Should You Be Treating Sleep Apnea?

Dr. Halligan
Dr. Halligan

Courses on oral appliances for the treatment of obstructive sleep apnea (OSA) must be the newest growth industry. A few months ago, I could count on getting a few emails a week inviting me to a weekend seminar on dental treatment for sleep apnea. And now? I’m getting at least three such advertisements every day. Must be a hot subject, right?

On the one hand, I think it is appropriate that sleep apnea is getting so much attention. Every month, new studies are published showing just how dangerous the condition is. Heart disease, especially sudden death from heart attack is all too common with these folks. High blood pressure, strokes, even ED are being linked to this nighttime drop in oxygenation.

And the condition itself is quite common. It is estimated that about 20% of the adult population suffers from OSA, and the vast majority of them are undiagnosed.

I can tell you that as a dentist you do have a crucial role to play. Dentists cannot legally diagnose the condition as of the fall of 2013. Although there is some pressure on the system to change that, it hasn’t happened yet. But that doesn’t mean that as a dentist you can’t perform some basic screening steps then refer your patients for an overnight sleep study.

At the same time, the MDs, especially primary care physicians, are largely unaware or largely ignoring the problem. If a 55 year-old man discloses to his physician that he drinks 10 cups of coffee every day just to stay awake because he is so fatigued, does the MD even discuss the possibility of sleep apnea or investigate it? Based on what patients are telling me, this kind of follow-up occurs very infrequently.

Why? Just my opinion, but I think it has a lot to do with managed care. Most people are aware that managed care has very little to do with care. It’s not managed care; it’s managed money. Or perhaps think of it as management of the caregiver by the insurance company. The result is that in many managed care practices, the MD has at most 15 minutes to interview and examine each patient. And the reality may be closer to 12 minutes. One patient, describing her visit to her primary care physician told me that her doctor rather sharply said to her, “Look, I’ve got about five minutes to see you. I don’t have time for any chit-chat.” One neurologist I know evaluates 40 patients per day with the help of a physician assistant. Do the math.

An experimental sleep appliance by lab technician John Feldin (www.oralsleepapnea.com)
An experimental sleep appliance by lab technician John Feldin (Oral Sleep Apnea)
The Moses appliance (www.themoses.com)
The Moses appliance (The Moses)

And then if sleep apnea is diagnosed, the sleep doc usually puts the patient on CPAP from the start. This is true even though the standard of care today—according to the Academy of Sleep Medicine—is to try an oral appliance FIRST for mild to moderate sleep apnea. Often, the prescribed CPAP machine ends up in the garage or for sale on Ebay. And the patient goes untreated.

 

Now back to the original question: should you be treating sleep apnea with oral appliances? The answer is yes, but with some caution.

First a few words about the ads that show up in your inbox. Be aware that there is a lot of hype—far too much in my opinion. And yet, many of the courses are excellent.

An ad for a sleep apnea course may make some rather bold promises, chief among them:

1) Making appliances to correct sleep apnea is the easiest dentistry you’ll ever do. In fact, you’ll want to give up general dentistry and just do sleep full time. And to be honest, some dentists have done that. But don’t believe all the hype. Nothing is as easy as it looks. It will take training, attention to detail and plenty of experience to become good at treating OSA with oral appliances.

2) It’s easy to become well known in the medical community. Sleep doctors and pulmonologists will refer lots of patients to you. Sorry, that’s not going to happen, or at least not easily. Even after two local pulmonologists became aware of my practice and saw for themselves that I achieved excellent results, they rarely referred. They occasionally refer when a patient categorically refuses to wear a CPAP, but they never refer for oral appliance treatment first, even for their patients with mild sleep apnea. So, will you fill your practice with patients referred by MDs? Don’t plan on it.

3) The insurance companies and even Medicare pay very well for oral appliance therapy for sleep apnea, so this can easily become a lucrative part of your practice. Yes, medical insurance can pay for these services, but, honestly, it’s a whole new game to play, and the insurance companies are the ones holding all the cards. You will need to learn to jump through insurance company hoops. Expect delays and denials, sometimes even after receiving authorization.

Discouraged yet? That is not my intention. But here’s what I believe. Sleep apnea is grossly under diagnosed and untreated. So, I do encourage dentists to read the available research on OSA and learn appropriate oral appliance therapy.

The Suad device by Strong Dental Lab.
The Suad device by Strong Dental Lab.
The popular Somnomed Appliance (www.somnomed.com)
The popular Somnomed Appliance.

I also want dentists to be very aware that oral appliances for sleep apnea can be improperly done and may cause more harm than good. Within the past few weeks I saw three new patients who were wearing oral appliances for OSA. These patients had problems ranging from TMJ pathology to occlusal changes that were so severe that orthodontics was going to be required to correct them. And in all three cases, the appliances were made by dentists who had not taken any C.E. courses in treating sleep apnea. For your snoring—and possibly OSA—patients, it is not as simple as taking a couple of impressions, doing a protrusive bite registration and handing the patient the appliances.

The courses? Well, I haven’t taken all of them, but I will say that courses given by the Academy of Craniofacial Pain are excellent. Also look into the Academy of Dental Sleep Medicine. I have taken classes from Dr. Barry Glassman. He is quite knowledgeable, and also a bit a showman—that’s okay; he’ll keep you awake.

I have not taken any courses given by Sleep Group Solutions, but in talking with dentists familiar with them, they receive excellent reviews. For information go to www.sleepgroupsolutions.com.

If you are interested, by all means take some courses. Next time, I’ll cover some of the screening steps you can do in your office to recognize OSA in your patients. You’ll be able to do a thorough screening in less than a minute.

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1 thought on “Should You Be Treating Sleep Apnea?

  1. My god Bill so spot on…please find a way to share this with the world. I am one of those guys that do nothing but sleep and tmd. Ortho tx skills became necessary due to the occlusal changes and need to be manage orthognathics as needed. Sorry sgs is one of those non stop advertising beasts. I have the contracts,the medical connections, the street cred with the community and the skills to deal,but never stop learning.so you are right that it is a bitch to dedicate your life to this noble pursuit. The dabblers will wash out and move on to the next big thing. But how many patients are put at risk. Frightening to me. There are some good docs out there. But the trend for dentists to dx and do hst is good and bad. Having cases dx remotely by some retired doc earning a few bucks is tragic. We need to be very careful what we wish for. Miss that one neurological disorder and you have destroyed a life. Work with the docs or stick to drill and fill. Thx for your honesty. Tim

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