In: Sleep Apnea26 Dec 2013
Purpose: Oral appliances (OAs) are used to treat obstructive sleep apnea (OSA). This study seeks to quantify the patterns of practice of OA use among dentists.
Design: Survey mailed to dentists.
Participants: Members of the Sleep Disorders Dental Society (SDDS).
Measurements: Dentists were asked questions regarding number of patients treated, types of OA used, average total OA cost to the patient excluding reimbursement, percentages of patients receiving pretreatment and posttreatment nocturnal polysomnography (NPSG), and whether they believe subjective patient reports alone or nocturnal pulse oximetry alone is an adequate substitute for NPSG to assess OS A treatment response. Summary statistics for the absolute value and percentage data are presented with the median, maximum, and minimum range.
Results: Three hundred fifty-five surveys were mailed, of which 124 (35%) were returned. These dentists treat a median of 27 OSA patients with OAs (range, 2 to 300) annually. Patients receive pretreatment NPSG in 95% of cases (range, 0 to 100%), and posttreatment NPSG in 18% of cases (range, 0 to 100%). Only 7% of dentists believe subjective patient reports alone are an adequate substitute for NPSG. Nocturnal pulse oximetry was perceived to be an adequate substitute for NPSG by 37%. Dentists who believe nocturnal pulse oximetry to be an adequate substitute for posttreatment NPSG are less likely to obtain pretreatment or posttreatment NPSG (Mann-Whitney U test, two-tailed; p=0.001, p=0.02).
Conclusions: Most SDDS dentists believe subjective reports and nocturnal pulse oximetry are inadequate to assess OA treatment response in OSA patients, yet posttreatment PSG is obtained infrequently.
The prevalence of obstructive sleep apnea (OSA), as defined by a respiratory disturbance index (RDI) of 15 events per hour on nocturnal polysomnography (NPSG), is approximately 3% for middle-aged adults in the United States. Continuous positive airway pressure (CPAP) is a very effective treatment for OSA, but compliance is only 60 to 70% under optimized clinical conditions.2 Thus, the use of alternatives to CPAP for the treatment of OSA, such as oral appliances (OAs), potentially involves large numbers of patients.
Based on a review of OA outcome studies, the American Sleep Disorders Association (ASDA) published practice parameters in 1995 which state that OAs are a primary treatment for patients with mild OSA and a secondary treatment for patients with moderate and severe OSA who cannot tolerate treatment with CPAP. Recent studies suggest that the role of OAs in the treatment of OSA may even be broader than that envisioned in the ASDA practice parameters. Randomized, crossover studies by Ferguson et al and Clark et al demonstrate that patients prefer treatment with OAs over CPAP, although OAs are less effective than CPAP for treating OSA. A study by Menn et al suggests that a serially adjusted appliance increases treatment efficacy, resulting in an overall 70% success rate as defined by >50% decrease in RDI and posttreatment RDI <20 events per hour. This appliance was also effective in five of nine (56%) patients with severe OSA (pretreatment RDI >40 events per hour).
The lack of standardization in the use of OAs for the treatment of OSA is problematic. There have been at least 40 studies to date evaluating various OAs, with efficacies of individual OAs varying widely. These studies also suggest that the patterns of practice among individual dentists are distributed among a broad spectrum with respect to the types of OAs used, the cost of these OAs, the intensity of patient follow-up, and the frequency of the use of NPSG both pretreatment and posttreatment. To our knowledge, no studies to date have evaluated this variability in the application of OAs for the treatment of OSA. Since dentists are currently the primary practitioners who manufacture, modify, and dispense OAs, we sought to determine these patterns of practice by surveying members of the Sleep Disorders Dental Society (SDDS). The SDDS is a special-interest group that consists primarily of dental clinicians and seeks to promote research and training for the application of OAs for the treatment of OSA and snoring.
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