Managing a multidisciplinary approach to the treatment of sleep-disordered breathing requires sleep medicine professionals and dentists to be savvy educators and communicators.
As a dentist, I treat patients with sleep-disordered breathing utilizing oral appliance therapy (OAT), as prescribed by their physicians. Fifteen years ago, I might as well have been practicing witchcraft; there were little data and research available regarding the efficacy and/or safety of OAT (therefore referrals and insurance reimbursement were practically nonexistent). But recent developments in the field, including research,1-9 clinical guidelines,10 and improvement in insurance coverage, have changed that. With the interest in sleep growing in leaps and bounds at both the public and professional levels, how do dentists and sleep physicians function using the multidisciplinary approach to sleep that we all seem to agree11 is necessary for optimal patient care? The solution lies in several areas that can be traced to education, economics, and communication.
In 1998, I was chair of the education and curriculum committee of what at that time was known as the Sleep Disorders Dental Society. I wanted to find out what physicians were learning about sleep in medical school. I contacted William Dement, MD, PhD, who was initiating a program, known as Taskforce 2000, to have sleep play a larger part in the medical school curriculum. Dr Dement told me that the average medical student graduated with less than 2 hours of formal training in the area of sleep, and since we spend nearly a third of our lives sleeping, he felt it deserved more than that. I told him that was 2 more hours than the dental students were getting.
That discussion with Dr Dement made me realize that until sleep had a meaningful presence in the dental and medical school curriculums, it would be years before the public would begin to benefit from what we all have to offer.
Two years later, I became president of the American Academy of Dental Sleep Medicine (AADSM); this presented me with many wonderful experiences and opportunities among which was the creation of a dental school curriculum committee. It has taken another 5 years and lots of work by many people, but the committee is finally near to completing a digital program that can be used at both the graduate and undergraduate levels in dental education. At present, dental sleep medicine is taught in some form at nearly half of the dental schools in North America.12 This is a start, but far from where we need to be.
Dental and medical school curriculum advisors cite a lack of time and space for new inclusions. It has been suggested that, rather than making new time and space, sleep topics be integrated into already studied and included topics such as neuroscience, anatomy, development, physiology, and behavioral science courses during the preclinical years.13 The sleep history and physical examination can be integrated into the physical diagnostic courses, and treatment could be introduced at the clinical level.
Although we have made great strides by having sleep become a recognized and accepted medical specialty, we have done little to advance its teaching at the undergraduate level. Until every dentist, physician, and affiliated health care provider leaves school with an appreciation and ability to recognize and screen for sleep disorders, as well as an understanding of how and where each specialty fits into our multidisciplinary approach, our patients will suffer.
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Education of our patients is as important as that of our health care providers. A friend of mine suggested that if we told our SDB patients that apnea, if untreated, would cause cancer, he thought they would be more motivated to lose weight, work with their CPAP, and stay off their backs while sleeping—in short, they would try harder. I am not one who goes for scare tactics, but all too often I explain the consequences of untreated OSA to patients who tell me that no one has told them what their condition is, what its consequences are, and, most importantly, what they need to do to fix it. When patients understand their condition and its consequences, they are much more likely to do what is necessary to get better.
Economics certainly plays a part in providing optimal patient care. Insurance reimbursement is front-loaded; we are rewarded for diagnoses and initial therapy, but there is little, if any, economic reward for long-term, follow-up care. This is not an acceptable model for treating SDB—a condition for which there is no cure and that requires a lifetime of vigilance and therapy by those of us who care for these individuals. This is a mystery to me as common sense, supported by several studies, clearly demonstrates the overwhelming economic benefits of treating OSA patients versus the cost to the system when not treated.14,15
Reimbursement for OAT is much better now than it was in the past. I have been fortunate to have had several doors opened because of letters and phone calls from patients and physicians who spoke on my behalf, making it clear that what I do is medically necessary and, in many cases, a patient’s last resort. Oral appliances are considered durable medical equipment, the same as CPAP; they should be given the same consideration. We all need to help make this clear to the insurance industry.
Insurance aside, the average cost of treating a patient with OAT is less than the cost of replacing a single tooth with some type of permanent restoration. I think when placed in this context, rendering a potentially life-saving therapy demonstrates the excellent value of OAT. If a dentist cannot make a living providing this service, then he will be forced to abandon this field. For me, that is simply unacceptable.
The Goal of the American Board of Dental Sleep Medicine
The American Board of Dental Sleep Medicine (ABDSM) is an independent board of examiners that was established in 1998 for dentists who treat SDB. The purpose of the ABDSM is to help set standards for the scope of dental sleep medicine, which includes OAT and upper airway surgery to treat SDB, and to assure health care providers, patients, and the public of an acceptable level of education, training, and experience by those who become Diplomates of the ABDSM by examination. It does not represent a new specialty of dentistry or medicine, nor does it grant or imply any legal qualification, privilege, or license to practice. Rather, it simply recognizes those dentists who have successfully completed the board-certification requirements established by the ABDSM. The American Academy of Sleep Medicine (AASM) recognizes Diplomate status granted by the ABDSM.
While there is no easy solution to this problem, it is important that patients are educated as to the value and importance of the treatment they are receiving. Unfortunately, insurance reimbursement always lags years behind new technologies, and often, I will hear from patients that they don’t understand why their insurance company paid for their sleep studies, ear, nose, and throat exams, pulmonary work-ups, surgery, CPAP, etc, and yet they don’t want to pay for the OAT therapy that finally helped them.
We need to educate the insurance industry and empower our patients by providing them with the tools to influence payors. Insurers often have outdated or misinformation regarding OAT. I have found it useful to provide them with a copy of the 2005 position paper by the American Academy of Sleep Medicine on the use of oral appliances for the treatment of OSA. This paper can be found and downloaded from the AADSM Web site—aadsm.org. If the treating dentist has a prescription/referral, which also states the reason for the referral (CPAP intolerant, claustrophobic, surgical failure, combination therapy, etc) from the diagnosing physician, along with a copy of the sleep study, which establishes medical necessity, the odds of successful reimbursement increase. Patients also need to take an active role; after all, it is their insurance. We all, however, benefit from success in this area.
The case for oral appliance therapy no longer needs to be made—only its safe and effective usage and integration into the system remain. For those of you who are attempting to obtain accreditation for your sleep lab, one of the recommendations (not a requirement yet) is to have an AADSM dentist affiliating and working with you. The AADSM provides education and training in this area and, at present, has more than 1,200 members in North America.
The best place to find information about OAT or a dentist to affiliate with is to visit the AADSM Web site; if there is no one in your area, contact a local dentist, maybe even your dentist, and if they are interested, have them contact the AADSM. I would invite them to your clinical conferences and offices and develop a support system that works for you. If we can integrate sleep into the curriculum of every health care provider, resolve the economic issues associated with the long-term care of our patients, embrace a multidisciplinary approach to treatment, and better educate ourselves, everyone, most of all our patients, would benefit.
Don A. Pantino, DDS, DABDSM, is a past president of the American Academy of Dental Sleep Medicine (AADSM), serves as treasurer of the American Board of Dental Sleep Medicine, and is chair of the dental school curriculum committee of the AADSM. He is an associate clinical instructor at SUNY Stony Brook School of Dental Medicine and maintains a private practice in Long Island, NY, with a concentration on the treatment of sleep-disordered breathing.
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