive medical and dental history and, as healthcare professionals, they have the best expertise to evaluate the oral cavity and associated structures. Once appropriately screened, the patients should be referred to sleep physicians for a proper diagnosis. The ADA and the American Academy of Dental Sleep Medicine recognize that dentists play a critical and integral role in evaluating their patients with potential sleep-related breathing disorders but require the diagnosis of these disorders to be made by a physician.
We are better together. When the treating dentist encourages the patient to return for the follow up sleep test to confirm the treatment efficacy, partnership strengthens. Patients feel better and have usually received some interim feedback like pulse oximetry to confirm they are on the right track. Without a follow up sleep test, we do not have verification. The best way to help the patient near the end of the treatment cycle is to have the conversation at the beginning of that cycle. By creating the expectation of a follow up test and maybe even including it in the written treatment plan, testing compliance will improve. Similarly, when physicians and dentists confer and create a treatment agreement document, it will help serve as a roadmap of treatment protocol for the collaborators. Setting expectations up front for the professionals and patient improves outcomes and adherence.
The ADA statement delineates the dentist’s role and clearly emphasizes the importance of communication by the dentist with the referring physician and other healthcare providers. The policy emphasizes that follow-up sleep testing by a physician is imperative to evaluate the improvement or confirm treatment efficacy for the OSA, especially if the patient develops recurring OSA relevant symptoms or comorbidities.
The advent of home sleep tests (HST) has created some confusion and ambiguity as to who should perform and or interpret the post treatment efficacy studies. While dentists may utilize HST to assess the objective interim results of Oral Appliance Therapy, the ultimate efficacy studies should be interpreted by the sleep physician. The complexity and comprehensive treatment of SRBD is best achieved when there is open communication between the treating dentist (with the proper training and expertise) and the sleep physician. The dentist managing a patient with SRBD using a mandibular advancement device should have a system for regularly evaluating their patients for ongoing use and efficacy. The ADA policy statement is consistent with the best practices approach to optimize treatment of SRBD and is in the best interests of our patients.
The first part of the discussion regarding ADA recommendations for treatment of sleep-related breathing disorders can be found in Part 1 of this special feature, “Sleep-Related Breathing Disorders: The Role of the Dentist.”