Dentistry experienced a meaningful paradigm shift regarding patient management, circa the mid 1970’s. This shift took approximately a decade, and by the mid 1980’s, it was mostly complete. I am talking about the introduction of “Soft Tissue Management” (STM) programs, which transformed dental practices from being “Prophy Mills” that offered a quick buff and shine to the typical dental patient’s dentition, to STM offices, that screened, documented, referred and managed the periodontal status of the patient’s dentition. The net result has been a remarkable reduction in both periodontal disease and tooth loss, and an equally remarkable increase in overall Oral Health. As a 1983 University of Toronto graduate, I am proud to have participated in that era. Of course dentists that did not make that shift, became liable and were left susceptible to disciplinary action and litigation actions claiming negligence.
It is now 2015, and a paradigm shift of even greater significance has begun in dentistry, the introduction of “Sleep Disorders Dentistry” (SDD) programs for the typical dental office. The current “Airway Health” status of a typical dental patient is comparable to the “Periodontal Health” status of the typical dental patient during the 1970’s. Studies have shown that 57% of Americans snore, 20% have mild to moderate obstructive sleep apnea (OSA) and 7% have severe OSA. It is estimated that over 80% of these patients remain undiagnosed. These statistics are of epidemic proportions, and due to the regular follow up and continuing care programs dentistry currently has in place to manage the periodontal status of dental patients, the dentist is ideally positioned to play a major role in the management of a patient’s “Airway Health”.
Over the last 30 years, Oral Appliances that manage Snoring and OSA have become well established in the medical literature. This year, the American Academy of Dental Sleep Medicine (AADSM) and the American Academy of Sleep Medicine (AASM) jointly published Guidelines that include the use of Dental Oral Appliances as first line therapy for Snoring, and also for Mild, Moderate and Severe OSA “when or if” the patient prefers them to CPAP.
Although this is an exciting time to be a dentist, for many, the current paradigm shift will be even more difficult then that experienced in 1975, when the typical dentist was told that their “Prophy Mill” practice no longer met current standards; leaving them open to disciplinary action and litigation if they did not implement an appropriate STM program. Unfortunately, simply taking a weekend course does not adequately prepare a dentist and their team to manage OSA, and all of the associated responsibilities that go with managing “Airway Health”. The dentist needs to learn how to work harmoniously with physicians to screen, triage and treat these patients, following which comes a never ending obligation to monitor the patient and report to the prescribing physician at each follow up visit; this requires specific knowledge and training.
Today’s dentist must become well versed with the screening, referral process and management of “Airway Health”. The simple reason being that dentists are recognized as front line practitioners, responsible to evaluate and examine the oral cavity of patients. As Dentists become even more involved with the management of OSA, there will likely be an escalation in lawsuits for dentists that fail to diagnose their patients. Failure to recognize an airway problem can lead to litigation if it is alleged that the dentist should have recognized the condition and either failed to make the appropriate referral to a physician and or to appropriately manage the patient’s “Airway Health”. Failure to treat OSA predisposes the patient to a host of medical comorbidities including an increased risk of cardiovascular incidents, and workplace and automobile accidents due to daytime somnolence. Recently, a U.S. physician was successfully sued for not diagnosing OSA prior to surgery, which resulted in post surgical complications. Interestingly, I have noticed an increase in activity by Lawyers trained in dental issues on the SleepDisordersDentistry LinkedIn Discussion group that I manage. Lawyers are watching and learning, and their motives are transparent. In the not so distant future, dentists that fail to screen their patients for OSA will likely be considered liable; the assertion being that the dentist was negligent, based upon community standard of care, to identify signs and symptoms of OSA and failing to make the appropriate referral to a physician.
The management of “Airway Health” also involves a second paradigm shift; the notion that a procedure performed by a dentist has a “Side Effect” associated with it. The typical dentist is trained to enter the oral cavity, perform their procedure, while ensuring no harm to the surrounding dentition and oral structures and exit with minimal psychological or physical trauma to the patient. However, Oral Appliance Therapy is not typical dentistry, it is part of the medical model, where side effects are an acceptable outcome provided the Risk/Benefit ratio is transparent, understood, acceptable and consented to by the patient. These appliances lead to occlusal changes that in the past have prompted the need for bite adjustments, comprehensive restorative work and even orthodontics in an attempt to stabilize the dentition. However, what we have seen is that patient’s experiencing these bite changes fair very well and that all the “bad” things we once thought would happen if the dentition was not maintained in a centric occlusion relation actually do not happen. With the guidance of Dr. Alan Lowe, those of us involved in this field for many years have already gone through this paradigm shift. However, for those new to, or unfamiliar with this field, the notion that side effects associated with Oral Appliance Therapy are unacceptable has the potential to lead to numerous problems; unnecessary orthodontics and comprehensive restorative dentistry being suggested or performed only because a dentist or orthodontist has made a case that the dentition will suffer if it is not done, and even worse, termination of Oral Appliance wear, potentially leaving the patient’s “Airway Health” compromised. As Dr. Lowe shared with us many years ago, “no one has ever died of a malocclusion”; airway health is the priority.
Another very important concern is the appropriate use of the devices that industry sells to dentists. As this field grows, dentists will be attending more and more industry sponsored courses, the potential for misrepresentation or inadequate training in the appropriate use of these devices exists. For example, in my province of Ontario Canada, the absence of RCDSO guidelines regarding Home Sleep Screening equipment can be problematic if the dentist is not adequately trained ensuring appropriate and ethical use of these devices.
Currently, education in dental, hygiene and auxiliary schools, is inadequate to prepare new graduates for this environment. Of course, the many dentists, hygienists and auxiliaries already in practice are also ill prepared for these paradigm shifts. In the U.S., litigation lawyers are paying very close attention to this issue, it is only a matter of time before one of the standard questions asked when someone is in an automobile accident is, “Did your dentist screen you for sleep apnea at your last dental visit?”
It is time that the typical dentist has a SDD program in their dental practice, utilizing the same auxiliaries and systems they currently have in place for their STM program. Just think of how proud we can be 20 years from now when we take ownership (at least in part) of the remarkable reduction in deaths and fatal accidents being caused by the current levels of untreated OSA.
John Viviano DDS D ABDSM