Editor’s intro: The recent ADA mandate contained language that states: “Dentists are the only health care provider with the knowledge and expertise to provide oral appliance therapy.” Find out the details from Jayme R. Matchinski, health care attorney.
by Jayme R. Matchinski, Esq.
In 2017, the ADA House of Delegates passed Resolution 17H-2017 which included language stating that: “Dentists are the only health care provider with the knowledge and expertise to provide oral appliance therapy”. The Council on Dental Practice developed the ADA Policy Statement on the Role of Dentistry in the Treatment of Sleep-Related Breathing Disorders. The Council on Scientific Affairs formed the Oral Appliance Evidence Workgroup and produced an evidence brief, Oral Appliances for Sleep-Related Breathing Disorders, which was used as background to draft this policy. The objective of this brief was to provide a summary of recent literature for the use of oral appliances in the management of SRBDs, specifically, OSA. This brief reviewed clinical practice guidelines from the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine, which found that patient adherence with oral appliances was better than that for CPAP, and that oral appliances have fewer adverse effects that result in discontinuation of therapy, compared with CPAP.
The passage of this ADA policy statement is the result of several years of analysis and discussions regarding the role of dentists in the treatment of sleep related breathing disorders (SRBDs). It was the ADA’s intention to set forth a comprehensive policy to provide guidance to dentists and further define and refine dentistry’s role in the treatment of SRBDs.
Mandate of the ADA Policy Statement
The adopted ADA policy statement outlines the role of dentists in treating SRBDs. Key components include: assessing a patient’s risk for SRBD as part of a comprehensive medical and dental history and referring affected patients to appropriate physicians; evaluating the appropriateness of oral appliance therapy (OAT) as prescribed by a physician; providing OAT for mild and moderate sleep apnea when a patient does not tolerate a continuous positive airway pressure (CPAP) device; recognizing and managing OAT side effects; continually updating dental sleep medicine knowledge and training; and communicating patient’s treatment progress with the referring physician and other health care providers.
SRBDs comprise multiple diagnoses that involve difficulty breathing during sleep. The disorders, which include obstructive sleep apnea and snoring, can be potentially serious medical conditions caused by anatomical airway collapse and altered respiratory control mechanisms. Obstructive sleep apnea has been associated with metabolic, cardiovascular, respiratory, dental and other systemic diseases. In children, undiagnosed and/or untreated obstructive sleep apnea (OSA) can be associated with cardiovascular problems and impaired growth, as well as learning and behavioral problems.
ADA Policy Statement Recommends that Dentists Conduct Specific Functions
The ADA policy statement emphasizes the dentist’s significant role in screening for SRBDs since dentists are often the first health care provider to identify symptoms and discuss medical and dental history with the patient. The ADA policy statement recognizes the importance of referring at-risk patients to a physician for diagnosis and treatment. It emphasizes that dentists are the only health care provider with the knowledge and expertise to provide oral appliance therapy for those individuals with mild or moderate OSA who are intolerant of continuous positive airway pressure (CPAP) therapy.
Upon adoption of the ADA policy statement, the Council on Dental Practice began sponsoring continuing education opportunities to educate the dental profession about SRBDs and to inform the council’s medical colleagues of the policy and develop information for the public on dentistry’s role in SRBDs.
According to the ADA policy statement, the dentist’s role in the treatment of SRBDs includes, but is not limited to, the following:
- Dentists are encouraged to screen patients for SRBDs as part of a comprehensive medical and dental history to recognize symptoms such as sleepiness, choking, snoring or witnessed apneas and an evaluation for risk
factors such as obesity, retrognathia, or hypertention. These patients should be referred, as needed, to the appropriate physicians for proper diagnosis.
- For 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. 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.
- A dentist should be the one to fabricate an oral appliance when oral appliance therapy is prescribed by a physician through written or electronic order for an adult patient with OSA.
- Dentists should obtain appropriate patient consent for treatment that reviews the proposed treatment plan, any potential side effects, and all available options of using oral appliances.
- Dentists treating SRBDs with OAT should be capable of recognizing and managing the potential side effects through treatment or proper referrals.
- Dentists who provide oral appliance therapy to patients should monitor and adjust the appliance for treatment efficacy as needed, or at least annually.
- Surgical procedures may be considered as a secondary treatment for obstructive sleep apnea when CPAP or oral appliances are inadequate or not tolerated. In selected cases surgical intervention may be considered as a primary treatment.
- Dentists treating SRBDs should continually update their knowledge and training of Dental Sleep Medicine with related continuing education.
- Dentists should maintain regular communications with the patient’s referring physician and other health care providers regarding the patient’s treatment progress and any recommended follow up treatment.
Objective Testing and Usage of HSAT
The ADA policy statement includes the following language in the seventh recommendation for dentist’s role in the treatment of SRBDs:
- Dentists who provide OAT to patients should monitor and adjust the Oral Appliance (OA) for treatment efficacy as needed, or at least annually. As titration of OAs has been shown to affect the final treatment outcome and overall OA success, the use of unattended cardiorespiratory (Type 3) or (Type 4) portable monitors may be used by the dentist to help define the optimal target position of the mandible. A dentist trained in the use of these portable monitoring devices may assess the objective interim results for the purposes of OA titration.
Based upon the ADA policy statement and this objective testing, there has been a lot of discussion regarding whether dentists, who are trained in the use of HSATs, may provide the patient with an HSAT and then assess the results to determine OA titration. Given that the ADA policy statement provides guidance to dentists who practice Dental Sleep Medicine, and the policy statement is not a regulation, dentists should check their state licensure and third party payor agreements regarding whether they can prescribe HSAT and utilize the objective interim results for purposes of OA titration. While sleep testing companies are encouraging dentists to provide HSATs to their patients for the screening and diagnosis of OSA, this may be outside a dentist’s scope of practice depending upon state licensure. Additionally, certain third party payors, including the Center for Medicare & Medicaid (CMS), require a licensed sleep physician to prescribe an HSAT and interpret the results from the HSAT. Dentists should consider setting up protocols and agreements with referring physician, including sleep physicians, in order to identify each doctor’s responsibilities for the sleep testing, diagnosis and treatment of a patient with OSA. Dentists should be careful not to practice outside their scope of practice and state licensure.
Read another perspective on the ADA mandate from Ken Berley, DDS, JD, DABDSM, here.