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Editorial 1, Issue 10.1
An Inconvenient Truth
Jean-François Masse, DMD, MSc, FACD, Diplomate, ABDSM
Editor-in-Chief Journal of Dental Sleep Medicine
Universite Laval, Quebec City, Quebec, Canada
Last month, the US Preventive Services Task Force (USPSTF) released its final recommendation on OSA screening in adults. This document was published in the November issue of the Journal of the American Medical Association.1
For us dental sleep medicine providers, the most interesting aspect of the report is that the USPSTF recognized oral appliance therapy (OAT) as a first-line therapy, alongside continuous positive airway pressure. Surgery is also mentioned and is considered as a second-line treatment.1 Will the report make a difference in the short term for oral appliances? I am hopeful, yet cautiously optimistic as habits change slowly. Nevertheless, this report clearly shows a trend toward better acceptance of oral appliances by the medical community.
There is at least one other interesting aspect to this report - with a background in epidemiology, I am always interested in looking at the data regarding the populations studied. Interestingly, the authors mention that the current prevalence of obstructive sleep apnea (OSA) in the US is not well-established. I don’t think it is because the United States does not have the means to evaluate the number of patients suffering from OSA at a specific time, but rather because the number of people entering the pool of new OSA patients each year is always increasing. The difference between the results of the WHO2 and the ResMed3 studies illustrate that clearly. Are sleep physicians doing their best in diagnosing sleep apnea patients? They certainly are, according to National Ambulatory Medical Care Survey data. This study showed that the diagnosis of OSA rose by 442% between 1999 and 2010.4 Despite all this hard work by clinicians, it seems like the situation is out of control - especially if you consider that the number of sleep physicians is decreasing.5
The unfortunate part of this report is that it indicates that there is not enough research for or against encouraging physicians to screen patients for OSA. Should physicians take this recommendation to mean that they should not screen patients, this could be very detrimental to public health. Fortunately, dentists are in a position to take on this important role of screening and fortunately, we have technology to also help patients navigate diagnosis by a physician. Over the last year or so, we have witnessed the introduction of disposable sleep tests. These tests offer convenience to both patients and providers: you send the device by mail, and the patient watches a YouTube video on how to use it. The results are electronically sent directly to the manufacturer for analysis. No longer is there a need for a receptionist to handle the patient and the devices. The devices do not need any costly maintenance by the sleep lab, as they are thrown away once the report is performed. The analysis, which seems surprisingly good, does not require manual scoring of the raw data by the sleep technologist (which is a very valuable commodity nowadays). Recognizing the role of disposable sleep tests in the future of OSA diagnosis, the American Academy of Sleep Medicine recently supported the addition of a Level III code for a disposable sleep test! Expect more disposable tests to come. This is ideal! Well, almost...
A question arises: when reading this description of the process involved with these new devices. How do they change the current model of care and allow us to help the growing population of patients with OSA? For patients with a high probability for OSA, if everything is done outside the sleep lab, do we need a sleep lab for simple tests? Could other health care providers provide these tests? And if the sleep physician does not need to interpret the test results, can they allocate their time to more severe cases of OSA and other sleep disorders, while other health care providers care help them address the overwhelming population of patients with OSA? I am sure sleep labs and sleep physicians both have answers for this. So will insurance companies for that matter...
We thought oral appliances would change the game of OSA treatment, and indeed they have. But, never have I considered that the introduction of new testing technologies could possibly change the paradigm under which we treat patients.
I think we may be on the verge of a paradigm shift as to who is doing what in the sleep industry. Only time will tell if this is the truth! Happy new year to everyone!
- US Preventive Services Task Force. Screening for Obstructive Sleep Apnea in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2022;328(19):1945–1950. doi:10.1001/jama.2022.20304
- Sleep apnea included in world health organization (WHO) report. American Academy of Sleep Medicine. October 12, 2007. Accessed January 4, 2023. https://aasm.org/sleep-apnea-included-in-world-health-organization-who-report/
- Nearly 1 billion people worldwide have sleep apnea, international sleep experts estimate. ResMed . May 21, 2018. Accessed January 4, 2023. https://investor.resmed.com/investor-relations/events-and-presentations/press-releases/press-release-details/2018/Nearly-1-Billion-People-Worldwide-Have-Sleep-Apnea-International-Sleep-Experts-Estimate/default.aspx
- Ford ES, Wheaton AG, Cunningham TJ, Giles WH, Chapman DP, Croft JB. Trends in outpatient visits for insomnia, sleep apnea, and prescriptions for sleep medications among US adults: findings from the National Ambulatory Medical Care survey 1999-2010. Sleep. 2014 Aug 1;37(8):1283-93.
- ABMS board certification report: 2018-2019. 2019. Accessed October 8, 2020. https://abms.org/media/257753/abms-boardcertification-report-2018-2019.pdf
CITATIONMasse, JF. An inconvenient truth. J Dent Sleep Med. 2023;10(1)
SUBMISSION AND CORRESPONDENCE INFORMATION
Submitted in final revised form January 2, 2023.
Address correspondence to: Jean-François Masse, DDS, MSc, FACD, D.ABDSM, Professor, Universite Laval, 2780 Masson #200, Quebec City, QC, G1P 1J6, Canada; Tel: 418871-1447; Fax: 418-871-4983; Email: firstname.lastname@example.org