Confirmation of Care is Key to Success with Mandibular Advancement Device
In a little fit of frustration, I started a discussion thread regarding dentists ordering follow up sleep testing after treating a patient with a Mandibular Advancement Device. The discussion has over 100 comments now and it’s still going. (If you haven’t already been bombarded by the LinkedIn notifications about it, you can see it here.) The quick gist of my motivation was that I found only a small percentage of dentists who order Diagnostic Home Sleep study from my company (Sleep Services) also order follow up tests for their patients from me. I think that’s a sign of a bigger problem, but I won’t go into it here because it’s been addressed in the discussion many times over. Now in a much better mood, what I’d like to speak about here are two issues (out of about 650) that I saw in some of the responses I read. First off, I believe we have skewed perception of the effectiveness of Oral Appliance Therapy, and secondly, I also believe many of
us have unrealistic beliefs regarding who should be involved in it.
Other than not getting distracted online by adverts for cars, it doesn’t take a lot of effort to find the clinical studies that address Oral Appliance Therapy for OSA. In fact, I’ve compiled a few and created a little self-serve webform I call “Docusend” for anyone who wants to see them: here. What I found is that these studies all revolve around a self selecting group of doctors and patients. I would categorize them as “compliant.” Unfortunately, my own experience with hundreds of sleep dentists and thousands of sleep patients around the country leads me to believe that the majority of them do not follow the same protocols as the folks who are involved in these studies.
Think about it for a second and it makes perfect sense. A doctor who takes sleep apnea treatment seriously probably researches sleep apnea, attends sleep apnea education events, follows protocols such as ordering follow up sleep testing, and is interested in participating in clinical studies. But a doctor who’s new to sleep apnea and doesn’t know better (or knows better but just doesn’t care) isn’t following the same protocols as the experts, and their patient outcomes are not included in these studies. So when we read that MAS treatment was successful for 63% of the patients in the University of New South Whales Study, or that the therapy produced a 52% reduction in mean RDI, we have to remember that the sample pool was comprised entirely of patients being seen in a University setting, by doctors who take this whole sleep thing very seriously. It’s like saying we know the average car is capable of 180 mph, because we tested all the Maseratis.
So how accurately do those sleep results reflect what happens in the real world? Everyday some number of dentists take on their first sleep apnea case, and we would be crazy to think that their results would mirror the results that Sleep Scholar Dentists who have been doing this for years should expect. While I don’t have the resources or the interest to try and estimate the number of dentists across North America who are currently involved in treating OSA, I do know they exist. And as the number grows every day, it’s impossible for all of them to be experts. When I personally speak to patients or to dentists, my standard line is usually something like “studies show OAT is effective about 60% of the time… CPAP close to 100%…Patient Compliance!… Surgery, lose weight, sleep hygiene…” I’m sure you can all fill in the rest. But am I really spitting out accurate information, or am I like the EPA just passing along possibly inaccurate data about MPG? I don’t think there’s any way to know the real answer because no dentist is going to self report that they aren’t really doing a great job.
Some have suggested that we could eliminate the problem by limiting the dentist’s role in sleep to nothing more than a DME provider, or that an arduous training and examination process should be required of all sleep dentists. However, I don’t believe either of those things are really in the best interest of the patient. One of the stats that we can all agree on is the staggering number of undiagnosed patients in the population. While we’ve made great strides in the past few decades of bringing sleep disorders and Sleep Apnea into the common vernacular, it hasn’t been by limiting patient access to treatment. 30 years ago, a sleep doctor (who many years later became the medical director of one of the largest HST manufacturers in the country) said we would not live to see the day when a patient is tested for sleep apnea outside of a hospital. Ten years ago, Oldsmobile was in business and there was only one sleep apnea dentist within miles of my neighborhood. That dentist is still around (and there’s a good chance he’ll read this) but there are also probably a dozen others now, and four or five of them are board certified and highly trained.
The idea that treating sleep apnea is going to be harder to do in the future than it is today, is like being in 1999 and thinking electric cars were just for holding Greenpeace bumper stickers and trips to the health food store. There may be many good reasons for thinking that, but it’s just not going to play out that way. As many have said, you can’t become a sleep apnea expert from a weekend class, but the truth is, you can learn enough to start helping patients pretty quickly. It’s easy for us to say that anyone not doing the job to our standard is not doing a good enough job at all, but just remember that statistically, half of all dentists do a below average job. While we can certainly try to raise the bar for “average” by doing a better job in the practices we have influence or control over, what should be the minimum standard of care that a patient receives?
In the United States, the fact is that not everyone has the means or the willingness to seek the care of an expert. Even though everyone has/will have/is supposed to have/if Healthcare.gov isn’t broken, might get some sort of medical insurance at some point, the vast majority of people who need treatment for OSA will never find themselves in a (medical or dental) Sleep Specialist’s office. A dentist with even minimal sleep training still has an opportunity to help a patient, and if nothing else, they are at least making the patient aware that the problem exists. Although I have evidence that dentists do, sometimes, make sleep apnea worse, I think that is more likely to be the exception than the rule. Overall, we’re better off encouraging as much participation as we can with the understanding that the benefit of increasing the number of good sleep dentists outweighs the risk of making it easier for bad sleep dentists to exist. I mean, as much as I dislike the hybrid craze, it’s what lead to the Audi R-18 e-tron .