For the first time, the two major sleep medicine associations representing dentists and physicians have issued a guideline for oral appliance therapy in the treatment of obstructive sleep apnea.
To provide the best care for patients with obstructive sleep apnea and guide the successful administration of oral appliance therapy, sleep physicians and dentists recently collaborated to publish the first-ever joint clinical guideline for sleep medicine professionals-marking a milestone in the field. The American Academy of Sleep Medicine (AASM), which represents physicians and other medical professionals dedicated to sleep medicine, and the American Academy of Dental Sleep Medicine (AADSM), the only nonprofit professional association dedicated exclusively to the practice of dental sleep medicine, issued the new Clinical Practice Guideline for Oral Appliance Therapy this past July. Ultimately, the six practical recommendations in the guideline (1) validate the efficacy of oral appliance therapy, (2) suggest best practices for providing treatment, and (3) clarify the roles for both dentists and physicians in the patient-care continuum.
Past practice parameters published in 1995 and 2006 were established only by the AASM and were based on a small body of oral appliance research. However, during the past decade, the clinical use of oral appliance therapy-and the supporting research on treatment outcomes-has increased remarkably. Consequently, more medical professionals are accepting dentists as part of the sleep medicine team, leading to increased teamwork between physicians and dentists. To better serve this new collaborative environment in the field of sleep medicine, the first joint AASM and AADSM clinical guideline endorses the physician-dentist partnership as playing a key role in providing optimal patient care for the treatment of obstructive sleep apnea with oral appliance therapy.
How dentists and physicians can use the guideline
The guideline is a great resource for general dentists and physicians who may encounter questions about snoring, sleep apnea, or oral appliance therapy during routine patient visits, as well as for dentists interested in integrating dental sleep medicine into their practices and those already providing dental sleep medicine services.
General dental and medical practitioners can use the guideline to help them provide patients with a more thorough overview of treatment options for obstructive sleep apnea. With its insights, they can better set the patient's expectation of what type of treatments may be prescribed and the steps in obtaining optimal care.
For dentists who are just getting into dental sleep medicine, the guideline offers more of a step-by-step plan to aid their patient treatment approach. It instructs that after a physician has diagnosed a patient with sleep apnea and prescribed oral appliance therapy, the dentist should consider a custom, titratable oral appliance, conduct patient follow-up to survey for and reduce dental-related side effects, and refer patients back to sleep physicians for periodic office visits.
Recognizing that oral appliance therapy requires the technical skill, acquired knowledge, and professional judgment of an experienced dentist, the guideline emphasizes "qualified dentists" as being best prepared to provide optimal care. A qualified dentist has a valid state dental license, proof of liability coverage, and additional training or experience through at least one of the following:
- Certification in dental sleep medicine by a nonprofit organization
- Designation as the dental director of an accredited dental sleep medicine facility
- Minimum of 25 hours of recognized continuing education in dental sleep medicine provided by a nonprofit organization or accredited dental school in the last two years
Qualified dentists with experience in dental sleep medicine can leverage the new research and best practices found in the guideline to help strengthen referral relationships with sleep physicians and increase their patient rosters.
The clinical guideline recommendations
Within the new guideline, the AADSM and AASM support six clinical recommendations for administering oral appliance therapy to patients with snoring or obstructive sleep apnea. The grades show the strength of each recommendation weighed against factors such as the benefits of the treatment and potential risks.
- We recommend that sleep physicians prescribe oral appliances, rather than no therapy, for adult patients who request treatment of primary snoring (without obstructive sleep apnea). (STANDARD)
- When oral appliance therapy is prescribed by a sleep physician for an adult patient with obstructive sleep apnea, we suggest that a qualified dentist use a custom, titratable appliance over noncustom oral devices. (GUIDELINE)
- We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. (STANDARD)
- We suggest that qualified dentists provide oversight-rather than no follow-up-of oral appliance therapy in adult patients with obstructive sleep apnea, to survey for dental-related side effects or occlusal changes and reduce their incidence. (GUIDELINE)
- We suggest that sleep physicians conduct follow-up sleep testing to improve or confirm treatment efficacy, rather than conduct follow-up without sleep testing, for patients fitted with oral appliances. (GUIDELINE)
- We suggest that sleep physicians and qualified dentists instruct adult patients treated with oral appliances for obstructive sleep apnea to return for periodic office visits-as opposed to no follow-up-with a qualified dentist and a sleep physician. (GUIDELINE)
How the guideline will shape dental sleep medicine
Both the AADSM and AASM anticipate that the new Clinical Practice Guideline for Oral Appliance Therapy will have a positive impact on professional behavior and patient outcomes, while potentially contributing to reduced health-care costs in the future.
Most significantly, the clinical guideline clarifies the individual roles of the dentist and sleep physician to ensure an effective, working relationship that involves collaboration from the start, so that patients understand the process for diagnosis, treatment options, and the roles of their care providers. By underscoring the vital importance of this physician-dentist team approach to treating obstructive sleep apnea, the path to treatment will become more patient-focused, resulting in higher patient satisfaction and better efficacy.
Overall, the patient care model defined in the guideline-evaluation and diagnosis by physicians and collaborative treatment involving dentists-is the way of the future in dental sleep medicine. The AADSM and AASM guideline provides research-supported practice parameters and important recommendations to help sleep physicians and dentists promote long-term therapeutic success with oral appliance therapy.
Kathleen Bennett, DDS, is the president of the American Academy of Dental Sleep Medicine. She has more than 30 years of experience in private practice restorative dentistry and currently has a practice at the University of Cincinnati that focuses exclusively on oral appliance therapy. Dr. Bennett became certified by the American Board of Dental Sleep Medicine (ABDSM) in 2002 and served as a director of ABDSM from 2012 to 2014.