By Randy Clare
Access to sleep diagnostic services is the limiting factor for dental patients who suspect that they have sleep apnea and require sleep treatment. In recent years, changes to insurance reimbursement and insurance qualification requirements have only made the issue much worse.
Dr. Ward Flemons, MD wrote an article for the Journal of Respiratory and Critical Care Medicine published in 2004, “access to diagnosis and treatment of patients with suspected sleep apnea”. In his article, Dr Flemons reviewed the access to sleep diagnostics in five countries.
His analysis of the US sleep field was very telling. Dr. Flemons’s team identified that in 2001, there were 280 million people in the United States. At that time, there were estimated to be 1,292 sleep clinics conducting 1.17 million in-lab polysomnograms.
This is about 427 PSGs per 100,000 population. The Veteran’s Health Administration (VHA) was found to be under much more stress than the public hospital system. In 2001, the VHA system cared for 3.75 million veterans with only 55 sleep labs. This resulted in only 160 studies per 100,000 patients.
The health risks associated with untreated snoring and sleep apnea are well documented. Hypertension is perhaps the leading condition associated with sleep apnea. Comorbid conditions include heart disease, stroke, and diabetes.
There is no requirement that a dentist initiate treatment; however, the patient must be advised of the possibility of sleep apnea, and a referral to a sleep physician should be made. The challenge is that access to diagnosis has continued to erode since the early 2000s when Dr. Flemons’ data was collected.
With the change in guidelines by the ADA, we now have a total patient population of over 200M people who see their dentist every year to be screened for sleep-disordered breathing. The ASA says that 48% of these patients snore, and 38% report having fallen asleep unintentionally during the day at least once in the last month.
It is clear that treating patients’ symptoms as quickly as possible is the prudent choice for the dentist. But how to do this without a medical diagnosis?
The Dental Solution
The answer may be provisional treatment with a provisional mandibular advancement device (PMAD).
Patients with sleep-related breathing disorders often present in the dental office with snoring as their primary complaint, and chronic snoring is often associated with a high risk of sleep apnea.
But, sleep apnea is a condition that can be life-threatening and is required to be diagnosed by a sleep physician using specialized equipment that is not available everywhere or is in high demand due to the prevalence of sleep-related breathing disorders in the general population. These wait times can result in treatment delays of six months or more.
Therefore, it is prudent for patient care to treat the patient’s snoring symptoms immediately in the dental office and refer the patient to a physician for diagnostics and management as soon as possible. From a medical-legal perspective, an informed consent document is required to confirm that the patient is aware that they are being treated provisionally, that they understand that their condition has medical risks, and they need to consult with a physician.
As recently reported by the AASM, “Frost & Sullivan calculated that the annual economic burden of undiagnosed sleep apnea among U.S. adults is approximately $149.6 billion. The estimated costs include $86.9 billion in lost productivity, $26.2 billion in motor vehicle accidents and $6.5 billion in workplace accidents.”
A provisional treatment is fundamentally no different from traditional mandibular advancement therapy for airway management.
The tools and the techniques are, in fact, the same. The major distinction is that with provisional therapy, medical insurance is not an option because there is no diagnosis or prescription for a therapeutic device.
The patient will pay for the therapy out of pocket, and the cost of the therapy will play a role in treatment acceptance.
Once a diagnosis is made by a sleep physician, the dentist can replace the provisional appliance with a more durable long-term appliance that meets medical insurance reimbursement guidelines and clinical goals established by the dentist and the patient.
From a practice management perspective, the provisional treatment of patients will open many more patients up to sleep treatment. It is estimated there are 2.5 million people in the US who have sleep apnea. The American Academy of Otolaryngology-head and Neck Surgery reports that nearly half of adults snore, and over 25 percent are habitual snorers. With an estimated 211 million Americans seeing the dentist every year, the opportunity for dentists to make a difference in their patients’ overall health has never been more attainable.
References
https://www.atsjournals.org/doi/pdf/10.1164/rccm.200308-1124PP
https://www.nhlbi.nih.gov/health-topics/sleep-apnea
https://www.ama-assn.org/delivering-care/ethics/informed-consent
Dr. Ken Berley, DDS, JD, a practicing dentist and attorney, has spent some time examining the concept of provisional therapy. He has also prepared an informed consent document that is available for free download.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2958867
Randy Clare has been involved with the development and distribution of sleep therapy products, including mandibular advancement devices, CPAP supplies, and sleep diagnostic devices, for over 20 years. Follow him at the thesleepandrespiratoryscholar.com.
