In: Sleep Apnea3 Jan 2014
The dentists of the SDDS may not be representative of all dentists using OAs to treat OSA. Members of the SDDS receive educational materials, monthly newsletters, and approximately 25% of the members attend an annual national conference that keeps members appraised of new developments and the evolving standard of care for the use of OAs. The patterns of practice for non-SDDS dentists treating OSA patients in the United States is unknown, but may not be up to the standards of the SDDS, in which close cooperation between dentists and sleep disorders physicians is strongly emphasized. It will be important to determine patterns of practice in other groups of dentists, since OSA patients may be treated only by dentists, without the involvement of the sleep disorders physicians. Lack of physician involvement can lead to the failure to recognize and treat medical sequelae of OSA such as hypertension or to the failure to recognize other underlying pulmonary or cardiovascular diseases, which might be mistakenly treated as OSA.
The SDDS dentists use custom-fit mandibular advancement appliances most frequently, although both prefitted and serially adjusted mandibular advancement appliances are also commonly used. There are few peer-reviewed studies directly comparing specific appliances to each other. Thus, it is unclear from studies to date whether custom-fit or serially adjusted appliances are more effective than prefitted appliances. Tongue-retaining devices are used by many dentists, but are used much less frequently than mandibular advancement appliances. Adjustments of an individual appliance are made an average of 2.5 times; however, our study did not determine whether these were made for patient comfort or to maximize OSA treatment. Unfortunately, our study did not distinguish which types of OAs were adjusted, which is an important consideration since individual OAs require different amounts of chair time and subsequent follow-up. Further studies are needed to characterize the methods dentists use to choose and adjust specific devices for individual patients.
A potential flaw of any questionnaire study is that respondents may be biased to answer questions in a manner that is most beneficial to their own interests. This behavior likely occurred with our study, as these dentists believe that most of their OSA patients were successfully treated with OAs. Since posttreatment NPSG is performed infrequently, this belief contradicts the perception of the majority of dentists that subjective reports are inadequate to assess treatment response. A similar bias may exist with these dentists’ response that only 10% of OSA patients fail to tolerate OAs after 6 months of treatment. A recent study shows an OA noncompliance rate of 24% for a custom-fit, preformed, preset, single jaw position, “boil and bite” mandibular advancement appliance (Snoreguard™). Preliminary data from a study evaluating the tongue-retaining device found a noncompliance rate of 39% at a mean of 4.5 years after the appliance was dispensed. Compliance rates may be higher with fully custom-made and serially adjustable OAs, although this has not been well demonstrated in the literature to date. Compliance rates are dependent on many factors, including patient comfort and treatment efficacy of OSA and snoring. Reasons for patient noncompliance are not evaluated in our study, but they warrant investigation in future studies.
The cost of OAs in the United States may be more expensive than previously thought. Schmidt-Nowara et al specified a fee range of $400 to $900 for various OAs, although this estimate was made before serially adjustable OAs were available and this may explain the cost differences observed. For SDDS dentists, the median fee approximated the upper range of that estimate. Other cost factors include whether the OA was preformed or custom made, the specific design and material used in manufacturing the OA, and whether patented or nonpatented components are included in the OA. In addition, whether a general dentist or a specialist fits, adjusts, and oversees OAs has direct bearing on the overall cost. However, the median price for OAs is still lower than for most CPAP units. Comparisons of long-term costs for OA and CPAP are difficult, in view of the paucity of data on the long-term durability of OAs.
In conclusion, SDDS dentists’ treatment of OSA patients with OAs encompasses a wide spectrum of clinical patterns of practice. Most of these dentists appear to consider NPSG as the preferred technique for diagnosing and treating OSA, although posttreatment NPSG is infrequently obtained. Future efforts at enhancing cooperation between dentists and sleep disorders physicians in the treatment of OSA with OAs should be promoted as a means of standardizing treatment.
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