Why referring sleep apnea patients to their general dentists to fill oral appliance therapy prescriptions is a terrible idea.
By John Viviano, DDS, DABDSM
Oral appliance therapy for sleep apnea involves the fitting of an oral appliance into a patient’s mouth, which is well within the scope of any general dental practice. However, just because a dentist is the best-qualified clinician to fashion and deliver an oral appliance, referring sleep physicians should not assume this means just any person with DMD/DDS credentials is qualified. Dental sleep medicine is unlike anything else in dentistry; without adequate, evidence-based training, a dentist is unlikely to manage obstructive sleep apnea (OSA) patients optimally—resulting in unnecessary therapy failures.
While the American Academy of Dental Sleep Medicine (AADSM) has done an admirable job in establishing evidence-based guidance and provides the AADSM Mastery Program for dentists to teach the training and skills they need to provide oral appliance therapy, to date, there remains an absence of evidence-based guidance from dental licensing boards in the United States and Canada. This means individual dentists determine the level of competency they wish to establish and where they will obtain their dental sleep medicine education.
So when I hear of sleep physicians who advise their patients with OSA to go to their general dentist to fill their oral appliance therapy prescriptions, I am dismayed. After all, that same sleep physician would not direct an OSA patient to purchase a CPAP device over the internet. No, they would refer patients only to durable medical equipment providers they trust.
Likewise, if a sleep physician simply sends a patient to their dentist to inquire about oral appliance therapy, there is no assurance regarding the standard of care they will receive. Recommending an untrained dentist is akin to telling patients to just find a CPAP online.
Dental School (Lack of) Education
I strongly believe that good outcomes are more about what the dentist does with the appliance than about which brand of oral appliance is used. The “what” aspect of oral appliance therapy requires training that is not typically provided by dental schools and taught to varying competencies in myriad dental continuing education programs.
A review article published in 1998 reported on the potential for patients to drop out of oral appliance therapy due to poorly managed clinical issues. Mandibular advancement devices (MADs) “should be carefully fabricated by dentists who work on a referral basis with sleep medicine physicians, and patients using MADs must be monitored regularly for ongoing efficacy and for associated complications,” wrote author Glenn T. Clark, DDS, MS.
Notwithstanding these recommendations, 25 years later, very few dental schools provide meaningful dental sleep medicine education in their curriculum, leaving most dentists suboptimally trained to provide oral appliance therapy. A study of 49 US dental schools published in 2012 found that students received 0.5, 0.64, 1.81, and 0.97 hours of sleep-disordered breathing curriculum in years one, two, three, and four, respectively—in the 37 schools that actually covered the topic at all.
Unfortunately, not much has changed since then. My personal survey of recent University of Toronto, Canada, dental school graduates found they completed their degree requirements with only about an hour of education on sleep-disordered breathing.
My personal communications with two dental laboratories also illustrate how dentists inexperienced in dental sleep medicine are fulfilling oral appliance prescriptions. An Ontario, Canada-based dental lab told me that, of the 179 dentists who ordered sleep apnea appliances (20% of its client base), only seven ordered 10 or more. Ninety-nine ordered two or fewer. Similarly, a California-based dental lab told me that 20% of its customers ordered a sleep apnea appliance in 2019 but that fewer than 1% of accounts ordered 10 or more appliances for the year. This data highlights the minimal experience that most dentists have in this area of practice.
Oral Appliance Outcomes
Inadequate knowledge of the medical implications associated with unmanaged sleep apnea limits the dentist’s ability to communicate the ramifications of not following through with treatment. This can lead to poor initial patient treatment acceptance and, for those who proceed, poor adherence to therapy.
Inadequate knowledge of oral appliance advancement mechanisms can result in selecting an oral appliance design that does not best suit the patient’s dentition. This may lead to inadequate oral appliance retention and/or strain on a weakened dentition, compromising patient adherence and/or outcomes.
Inadequate knowledge about the bite registration technique can result in fabricating an oral appliance that holds the patient’s jaw in a position beyond their adaptive capacity. This leads to an increase in side effects.
Inadequate knowledge of positional OSA and the implications of jaw drop during sleep results in unresolved supine sleep apnea. This leads to less successful outcomes, less satisfaction with therapy, and higher therapy abandonment.
Inadequate knowledge of the importance of maintaining balance as the jaw is translated forward, or settling for a less-than-optimum jaw position due to erroneously believing further advancement is not an option due to discomfort, can result in unnecessary side effects.
Inadequate knowledge of adjunctive therapies for patients burdened with residual sleep apnea post-oral appliance optimization leads to less optimum outcomes, less satisfaction with therapy, and higher treatment abandonment.
Inadequate knowledge of night-to-night sleep variability and how to evaluate the quality of the baseline sleep study can result in misinterpretation of outcomes and impact the dentist’s ability to establish the true impact of the oral appliance. This leads to treatment abandonment, even when the appliance is providing a benefit, or concluding that the appliance is optimized when it is not.
Inadequate knowledge of dentist-physician reporting requirements results in poor or inadequate coordination of care.
What Sleep Physicians Should Do
When a patient fails oral appliance therapy due to a lack of adequate training on the dentist’s part, the patient effectively loses the only high success rate, conservative alternative therapy available, leaving them either considering more invasive therapy alternatives or completely unmanaged.
Sleep physicians should provide guidance that supports optimum outcomes, whichever therapy is selected. To optimize oral appliance outcomes, investigate which dentists are best qualified in your area and establish relationships with them. Do not refer patients to their general dentists. Set your patients up for OSA therapy success through an efficient medical-dental collaborative effort, increasing the chance of optimal oral appliance therapy outcomes.
The author thanks John Bouzis, DDS, for the constructive discussion while driving through the beautiful state of Wyoming and his critical review of this manuscript.