KEITH THORNTON , DDS improving cardiovascular morbidity and long term compliance . These studies resulted in a recommendation by the American Medical Association and an editorial in the New England Journal of Medicine to use CPAP only for symptoms . Studies have documented a failure rate of CPAP of approximately 75 % the first year even using the definition of success as four hours per night , five days a week . Studies in the medical literature have shown comparable efficacy of oral appliance and CPAP but much greater effectiveness of oral appliances due to better compliance . With patients preferring oral appliances in some cases 20 to 1 over CPAP , three questions come to mind :
1 . Why don ’ t sleep physicians give OSA patients the choice between oral appliances and CPAP ?
2 . Why are less than 20 % of OSA patients who fail CPAP referred to a dentist for an oral appliance ?
3 . Why are oral appliances only 10 % of the OSA treatment market ? I think the answers are obvious .
The second development is the recent policy of the ADA . There are four statements that are the most cogent . I have paraphrased them :
1 . Dentists should screen for SRBD and as “ necessary ” refer to the “ appropriate ” physician .
2 . For children , the quarter back in all SRBD treatment is the dentist with few exceptions
3 . Oral appliances can be used for all levels of SRBD .
4 . Home sleep testing can be used to evaluate outcomes of oral appliances .
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The first statement is the most compelling . “ Necessary ” and “ appropriate ” are the operative words . The dentist can make an independent decision to refer and whether a referral is needed . The “ appropriate ” physician is not necessarily a sleep physician . The greatest benefit of the policy is that the dentist ’ s scope of practice remains very broad and is not encroached by the desires of a special interest guild . Although the policy is not law , ultimately it will become the standard of practice which goes to the law .
The AASM and the American Academy of Dental Sleep Medicine are involved in a lawsuit with the Texas Medical Association against the Texas State Board of Dental Examiners . Their contention is that dentists ’ treatment “ jeopardizes the quality of care ” and therefore “ causes harm to patients ”. Dr . Nathaniel Watson , a former president of the AASM , reiterated these sentiments as the only person opposed to the policy at a hearing of the ADA Council on Dental Practice . I wonder how he can justify his stand knowing that very few patients on CPAP ever get seven hours of sleep per night much less the people who fail or reject CPAP therapy .
The last development is the FDA clearance for over-the-counter ( OTC ) sales of an adjustable , protrusive oral appliance , the SnoreRx , for treating snoring .
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The device has a limited protrusive range and has warnings based on the STOP-Bang questionnaire . However , the FDA no longer considers an oral appliance a significant risk warranting a prescription by a dentist or physician . If the patient answers positively to the questionnaire , the patient is warned to see a clinician first .
It is my belief that these developments bode well for not only dentists but more importantly patients . The OTC oral device will point patients to the dentist as a first stop in resolving their SRBD problems . From there , I think the treatment algorithm will change dramatically from a focus on diagnosis to one on long term management and treatment with the dentist as the primary clinician ( see Fig . 1 ). Obviously , other issues must be resolved such as education , standard of care , and reimbursement . However , in the long run , the patient will be better served under a dentist ’ s care .
References :
1 . http :// www . mdmag . com / conference-coverage / chest-2017 / barbara-phillips-md-sleep-apnea-diagnosis-is-too-complicated ) 2 . http :// www . ada . org /~/ media / ADA / Member % 20Center / FIles / Role _ of _ Dentistry _ in _ the _ Treatment _ of _ Sleep _ 1-5 . pdf ? la = en 3 . https :// www . accessdata . fda . gov / cdrh _ docs / pdf17 / K170825 . pdf 4 . Phillips B , Gozal D , Malhotra A . What is the future of Sleep Medicine in the US ? AJRC- CM . August-2015 ; 10.1164 / rccm . 201508-1544ED