Collaboration with Dentists Essential to Increase Sleep Apnea Treatment Adherence

Healthcare professionals understand that patients who can’t tolerate their therapies quickly abandon them, leaving them vulnerable to adverse health effects. Continuous positive airway pressure (CPAP) therapy remains the gold standard for the treatment of obstructive sleep apnea (OSA), but studies demonstrate that half of patients become non-adherent after one year.¹ By understanding the research behind dental sleep medicine and the best practices of a successful physician-dentist collaboration, sleep physicians can leverage oral appliance therapy to help their non-adherent patients move from being untreated to improving OSA symptoms in a few short months.

“Inter-disciplinary collaboration provides the best avenue for treatment when a patient is non-adherent with CPAP,” says Harold A. Smith, DDS, president of the American Academy of Dental Sleep Medicine (AADSM), in a release. “The AADSM wants to help dentists and physicians work together to optimally treat adults who have OSA.”

Clinical Support for Oral Appliance Therapy

There has been methodical and results-driven growth of the dental sleep medicine field over the past 25 years, including a wealth of published research supporting the effectiveness of oral appliance therapy, the development of professional associations and the establishment of recognized continuing education and credentials.

In alignment with this growth, the Clinical Practice Guideline for Oral Appliance Therapy published jointly in 2015 by the American Academy of Sleep Medicine (AASM) and the AADSM officially recommends that sleep physicians consider prescription of oral appliances for adult patients with OSA who are intolerant of CPAP therapy or prefer alternate therapy.²

“The first AADSM and AASM joint Clinical Guideline is a testament to the importance of dentist-physician relationships in treating OSA with oral appliance therapy, and it provides a framework for ensuring the best outcomes for patients who are prescribed a custom-fitted oral appliance,” Smith says.

According to the Clinical Guideline, meta-analyses show that CPAP is superior to oral appliance therapy in improving apnea hypopnea index (AHI) and lowering both the arousal index and the oxygen desaturation index (ODI), but the efficacy gap can be closed when adherence is taken into consideration. Among patients who begin CPAP therapy, it is estimated that only 50% continue with long-term treatment.³ In contrast, 76% of patients report using their oral appliance after one year, and 62% of patients after 4 years.⁴ Research further suggests that patients use CPAP on average between 3 and 5 hours per night,⁵ while oral appliances have been found, through objective adherence monitoring, to be used a mean of 6.7 hours per night.⁶ Together these scientific studies suggest that the treatment adherence rate for oral appliance therapy is greater than CPAP and, therefore, its overall therapeutic effectiveness may be comparable.⁷

“For patients with OSA who do not adhere to CPAP, an oral appliance has proven to be a viable option,” Smith says.

Oral appliance therapy also has proven to be similar to CPAP in its effect on several clinical measures. In addition to reducing snoring and the severity of sleep-disordered breathing, oral appliances can reduce blood pressure, cardiovascular mortality, and subjective daytime sleepiness, and they can improve quality of life and neurobehavioral functioning.^8,9,10,11

Best Practices for an Effective Physician-Dentist Collaboration

When a sleep physician and dentist work collaboratively, the evidence-based Clinical Guideline provides best practices to help ensure successful outcomes. The following recommendations take into account the knowledge, skill, and licensure of each profession for the ultimate benefit of the patient:

1. OSA is best diagnosed by a sleep physician who is either board-certified or board-eligible in sleep medicine.
2. Once a patient is diagnosed with OSA by a board-certified sleep physician, a dentist trained in dental sleep medicine can provide treatment with oral appliance therapy.
3. When oral appliance therapy is prescribed by a physician, the dentist should use a custom, titratable oral appliance instead of a non-custom oral device.
4. Dentists should provide oversight—rather than no follow-up—of oral appliance therapy to survey for dental-related side effects or occlusal changes and reduce their incidence.
5. Sleep physicians should conduct follow-up sleep testing to improve or confirm treatment efficacy, rather than conduct follow-up without sleep testing.
6. Periodic visits with both the sleep physician and dentist are recommended for adult patients treated with oral appliance therapy for OSA.

The AADSM’s 3,000 members have access to exclusive educational resources and practice management support that help them excel in dental sleep medicine. “The AADSM membership consists of dentists who understand that effective communication with medical colleagues is critical,” Smith says.

Among AADSM members are dentists who have earned designations further demonstrating that they have the technical skill and knowledge that dental sleep medicine requires. For example, the American Board of Dental Sleep Medicine (ABDSM) provides Diplomate certification to dentists who complete a rigorous examination and submit a series of clinical case studies. Similar to accreditation of a sleep center, the AADSM Dental Sleep Medicine Facility Accreditation program verifies that a practice’s entire team upholds high standards of patient care, indicating that the office meets standardized guidelines and follows meticulous protocol.

To find an AADSM member in your area, visit www.localsleepdentist.org.

References

1. Ballard R.D., Gay P.C., Strollo P.J. Interventions to Improve Compliance in Sleep Apnea Patients Previously Non-Compliant with CPAP. J of Clinical Sleep Medicine, 2007 3(7): 706-712.
2. Ramar K., Dort L.C., Katz S.G., Lettieri C.J., Harrod C.G., Thomas S.M., Chervin R.D. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. J of Dental Sleep Medicine, 2015 2(3): 71-125.
3. Wickwire E.M., Lettieri C.J., Cairns, A.A., Collop N.A. Maximizing Positive Airway Pressure Adherence in Adults. CHEST, 2013 144(2): 680-693.
4. Walker-Engstrom M., Tegelber A., Wilhelmsson B., Ringquist I. Four-year Follow-up of Treatment with Dental Appliance or Uvulopalatopharyngoplasty in Patients with Obstructive Sleep Apnea. CHEST, 2002 121: 739-746.
5. Journal of Clinical Sleep Medicine, 2009.
6. Vanderveken O.M., Dieltjens M., Wouters K., et al. Objective Measurement of Compliance during Oral Appliance Therapy for Sleep-disordered Breathing. Thorax, 2013 Jan. 68(1): 91–96.
7. Weinstock T. and Redline S. Comparative Effectiveness Research in Obstructive Sleep Apnea: Bridging Gaps between Efficacy Studies and Clinical Practice. J of CER, 2012 1: 1-23.
8. Iftikhar I.H., Hays E.R., Iverson M., Magalang U.J., Maas A.K. Effect of Oral Appliances on Blood Pressure in Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. J of Clinical Sleep Medicine, 2013 9(2): 165-174.
9. Anandam A., Patil M., Akinnusi M., Jaoude P., El Solh A.A. Cardiovascular Mortality in OSA Treated with CPAP or Oral Appliance: An Observational Study. Respirology, 2013 18(8): 1,184-190.
10. Barnes M., et al. Efficacy of Positive Airway Pressure and Oral Appliance in Mild to Moderate Obstructive Sleep Apnea. American Journal of Respiratory and Critical Care Medicine, 2004 Sep. 170(6): 656-664.
11. Naismith S.L., et al. Effective Oral Appliance Therapy on Neurobehavioral Functioning in OSA: A Randomized Controlled Trial. J of Clinical Sleep Medicine, 2005 Oct. 1(4): 374-80.