Oral appliance therapy (OAT) has become a hopeful therapeutic alternative to continuous positive airway pressure (CPAP) therapy over the last few years.
Last July, the American Academy of Sleep Medicine (AASM) officially declared the use of the dental appliance as an appropriate first-line treatment for obstructive sleep apnea (OSA) for specific qualifying patients based on comprehensive, long-term evidence showing its efficacy.
Further, the AASM sealed this position by joining with the American Academy of Dental Sleep Medicine (AADSM) to create new practice guidelines for sleep physicians and board-certified, sleep-trained dentists to better collaborate for patients who qualify for it.
The dental sleep medicine industry has been poised for some time to become a sanctioned element of the patient-physician collaboration for OSA therapies. The AASM's seal of approval is an exciting shift, not only for sleep-trained dentists and sleep specialists, but for patients as well, who often aren't aware of this option for treating OSA.
Why Patients Need To Know Their OSA Treatment Options
According to Kathleen Bennett, DDS and president of the AADSM, "more than 25 million adults in the United States suffer from obstructive sleep apnea, and up to 50 percent of sleep apnea patients do not adhere to the continuous positive airway pressure machine and mask recommended as a first line of treatment."
Patients who stop using their CPAP therapy complain of claustrophobic or allergic reactions to using the mask, problems with the tubing, noise from the machine or due to mask leakage, or complaints from bed partners.
Untreated OSA has been shown repeatedly to lead to potentially life-threatening chronic health problems (hypertension, diabetes, heart disease, stroke, dementia, obesity, depression and impotence) or dangerous behaviors (drowsy driving and workplace accidents) if left unchecked.
If patients cannot successfully treat their sleep apnea because of problems using CPAP, they absolutely need other options. While CPAP is still considered the "gold standard" for treating OSA, the future of the dental appliance looks equally promising.
The Story of Dental Sleep Medicine and Oral Appliances for Sleep Apnea
It's well understood among all healthcare professionals that patients who cannot tolerate their therapies quickly abandon them.The search for comfortable and effective treatments for OSA did not begin and end with CPAP, as it was learned early on that not everyone could tolerate it. Dentists introduced OAT 30 years ago as a means to help patients treat snoring, upper airway resistance, and OSA.
Today, after years of research and development, OAT has earned its keep, satisfying critical benchmarks in trials to prove it can be effective in the long term for patients with mild to moderate apnea. With so many millions of Americans living with OSA, and with so many of them dissatisfied with CPAP, sleep-trained dentists are poised to meet the needs of these patients.
Bennett asserts "there is a great need for sleep apnea treatment, and dentists who practice dental sleep medicine provide a treatment that is easier to live with, proven effective, and in high demand among both patients and sleep physicians."
Sleep Healthcare: A Collaborative Effort Between Physicians and Dentists
It makes sense that dentists play an active role in treating sleep-breathing disorders. Bennett points out that as dentists, "build long-term relationships with patients and routinely seem them twice a year... dentists can play an important role in identifying patients who have a high risk of a chronic disease such as obstructive sleep apnea." More frequent encounters mean more opportunities to help patients seek solutions for their health problems or tackle challenges to their current therapies.
The relationship between the dental and medical professions is nothing new, says Bennett. However, she points out that collaborative opportunities between the two are sometimes overlooked, which is why the historic joint guidelines established last year by the AASM and the AADSM are so noteworthy. They "encourage dentists and sleep physicians to collaborate from the start to help ensure patients understand the process for diagnosis, treatment options, and the roles of their care providers," said Bennett.
Compliance and Reimbursement: CPAP versus OAT
Medical reimbursement of OAT has been spotty in the past, but this has changed. Bennett reports tha
t "Medicare and most medical insurers in the United States cover oral appliance therapy from a dentist as they would a CPAP machine from a physician."
As with all prescriptions, insurers generally require patients to be evaluated by a sleep physician to show medical necessity for the dental appliance and to order it based on those objective findings.
However, there have been recent changes in the way Medicare reimburses patients for CPAP usage that may make choosing OAT more appealing.
Medicare policies, by necessity, focus on patient compliance, a term that describes how faithfully and frequently a patient uses their CPAP or other prescribed treatment to manage their condition. Most CPAP kits include data chips which measure usage remotely so that doctors (and insurance companies) can be assured their patients are using their equipment to an established minimum in order to see results.
Patients who are noncompliant generate higher costs for Medicare services overall. Their failure to meet minimum compliance measures by three months' time (for whatever reason) mean they risk losing their machines and/or reimbursements. In addition, reimbursement rates in 2016 have been reduced to around 75 percent of usual payouts as an additional cost-cutting measure, which means patient out-of-pocket costs have increased.
However, OAT currently has less stringent compliance guidelines. What's more, the lifespan of a typical MAD is anywhere from five to ten years, if cared for properly. Without any additional need for expensive replacement parts (for CPAP, masks and machines are frequently swapped out), its reimbursement picture is far less complicated and is not subject to CPAP's current challenges to reimbursement by insurers.
How Does Oral Appliance Therapy (OAT) Work?
Dental appliances (often referred to as oral devices or mandibular advancement devices [MAD]) achieve result that are similar to CPAP in that they also splint open the upper airway during sleep to prevent breathing obstructions.
The devices are worn like mouthguards but with a custom design which repositions the lower jar and tongue forward; this changes the structures of the upper airway to allow for unobstructed breathing space.
The patient simply places the dental appliance in their mouth, goes to bed, then awakens, removes the MAD and replaces it in the morning (for a short period) which a "repositioner," which resets the jaw to its normal position.
The device itself is cleaned with a toothbrush and soaked in a denture cleaning solution to sanitize until its next use. Spare parts (like spacers, keys, storage trays, or dental rubber bands) are inexpensive and usually provided by the dentist.
OAT offers a range of advantages over CPAP worth consideration.
Advantages of Dental Devices for Sleep Apnea
It is considered the least invasive of all the various therapies available for treating OSA
The MAD is custom fitted to the user's specific oral structure
The dental appliance is considered "more attractive" to bed partners than the CPAP mask
The mouthpiece itself is portable and small, making it easy to transport during travel
It does not require electricity to work
The dental appliance is easy and inexpensive to keep clean
OAT is considered more comfortable than CPAP for many patients
It makes no noise while in use
MAD can be used in concert with treatments for other related problems, such as bruxism, or issues related to allergies and congenital physiology, both which can interfere with breathing during sleep
OAT is usually reimbursed by insurance companies
Patient compliance for those using the dental appliance is thought to be equal to or higher than compliance for those using CPAP
Even when OAT is less effective than CPAP for treating OSA, it is still considered better than no therapy whatsoever
- OAT can be used in conjunction with CPAP for challenging sleep-breathing disorders
However, as with any therapy, OAT may not be right for everybody.
Disadvantages of Dental Devices for Sleep Apnea
There are several different styles of MAD; it may take trial and error to find the right device
Some patients experience a slower-than-normal repositioning period in the morning and have difficulty regaining their normal bite
Some versions of the dental appliance can be difficult to titrate by patients at home or by techs in the lab setting
There is a risk of repositioning the lower jaw and/or the shifting of teeth in the gums after using these devices long term which can result in changes to the bite, friction-related sores on oral tissues, and/or temporal mandibular joint pain
OAT can be as expensive as CPAP and reimbursement can vary widely
Patients with more severe cases of OSA may not find OAT effective
OAT doesn't treat central sleep apnea
Older devices not outfitted with compliance tracking chips mean the sleep physician or dentist following up on the patient must generally rely on their word that they are actually compliant
Oral devices provided by dentists not trained in sleep medicine may be unsafe, if not uncomfortable; what's worse, they may not treat OSA at all
Dental sleep medicine is not a new discipline; still, not all sleep physicians understand OAT well enough to offer it as a potential treatment, nor do they have always have the referrals of sleep-trained dentists or staff training necessary to provide it
- Patients using OAT may not receive AASM recommended titration studies or general followup from a sleep laboratory (although board-certified sleep-trained dentists may be poised to fill in this gap)
How to work with a dentist to treat your sleep breathing problems
Patients can benefit greatly from a dental sleep medicine model which unites sleep physicians with board-certified sleep dentists to collaborate.
"Communication and teamwork between sleep physicians and dentists are imperative to providing exceptional patient care," says Bennett.
Dentists with formal, board-certified education in dental sleep medicine are trained to identify potential markers of OSA, such as:
a thick or short neck
patient complaints of excessive daytime sleepiness, dry mouth or morning headaches
patients who fall asleep while having dental work done
problems with opening the jaw
- abnormalities in the lower part of the face—a small or receding chin or jaw, an overlarge tongue, an airway crowded by oversized tonsils, a "floppy" uvula, an enlarged soft palate (or a combination of these)
A sleep-trained dentist who identifies these markers can refer their patients to sleep physicians for a more thorough examination. If a sleep study is performed and sleep-disordered breathing is the final diagnosis, that sleep physician may then refer the patient back to the dentist to custom prepare an oral device as the patient's first line of therapy for treating their OSA.
Devices are built usually as a collaboration between a board-certified sleep-trained dentist and the device's manufacturer: molds of the patient's mouth are generated by the dentist, then sent to a lab where specialists create durable mouthguard-like forms for both the device worn at night and the morning repositioner, which are both then sent back to the dentist for a formal fitting.
A titration study may or may not follow up, as determined by the sleep physician and the kind of device employed (some devices are difficult to titrate in a lab setting). However, it's in the best interest of all involved to keep a watchful eye on patient usage, comfort and symptom relief over the long term to ensure that OAT is helping to improve the patient's sleep-disordered breathing. The AASM recommends a sleep study before the oral appliance is used, to establish the baseline severity of the patient's condition, followed by a study after the patient has adjusted to the device, to measure its effectiveness.
Patients interested in trying OAT should ask about their dentist's credentials: not all dentists have the proper training. Look for those who are members of the AADSM, which imposes high standards of care and requires board certification and extensive training of all their members.
If you think you have OSA, you first need to consult a sleep physician and undergo diagnostic testing to confirm it. Upon confirming a diagnosis, you have the right to ask your sleep physician about this option. If you qualify to use OAT, based on objective criteria established by the AASM, there is no reason why you shouldn't be offered this option.
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