Dentists have many things to consider when deciding to enter the field of dental sleep medicine. Much of the technical and policy side of entry into the field is outlined by organizations such as the American Academy of Dental Sleep Medicine and The Metz Center offered Dr. James Metz, a pioneer in the field. Many other websites and resources are available to facilitate collaboration between the dental and sleep medical fields.
In this post, I want to discuss a more pragmatic side to venturing into the field of dental sleep medicine by focusing on the natural patient-centric capabilities for dentists to serve as primary sleep medicine providers. On my primary blog work at classicsleepcare.com, you will notice fairly quickly my rationale for the use of PAP therapy in the large majority of sleep apnea patients. Specifically, I outline how we have learned to increase adherence rates, especially among patients who were reluctant to use PAP, as well as reverse CPAP failure by using of advanced PAP technology.
One might ask, then, why promote the value of oral appliance therapy (OAT) over PAP therapy? Technically I am not recommending OAT over PAP, but pragmatically as you will see in the following discussion, I have long advocated for the dental sleep medicine community to become more active and assertive in the field of sleep in light of several indisputable facts about the medical sleep medicine community. First, the sleep field remains unprepared to manage the vast majority of undiagnosed sleep apnea patients. Second, sleep medicine physicians are not producing excellent compliance rates for PAP therapy among sleep apnea patients. And third, due to assorted factors within our medical field (the scarcity of sleep docs and the one size-fits-all devotion to CPAP modes of therapy) and external factors outside the field (anti-sleep insurance policies and government-induced administrative burdens), there are no easily navigable pathways for sleep centers to introduce a personally-tailored, patient-centric program, which in my experience is the best method to engage sleep apnea patients to use a PAP device consistently and over the long-term.
My friend and colleague, Dr. Steven Park, has often declared, “some treatment is better than no treatment.” And, oral appliance therapy provides a tremendous opportunity to initiate treatment for a vast number of sleep apnea patients who might never visit a sleep center or who might never even discuss sleep problems with their primary care physicians. To be clear, this perspective is not attempting to encourage the dental sleep medicine community to aggressively address the problem of snoring, which should be viewed as a secondary objective within dentistry. My position strongly advocates for the value of dentists as front-line providers for the treatment of sleep apnea with certain clinically relevant caveats:
- The dentist must determine a valid, transparent, and effective way to recommend oral appliance therapy as a first-line treatment for select OSA patients.
- The paradigm for selecting OSA or UARS for OAT must assiduously avoid recruiting individuals with cardiovascular disease (with some exceptions).
- Whereas CPAP failure patients are another potential group to target for OAT, the complexity of their other medical co-morbidities must be relatively limited, because in many instances, such patients should first receive the opportunity to try advanced forms of PAP therapy prior to OAT.
While there are additional caveats, these three are of major importance and often overlap in the process of engaging patients to work with OAT sooner than later, so let’s examine these circumstances and let’s begin by demonstrating why a dentist’s role is so vital as a front-line provider to sleep medical care.
To begin this discussion, ask yourself which type of healthcare practitioners are the most likely to ask their patients about sleep and what is their motivation for doing so? If you said mental health professionals, including psychiatrists, psychologists, social workers, therapists, and counselors, then you are correct! These professionals are more in tune with sleep dysfunction, for the obvious reason that their handbook to diagnosis mental disorders (DSM-V) lists sleep complaints in anywhere from 80 to 90% of all psychiatric disorders. Not only is the complaint listed as a symptomatic manifestation of the mental disease, but also various sleep symptoms (notably non-restorative sleep, insomnia, hypersomnia, nightmares) are actual criteria components used to make the diagnosis. Unfortunately, there is one flaw in this psychological pathway, which is the lack of training or credentialing for mental health professionals to evaluate the human airway.
Which brings us to the next question. Which two healthcare professions invariably examine the human airway during a clinical appointment? If you said otolaryngologists (ear, nose, throat docs) and a host of dental professionals, you have again hit the mark. Sadly, many primary care physicians not only do not ask about sleep, but their examinations of the nasal and oral airways are often cursory efforts to confirm the absence of any major pathology.
Nowadays, many ENT doctors ask about sleep, because it benefits them to do so, given how various nose and throat surgeries have some potential to help OSA/UARS patients. And, with increasing sophistication in the ENT community many doctors recognize they rarely cure OSA/UARS, but instead their services often facilitate patients’ efforts to use PAP therapy in the aftermath of such procedures as septoplasty, turbinoplasty, and tonsillectomy.
Which brings us to dentists who already perform detailed examinations of the oral airway. If no other step beyond assessment and diagnosis occurred, then a great service would be provided to their patients by nudging them in the direction of sleep medicine providers. But, why not go the extra step of recommending a treatment option through dentistry?
We already know 50% of patients referred to CPAP treatment might fail and fail rapidly. We also know a substantial portion of less severe OSA/UARS patients are likely to demonstrate a 50 to 60% improvement upon use of OAT. And, we have not even begun to factor in the obvious dropout rates among patients referred by dentists to a sleep center. Unquestionably, a majority of patients prefer expedient treatment and are not knocking down doors of sleep centers to complete overnight polysomnography.
In other words, with the proper algorithm that avoids recommending oral appliance therapy in cardiovascular patients or others with extensive co-morbidity (2nd and 3rd caveats), the dentist can offer a valid, transparent and effective way to initiate a sleep-disordered breathing treatment program as first-line therapy (1st caveat). If you are wondering why this clearly proactive approach should be deemed a caveat, I believe it is so because the dentist must err on the side of caution in the final selection among those offered OAT as first-line treatment.
So far, we’ve discussed relatively straightforward reasons for the dentists to enter the sleep medicine paradigm. The only other requirement is the dental professional must be educated on the nature, assessment and treatment of sleep disorders with special attention to OSA/UARS and in turn must create a format for gathering relevant sleep data from patients at their appointments. At minimum, dentists need to acquire basic survey information about symptoms of insomnia, sleepiness and sleep-related breathing symptoms. Coupled with the airway exam, the dentist then has the opportunity to consolidate the information for the patient who may gain the capability to rapidly digest and absorb the idea of a potential diagnosis of sleep-disordered breathing.
Which brings us to the most difficult part of the puzzle: why should a dentist seek training and credentialing to enter a field that clearly resides within a sub-specialty field of medicine? The answer, in my opinion, is as simple as: “because the dentist can.” Delving deeper affords us the chance to notice similar transformations in various fields of medicine. Consider as a prime example the development of pain clinics many of which are operated by anesthesiologists. What prompted this new therapeutic pathway for anesthesiologists? The answer is clear: they developed the delivery system to engage with pain patients in various ways to treat all sorts of pain conditions. Yet, anesthesia doesn’t equate to pain unless you consider the concept of nerve blocks during localized surgical procedures. Rather, anesthesia equates to sleep, yet we see very few anesthesiologists moving in this direction…as yet.
What about psychiatrists and neurologists developing practices based on neurofeedback and other brain stimulation modalities? The connection is clear when we think brain, but it’s not so clear when we describe the active stimulation of the brain by individuals who are not neurosurgeons or neuroscientists, yet they have learned to deliver a therapy to help their patients. What about dermatologists and all the assorted skin care interventions they now perform, which previously would have been placed in the domain of plastic surgeons? What about orthodontists who engage in maxillary expansion dental manipulations as well as newer orthodontic procedures, all in the hopes of treating or preventing sleep-disordered breathing? Again, the delivery of a treatment was the passageway through which a doctor in one field of health or medicine crossed-over to another field.
Dentists spend the majority of their time working inside the oral cavity of humans. Conceivably, no such thing as oral appliance therapy might ever have been invented or discovered, which would have left dentistry only with an assessment role. However, fortunately, OAT was discovered and invented. And, now we have experts in the field of oral airway health who have learned to deliver treatment for the medical condition obstructive sleep apnea or upper airway resistance. It is only natural in the spirit of innovation and entrepreneurship that dentists would expand their services with the application of oral appliance therapy. By doing so, it follows a pattern of cross-over experiences seen in other fields of medicine and which have often led to greater diversification of treatment delivery as well as higher quality of care.
About the author
Dr Barry Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr. Krakow started in sleep research in 1988 and helped pioneer innovative therapies for chronic nightmare patients. Since 1995, he has practiced sleep medicine full-time and currently operates Maimonides Sleep Arts & Sciences, Ltd., a private sleep medical center specializing in the treatment of sleep disorders such as insomnia and sleep apnea in mental health patients. He is also principal investigator of the Sleep & Human Health Institute, a non-profit research center that focuses on the complex interplay between physiological and psychological sleep disorders.