Ashley Spooner, DDS
Decreasing the number of undiagnosed cases of obstructive sleep apnea (OSA) may reduce automobile accidents, improve quality of life, and reduce the risk of chronic health problems, according to the Journal of Clinical Sleep Medicine.1 Moreover, proper screening and diagnosis can contribute to relieving the burden on the health-care system by decreasing utilization, as well as costs associated with doctor visits.
Ordering sleep studies
Some dentists are becoming educated in treating patients with mild to moderate OSA, and some are not. However, whether or not we choose to treat OSA or not, it is a deadly and frequently undiagnosed condition. I believe that identifying patients with OSA should be a part of every dentist’s practice; that dentists help promote awareness of OSA; and that we support our patients in getting necessary treatment.
State regulatory boards currently are looking at the reach of a dentist’s scope of practice and involvement in treating sleep apnea. Establishing a ruling that would prohibit dentists from ordering sleep studies for patients who are at risk for OSA may create an unnecessary barrier for patients to get diagnostic testing that could ultimately save their lives.
Many patients see their dentists more frequently than their other doctors, and spend more time on a per-visit basis with them. This creates the need for a dental environment that serves patients better in the identification, screening, and treatment of OSA. Furthermore, patients may have greater rapport and trust with their dentists, simply as a result of spending more time with them. This trust, coupled with appropriate dentist-physician communication, can improve compliance with screening tests, sleep studies, and the treatment that follows diagnosis by a board-certified sleep physician.
Preventing dentists from conducting the initial screening and ordering of sleep studies may reduce physician-led OSA diagnosis. A recent study of US adults being treated for OSA showed that only 30% of these individuals were alerted of this condition by their physician.1
Cotreatment with physicians
Dentists and physicians should strive to promote a symbiotic relationship that facilitates cotreatment of OSA patients, regardless of who orders the sleep study. Communication between dentists and physicians is critical to increasing the number of patients being diagnosed and treated. The dentist-physician team should work together to identify whether continuous positive airway pressure (CPAP) or oral appliance therapy (OAT) is the most appropriate treatment for the patient.
Education and ethics
When a dentist becomes involved in OSA treatment, education and ethics are paramount. Dentists should never diagnose the condition. Dentists should always treat the physician as an integral player in helping patients get the treatment and follow-up they need. Dentists who choose to treat sleep apnea have the responsibility to ensure that the patient has a comprehensive sleep examination, a sleep study with diagnosis by a sleep physician, and if needed, a prescription from a sleep physician that recommends an oral appliance.
The Clinical Practice Guideline: Diagnosis and Testing OSA, published by the Journal of Clinical Sleep Medicine, states that 76% of patients prefer home sleep apnea tests (HSATs).2 These patients have increased satisfaction with testing procedures, which increases their perceived value of diagnosis and promotes good clinical outcomes. Ultimately, this satisfaction is proven to increase compliance due to convenience. HSATs are less costly, more comfortable for the patient, more accessible, and can be ordered immediately. However, some patients will still require an in-lab test.
CPAP should always be offered as a gold standard treatment, especially in patients with severe sleep apnea. In patients who have been prescribed an oral appliance, dentists should be aware of the benefits of pharyngometry and rhinometry to properly assess the airway and measure the efficacy of the appliance.
Initial and follow-up sleep studies should be conducted to evaluate the apnea-hypopnea index (AHI) with the appliance in place. There should be continued communication between the dentist and physician during the course of treatment. Patients should always be encouraged to see their physician for continuing care, as well as to monitor and treat comorbidities. When this proper protocol is followed, treatment is safe and effective, and quality of life is improved.
Dentists who choose to be involved in sleep medicine must follow all guidelines of treating OSA patients. They have the ethical responsibility to provide proper referrals and follow-up care. Enforcement that dentists follow these guidelines, rather than revoking privileges to order sleep studies, will hold providers to a higher standard of care while also considering the patients who can benefit from the streamlined diagnosis that dentists can provide.
Taking action
The health-care system is making progress in reducing the number of undiagnosed and untreated OSA cases. This is being done through increased awareness of the condition, continued improvements of home sleep tests, polysomnography, pharengometry, rhinometry, and cotreatment between dentists and physicians. This will ultimately lead to enhanced collaborative care and healthier, happier patients.
References
1. Watson NF. Health care savings: the economic value of diagnostic and therapeutic care for obstructive sleep apnea. J Clin Sleep Med. 2016;12(8):1075-1077.
2. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guidelines: diagnostic testing of OSA. J Clin Sleep Med. 2017;13(3):479-504.
Ashley Spooner, DDS, graduated from University of Colorado School of Dental Medicine. She owns a PDS-supported practice in Highlands Ranch, Colorado. Dr. Spooner is a subject matter expert on patient and team retention and serves as a faculty member for the PDS Institute. She can be contacted at [email protected].
