No Patient Left Behind

There’s an epidemic that’s 85% undiagnosed, affecting people all around us. Every medical professional has responsibility, but, so far, patients are suffering.

As our country settles into a new norm and political direction, we find ourselves facing unique realities and engaging in new ways of processing and thinking. We are left with an understanding that the way things were done in the past may bear little weight on our current management or new way of business.

FAKE NEWS. Even new vocabulary has been introduced and streamlined into everyday lingo. National leadership campaigns have shockingly challenged the reporting giants of our country. The supreme, conventional agents of media reporting on truths are no longer accepted with full certainty.

New news, old news or lack of news — can no longer be accepted without question. It’s no surprise that even in our industry, this logic applies. Large dental sleep organizations are declaring new standards for accreditation and participation. When can we blow the ‘fake news’ whistle on these targets, which seem devoid of consequential benefits and significance regarding our greater goal?

No Patient left behind. That’s our goal. Isn’t that the essence of the pledge that we made as professionals in dentistry and medicine? We have an obligation to serve people to the best of our ability. Furthermore, as dental sleep medicine practitioners, we have a moral responsibility to help struggling patients with their airways and sleep disordered breathing.

Dental sleep medicine has become even more important because in 2015, the Center for Disease Control (CDC) released clear and indisputable information regarding sleep apnea: It declared that sleep apnea had become a national epidemic.

A homeland crisis of a grotesquely ever- growing sleep apnea epidemic has been happening for years, and now the light has been turned toward this disease. Unfortunately, we have also come to know from studies1 that approximately 85% of people who have Obstructive Sleep Apnea remain undiagnosed. We are faced with an epidemic and 85% of us are still in the dark about it.

Even more alarming may be the declining number of Sleep Medicine specialists available to treat this epidemic. In 2007, the American Board of Internal Medicine (ABIM) first administered the examination for certification in Sleep Medicine. In many ways, this recognition by the ABIM was crucial to legitimize the field of sleep medicine.

Many thought that adding Sleep Medicine to the ABIM would not only increase the awareness for quality sleep health but also increase the number of patients who would have access to a sleep test. Unfortunately, the disheartening reality is that the reverse is occurring and very few people are aware of it. Unfortunately, the acceptance by the ABIM has inadvertently restricted the access of care for patients. How is this possible?

According to the ABIM, in 2011, there were 1,575 new physicians who were boarded in sleep medicine. Many were physicians able to utilize a “practice pathway” program that ended that year.  These practicing physicians were ‘grandfathered in,’ but since then, the number of newly-boarded physicians depends on how many apply for fellowships and then take the certification exam. Since then, approximately 300 new physicians are boarded in sleep every other year, and 25% of fellowship training ‘slots’ go unfilled. No one has statistics on how many board certified sleep physicians retire or otherwise stop seeing patients every year, but no matter the precise numbers, we can be confident there are not enough to meet the epidemic of untreated people.
These untreated patients end up suffering from heart disease, diabetes, obesity, stroke and/or increase their chance of sudden death by 46%. More people need help and we have fewer sleep physicians to screen, test, and treat patients in need. Furthermore, we have newly proposed guidelines from organizations requiring OSA patients to have a face-to-face visit with a board certified sleep physician. How is this not restricting the access to care?

Perception is Reality — another trending topic. Not only are we becoming more aggressive in voicing national ‘truths’ but new perceptions are shaping global realities. Whether this is a strategic leadership approach, an intentional diversion or brilliant fusion of both, things are different. They are becoming what they appear to be.

We can find the same in our industry. For instance, let’s look at Home Sleep Test (HST) and the New Jersey state dental board from a few years ago. In 2015, dentists in the state of New Jersey heard that they were not able to recommend, distribute, or handle a home sleep test to patients due to the board voting to adopt this position. Some took that to mean that they couldn’t treat sleepy patients at all. New Jersey dentists began to fear discussing the topic of sleep and airway issues with their patients, but it was Fake News. Perception is Reality.

Restricting access to care for sleep apnea and airway issues has a tremendous effect on our country. “Approximately one in four patients in a dental practice is at risk of sleep disordered breathing. Dentistry has long been proactive in ensuring that patients are seen on a biannual basis for early disease detection and prevention,” states John Tucker, DMD ( He added, “The dental profession is a logical partner to the sleep physicians in continuing this practice of primary screening for sleep disordered breathing. If the sleep physician diagnoses a sleep disordered breathing problem, the dental professional can then provide appropriate treatment based on the sleep physician’s recommendation as well as the patient’s treatment preference.”

Dr. Tucker is referring to the “Prevalence of Symptoms and Risk of Sleep Apnea in the US Population” study2 from the chest physicians. This information leads us to consider the diagnostic options for patients of a dental practice. On the positive side, a full in-lab Polysomnogram (PSG) measures more channels than any home sleep test device currently on the market. Sadly, many patients who are prescribed a PSG for suspected OSA never follow through with the sleep test. This is why home sleep testing is a great option for patients that don’t have access to a local sleep lab or who refuse to stay overnight in one.

Regardless of what vehicle is used as a sleep test for patients, a board certified sleep physician is needed to read and diagnose the sleep test. The best case scenario for a dentist is to have a local sleep lab that is HST-friendly, and have a board certified sleep physician who is aware of the clinical validations for oral appliance therapy and willing to work with a dentist in a multidisciplinary approach to treating patients. Because these relationships are not always easy to foster, practitioners are encouraged to utilize home sleep testing in conjunction with working alongside a board certified sleep physician to obtain a diagnosis and the patient’s primary care physician for treatment.

No Patient Left Behind means fighting for your patients and not allowing them to continue to be in jeopardy of sub-optimal health. If they won’t attend an overnight sleep study at a lab, it’s your obligation to push for their health.  If a patient won’t agree to testing, treatment is not possible. When treatment is not possible, the epidemic continues and patients’ airway issues worsen to the extent of strokes, cardiac arrest, and even fatality.

Sleep testing is not a “one size fits all” game…just like choosing your oral appliance.  It is imperative to consider your state’s protocols, your training and clinical readiness, clinical benefits, and medical coverage. Just like a patient must own their diagnosis before accepting treatment for obstructive sleep apnea, a dentist must own his or her treatment plan. In fact, they must own every choice they make when “practicing” dentistry and/or medicine, then remain accountable for those choices and actions.

With the increasing number of sleep labs closing and insurance payers that won’t support reimbursement for sleep studies, it is time to get on board with new options that will ensure more patients get the care they need. If not, we will continue to see the rise in co-morbidities linked to sleep apnea and airway obstruction.

On that note, how about some good news? Dr. Sharon Keenan, PHD, RPSGT, the Founder of The School of Sleep Medicine Inc.™, recently mentioned, “We enthusiastically embrace the opportunity to welcome our dental colleagues in the fight against ignorance about healthy sleep and sleep disorders. Because dentists have a unique role in helping patients maintain, indeed maximize health, it is critical that we share and exchange knowledge to move forward in the quest of optimal health and well-being for our patients.” This instantly made my heart smile. Having the distinguished Dr. Keenan embrace the dental community has no doubt solidified our common goal to work in a multidisciplinary approach to treating patients. Organizations like The School of Sleep Medicine, Inc.™ ( ) will no doubt help propel dentists to work more closely with physicians for their patients needing sleep medicine services.

Too often, we hear of dentists who are highly educated and motivated to treat dental sleep patients encountering wasteful roadblocks/barriers along the way. They may spend tens of thousands of dollars (we have heard up to $150,000.00) just to get involved in dental sleep medicine. Recently, I spoke with a doctor who spent 14K for himself and his partner to attend a mini-residency program, only to hear that they cannot facilitate, administer, or even order a sleep test. This by the same organization that provided the education. Dentists feel dismayed with the process and may stop screening patients altogether.

If we all agree on the thought process of “No Patient Left Behind,” we must go beyond educating patients. We must create a “movement.” How does one help facilitate change? Let’s look beyond the status quo. If you ask Dr. Howard Hindin, DMD, MS, he says: “How we breathe, as well as the structure and function of our airway, determines our health, performance and quality of life. Today still only 15% of men, women and children have their “hidden” airway / sleep problems recognized and adequately diagnosed and treated. Addressing this detrimental condition can offer solutions to many of the widespread health problems in our society today. The dental team can and must play a “frontline” role in diagnosis and treatment of airway dysfunction. In the near future it will be the standard of care.” These are phenomenal words spoken by a true thought leader in our industry. Words that can transcend into motion can be used as a catalyst to activate change.

If we all want to help more patients get diagnosed and treated, let’s do it together! We all need to realize that we need to use a multidisciplinary approach to help treat patients. We approach the “tipping point,” when barriers of identifying patients and maximizing opportunities for treatment will become the way things used to be done, but not anymore.

Keep an open mind and remember your purpose, and you will help more people. “No patient left behind.” Become the movement. Fight the fight. Make a difference. Patients need you.

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