How Do Dentists Tackle the 54-million-pound Elephant Called Sleep Apnea?

by David Schwartz, DDS, D.ABDSM

The last paragraph of the American Academy of Dental Sleep Medicine’s (AADSM) position statement on the scope of practice for dentists ordering or administering home sleep apnea tests (HSATs) is the most important point in my mind. “As health care providers who live by the ethical code of “do no harm” and understand the harmful consequences of OSA, we owe it to the public to implement models of care that reduce barriers to diagnosis and treatment, ensure that sleep apnea is diagnosed and treatment efficacy is verified by physicians, and maximize the training and skills of qualified dentists.”

Would it be ideal for every patient in the country to have a face-to-face evaluation with a board-certified sleep medicine physician, have a polysomnogram, be presented with a variety of treatment options, get proper education on how to appropriately use their therapy, know who to contact when they have issues with their therapy and receive the appropriate follow-up care? Absolutely! And it’d be even better if all of this is done within seven to ten days.

But the reality is that this is impossible – for a bevy of reasons – for most of the 54 million Americans with sleep apnea. The American Academy of Sleep Medicine (AASM) has acknowledged that there are too few board-certified sleep medicine physicians; approximately 5,700 throughout the country, many of whom are in metropolitan areas and affiliated with academic institutions, to manage the obstructive sleep apnea patient population.

Primary care physicians (PCP) are stretched to their limits. Patients recognize how stretched PCPs are and often hesitate to raise concerns about things that may seem nonessential, such as concerns about their sleep. When the topic of sleep apnea is broached, PCPs do not always have access to the appropriate testing equipment.

Fingers get pointed at insurers and government regulations for creating barriers. Rather than throw our hands up in the air, the AADSM has focused its efforts on how qualified dentists can help meet the burden of OSA.

We believe that every patient with sleep apnea is entitled to effective treatment. Science is showing more and more every day the impact sleep apnea has on the overall health of Americans. If increased blood pressure, auto and workplace accidents, and heart disease weren’t enough, we now know that sleep apnea increases your likelihood of being hospitalized from COVID-19 and that there are some serious links between sleep apnea and Alzheimer’s. In a country where obesity continues to rise, we must ensure patients have access to diagnosis and treatment for sleep apnea.

We must also recognize that patients are looking for resolution to their healthcare needs. Fragmented care and lengthy wait times between screening and treatment cause people to ignore their health issues, especially when the consequences are more long term.

Considering all of this, the AADSM created the HSAT position statement to outline a way we can play a role in solving these very real concerns. Using our training, common interactions with patients, and a collaborative model of care, we can be most impactful and help our medical colleagues and patients.

This position statement makes it clear that the AADSM believes that:

1. It is within the scope of practice for a qualified dentist to order or administer HSATs.
2. Licensed medical providers should be diagnosing and verifying treatment efficacy.

In this model, trained dentists complete an appropriate screening process which includes taking a medical and family history and also using validated screening tools and performing a physical exam. If patients are at risk and appropriate candidates for HSAT, a qualified dentist can order or administer the HSAT directly from his or her practice, assuming it is allowed by their state laws. Patients then complete the HSAT. Pertinent patient information and the HSAT data are provided to a physician for diagnosis, and, if appropriate, the physician prescribes an oral appliance. The qualified dentist then determines whether the patient is a suitable candidate, fabricates, and delivers the appliance. After the appliance is at the appropriate therapeutic position, the qualified dentist once again orders or administers an HSAT. Pertinent patient information and HSAT data are shared with the physician who verifies treatment efficacy.

This model takes some burden off physicians. Trained dentists have a front seat view of our patients’ airways. Our appointment times allow us to incorporate conversations about sleep and a screening process into our workflows. This model requires fewer appointments for obtaining a diagnosis which reduces expenses and patient inconvenience while increasing the likelihood of treatment if sleep apnea is diagnosed. It also ensures that dentists and physicians are collaborating to provide optimal care for patients and allows for patients’ medical insurance to appropriately cover oral appliance therapy. In no way does it bypass the involvement of a physician in the diagnosis and verification of treatment efficacy and encourages dentists and physicians to work together to refine their practice models.

Some of those who have been practicing dental sleep medicine for a while may be saying, “It’s about time the AADSM finally took a position on HSAT,” but we must all remember that it is only in the last two years that we’ve published the standards for practice paper and launched the AADSM Mastery Program. Managing care for patients diagnosed with OSA requires postdoctoral continuing education, training, clinical judgement, collaboration with our medical colleagues, excellent patient care, and an understanding that we are treating a medical disorder. We are now in a position to ensure that dentists have the tools necessary to effectively provide the care outlined in the HSAT position statement.

It is one thing to publish a position statement. It is another to ensure the model of care gets implemented and patients realize the benefits of this model. The AADSM will be increasing our education on HSAT, working to get state dental boards currently prohibiting HSAT to change their regulations, and increasing our communications with physicians, the public, and insurers to educate them on this model of care.

Our influence on these initiatives is always substantiated by our membership numbers. The biggest step dentists can take to help advance these initiatives is to join the AADSM; it demonstrates that our field is united in reducing the number of undiagnosed and untreated people with sleep apnea.