Survey of Oral Appliance Practice Among Dentists Treating Obstructive Sleep Apnea Patients (Discussion Beginning)

In: Sleep Apnea

1 Jan 2014

Survey of Oral Appliance Practice Among Dentists Treating Obstructive Sleep Apnea Patients (Discussion Beginning)To our knowledge, this is the first study to evaluate systematically the patterns of practice among dentists using OAs to treat OSA. It is important to evaluate these patterns of practice because dentists are being asked to provide treatment for a medical syndrome, OSA, which if treated inadequately may lead to decreased daytime wakefulness, increased cardiovascular morbidity, and possibly increased overall mortality. Treating OSA patients with OAs requires close cooperation between dentists and sleep disorders physicians; otherwise patients may be unavailable for follow-up or treated inadequately. This study seeks to facilitate closer cooperation between physicians and dentists by identifying potential areas for improvement in this joint approach for treating OSA patients.

It is an encouraging finding that most SDDS dentists do not believe subjective patient reports or nocturnal pulse oximetry alone is adequate to assess treatment response for OAs in OSA patients. Previous studies support the validity of these beliefs.’ The need for objective testing is especially important in nonsnoring OSA patients such as those who have received uvulopalatopharyngoplasty or laser-assisted uvuloplasty prior to being fitted with an OA. Unfortunately, these dentists are unable to “practice what they preach” on this issue since most OSA patients treated with OAs do not receive posttreatment studies. Possible reasons for the lack of posttreatment NPSG were not determined in our study but could include the following: posttreatment NPSG completed but dentist unaware of results; patient does not follow up with sleep disorders medicine physician after receiving OA; sleep disorders medicine physician does not order posttreatment PSG; insurance company or managed-care system denies authorization for posttreatment PSG; patient refuses posttreatment polysomnography.

The ASDA practice parameters for the treatment of snoring and OAs state that posttreatment NPSG is not indicated for mild OSA unless symptoms worsen or do not resolve. However, the definition of mild OSA is not specified in these practice parameters, nor are there widely accepted criteria among sleep disorders physicians for classifying OSA severity. A study by Miljeteig et al of OSA patients who received uvulopalatopharyngoplasty demonstrated that although there was no objective postoperative change in OSA and snoring severity, most patients reported subjective improvement in snoring and sleep quality. A similar disparity between subjective and objective response to treatment may occur in OSA patients treated with OAs. This potential lack of objective treatment response to OAs is made more concerning by the fact that some of the OAs used have not been validated by clinical studies and that individual patient response to a particular appliance is highly variable and often difficult to predict. Indeed, a preliminary study by Jamieson et al of a serially adjustable OA suggests that some OSA patients have worsened conditions as jaw protrusion is increased, although these data must be interpreted with considerable caution since this study involved small numbers of OSA patients with severe disease. These findings suggest that objective treatment response as measured by NPSG may be important to measure in individual OSA patients treated with OAs, if the purpose of treatment is to adequately treat possible associated health hazards. The utilization of posttreatment NPSG could be enhanced by the application of ambulatory studies with limited montages. These limited montage studies may be cheaper and easier to perform than full NPSG.

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