Editorial 2, Issue 1.3

Connecting and Collaborating to Advance Dental Sleep Medicine

http://dx.doi.org/10.15331/jdsm.4132

Kathleen Bennett, DDS, Diplomate, ABDSM
Kathleen M. Bennett, DDS, LLC, Cincinnati, OH; President, American Academy of Dental Sleep Medicine

We live in an exciting time to be a dentist who provides oral appliance therapy (OAT) for obstructive sleep apnea (OSA), and the American Academy of Dental Sleep Medicine (AADSM) is in the midst of a strategic stage in its growth and development as the leading professional society for dentists who treat sleep-disordered breathing.

More people than ever before are in need of our expertise and care. Data from the Wisconsin Sleep Cohort suggest that the prevalence of OSA has increased substantially over the last two decades, likely due to the widespread obesity epidemic in the U.S.¹ The most current prevalence estimates are that 26 percent of adults between 30 and 70 years of age have at least mild OSA, and 10 percent of adults have moderate or severe disease. Based on this data, it has been estimated that OSA now afflicts at least 25 million adults in the U.S.²

Addressing this growing burden of OSA, we now have more dentists than ever before who are practicing dental sleep medicine. In the span of about two-and-a-half decades, the AADSM has grown from a small group to an expansive fellowship of colleagues, with a membership of more than 3,000 individuals. More dentists in more places throughout the U.S. and abroad are offering OAT, a treatment that is life-changing for many and that has the potential to be life-saving.³

Although we celebrate the rapid and necessary growth of dental sleep medicine, and recognize the contributions of those leaders who paved the way for us, we also must recognize the challenges that are both before us and on the horizon. Currently, the AADSM Board of Directors is in the initial stages of a strategic planning process that will address the most pressing concerns facing our organization and our membership. As we embark on this journey in the first half of my tenure as 2014– 2016 president of the AADSM, I anticipate that we will spend much of our time considering and discussing competition, connection and collaboration

COMPETITION

Dentists are no strangers to competition. In fact, I think we thrive on it. Most general dentists practice in markets that are highly competitive, where patients have numerous options available for their dental care. To succeed we learn to be proactive and innovative while understanding that our best form of advertising is to provide the highest quality of care for our patients.⁴

Dental sleep medicine was founded on this entrepreneurial spirit, which led to a veritable explosion of innovation and invention in the field.⁵ Currently, there are 107 anti-snoring devices and 23 jaw repositioning devices for snoring and OSA that have received 510(k) clearance for commercial distribution from the U.S. Food and Drug Administration.⁶ However, in the years ahead it is likely that continued competition driven by basic market forces will lead to contraction in the number of oral appliances available to clinicians.

We also are entering an era in which we will see increased competition with other therapies for OSA. Until recently OAT has enjoyed a certain degree of exclusivity as the non-invasive alternative to continuous positive airway pressure (CPAP) therapy, a position that is undergirded by a robust body of research and evidence-based clinical standards developed jointly by the AADSM and the American Academy of Sleep Medicine (AASM). However, in the last few years new technology and novel approaches to treatment have expanded the therapeutic options for OSA. These treatments include singleuse expiratory positive airway pressure (EPAP) valves inserted into each nostril and sealed with adhesive (e.g., Provent); oral pressure therapy (OPT), which stabilizes the airway using continuous negative pressure created by a vacuum pump connected with tubing to a polymer mouthpiece (e.g., Winx); a neck-worn device that delivers vibro-tactile feedback to limit supine sleep and reduce positional OSA (e.g., Night Shift); and an upper airway stimulation (UAS) device that requires surgical implantation but is considered to be less invasive than traditional surgical approaches (e.g., Inspire).^7-10

Because of the increasing diversity of treatment options, it is critical that we refine our methods to identify the candidates who will be most responsive to OAT. Dental sleep medicine has never involved a “one size fits all” approach to treatment. Now more than ever it is incumbent on us to develop validated protocols to predict treatment response, which will help us thrive in a more competitive treatment environment.¹¹

CONNECTION

Although the AADSM membership has expanded significantly since its establishment in 1991, there remains much more room for growth. According to the Bureau of Labor Statistics of the U.S. Department of Labor, dentists held about 146,800 jobs in 2012.¹² Over the next decade, dentistry is expected to grow 16 percent, which will be faster than the average of all occupations, producing more than 23,000 additional jobs by 2022.

Because of the high prevalence and destructive health consequences of OSA, we need many more dentists to join us in reducing the burden of snoring and sleep apnea. The recent cover story of AGD Impact is the latest evidence that the dental community is becoming more aware of dental sleep medicine, and the AADSM will continue to be the premier professional connection for dentists interested in treating sleep-disordered breathing.¹³

The AADSM also will continue to connect dentists to an increased offering of professional education opportunities that promote excellence in dental sleep medicine. Our diverse portfolio of courses—essentials, advanced, practical demonstration, and board review—provides learning opportunities for dentists at every level of experience, and our forthcoming online learning modules will greatly enhance the accessibility of this education. Each year the AADSM annual meeting also is the foremost educational event in dental sleep medicine, allowing dentists to learn from leaders in the field while connecting with colleagues from across the country. I encourage you to make plans to join us for the AADSM 24th annual meeting, which will be held June 4-6, 2015, in Seattle, Washington. The knowledge gained from this education promotes clinical excellence, and the AADSM Dental Sleep Medicine Facility Accreditation program gives dentists the opportunity to distinguish their practice by demonstrating that they meet high standards of proficiency, professionalism and quality patient care.

Through an ongoing national public relations campaign, the AADSM also continues to connect with consumers, building awareness of the effectiveness and benefits of oral appliance therapy. In two years the campaign has generated more than 2,000 stories and 125 million media impressions in both local publications and high-profile, national magazines such as Woman’s Day and Real Simple. This media coverage has raised the profile of dental sleep medicine and continues to drive patients to the online directory of member dentists on the AADSM website.

COLLABORATION

As dentists we have a tendency to be individualists, private practice pioneers who start our own business and enjoy working independently. Therefore, to the dentist who is a novice in providing oral appliance therapy for OSA, the required collaboration with a physician can seem counterintuitive. Yet this collaboration, which is outlined in the AADSM treatment protocol, is essential: It ensures professional alignment with state laws governing the practice of medicine and dentistry, while promoting effective, long-term care for patients with OSA.¹⁴ Building on the foundation of our treatment protocol, the AADSM Board of Directors recently approved the planning and implementation of a consensus conference to develop a comprehensive standard of care paper for the practice of dental sleep medicine. We believe that this will be a definitive resource, delineating the role of the dentist in the collaborative care of patients with OSA.

Since its establishment in 1991, the AADSM has been intentional at developing a positive working relationship with the AASM and our sleep medicine physician colleagues. Our Board of Directors purposefully emphasized this important dynamic in the language of the AADSM vision statement, “To lead and promote dentistry’s role in collaboration with our physician colleagues in reducing the burden of snoring and sleep apnea.” Together our organizations developed a joint policy statement to clarify the boundaries of this collaboration at a time when the lines are being blurred by companies that are marketing diagnostic devices and home sleep testing services directly to dentists.¹⁵ Currently, we are working together to update the practice parameters for oral appliance therapy, which brought unprecedented recognition to dental sleep medicine when it was published in 2006.¹⁶ Furthermore, AADSM leaders will be presenting a lecture about oral appliance therapy to an audience of 400 sleep medicine physicians at Sleep Medicine Trends 2015 in February.

Our constructive collaboration with physicians is especially important due to the ongoing implementation of the Patient Protection and Affordable Care Act (ACA), which is emphasizing integrated, coordinated health care. It will be critical for dentists who provide oral appliance therapy to be a “good neighbor” to the patient-centered medical home, working closely with primary care providers and sleep specialists to provide seamless, value-based care for patients with OSA.¹⁷ For some dentists the road less travelled may be to provide oral appliance therapy “under one roof ” as part of a sleep medicine practice, allowing for direct interaction with physicians and promoting streamlined patient care.¹⁸

CONCLUSION

During this period of transition when the U.S. health care system is changing dramatically, it is more important than ever for the AADSM to define the field of dental sleep medicine and solidify the role of the dentist in the treatment of snoring and sleep apnea. Over the next two years the AADSM will focus on issues of broad importance to the field: setting standards of care, outlining a pathway to board certification, developing outcome measures, promoting comparative effectiveness research, and preparing members for changes in insurance reimbursement. The AADSM also will increase its health policy engagement by representing the interests of members, establishing relationships with insurers, and helping members understand the impact of the ACA on the practice of dental sleep medicine.

In the years ahead the professional path of every dentist who provides OAT is sure to take some twists and turns as the U.S. health care system evolves, oral appliance innovations are introduced, and new OSA treatment options spark increased competition. However, the AADSM will continue to help members make the connections and promote the collaborations necessary to navigate these changes successfully.

CITATION

Bennett K. Connecting and collaborating to advance dental sleep medicine. Journal of Dental Sleep Medicine 2014;1(3):111–113.

REFERENCES

1. Peppard PE, Young T, Barnet JH, et al. Increased prevalence of sleepdisordered breathing in adults. Am J Epidemiol 2013;177:1006–14.

2. National Healthy Sleep Awareness Project. Stop the snore: sleep apnea action urgent for those at risk. 2014 Aug 12 [cited 2014 Sept 2]. Available from: http://sleepeducation.org/docs/default-document-library/stopthe-snore-sleep-apnea-action-urgent-for-those-at-risk.pdf.

3. Anandam A, Patil M, Akinnusi M, et al. Cardiovascular mortality in obstructive sleep apnoea treated with continuous positive airway pressure or oral appliance: an observational study. Respirology 2013;18:1184–90.

4. Dort LC. Quality. Journal of Dental Sleep Medicine 2014;1:81.

5. Rogers RR, Remmers J, Lowe AA, Cistulli PA, Prinsell J, Pantino D, Rogers MB. History of dental sleep medicine. Journal of Dental Sleep Medicine 2014;1:67–74.

6. U.S. Food and Drug Administration. 510(k) premarket notification. Search database. Updated 2014 Aug 25 [cited 2014 Aug 29]. Available from: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn. cfm.

7. Kryger MH, Berry RB, Massie CA. Long-term use of a nasal expiratory positive airway pressure (EPAP) device as a treatment for obstructive sleep apnea (OSA). J Clin Sleep Med 2011;7:449–53.

8. Colrain IM, Black J, Siegel LC, et al. A multicenter evaluation of oral pressure therapy for the treatment of obstructive sleep apnea. Sleep Med 2013;14:830–7.

9. Levendowski DJ, Seagraves S, Popovic D, Westbrook PR. Assessment of a neck-based treatment and monitoring device for positional obstructive sleep apnea. J Clin Sleep Med 2014;10:863–71.

10. Strollo PJ Jr, Soose RJ, Maurer JT, et al. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med 2014;370:139–49.

11. Scherr SC, Dort LC, Almeida FR, et al. Definition of an effective oral appliance for the treatment of obstructive sleep apnea and snoring: a report of the American Academy of Dental Sleep Medicine. Journal of Dental Sleep Medicine 2014;1:39–50.

12. Bureau of Labor Statistics, U.S. Department of Labor. Occupational outlook handbook. Dentists. 2014-15 Edition [cited 2014 Aug 28]. Available from: http://www.bls.gov/ooh/healthcare/dentists.htm.

13. Shepherd L. Breathing easier: helping patients with obstructive sleep apnea. AGD Impact 2014;42:16–20.

14. American Academy of Dental Sleep Medicine. AADSM treatment protocol: oral appliance therapy for sleep disordered breathing: an update for 2013. June 2013 [cited 2014 Sept. 2]. Available from http:// www.aadsm.org/treatmentprotocol.aspx.

15. American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine. Policy statement on the diagnosis and treatment of obstructive sleep apnea. 2012 Dec 7 [cited 2014 Sept 2]. Available from: http://www.aadsm.org/resources/pdf/jointpolicy.pdf.

16. Kushida CA, Morgenthaler TI, Littner MR, et al. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep 2006;29:240–3.

17. Morgenthaler TI, Badr MS. Ensuring patient access to sleep specialty care in the evolving U.S. healthcare system: introducing the Welltrinsic Sleep Network. An investment of the American Academy of Sleep Medicine. J Clin Sleep Med 2014;10:463–4.

18. Sharma S, Essick G, Schwartz D, Aronsky AJ. Sleep medicine care under one roof: a proposed model for integrating dentistry and medicine. J Clin Sleep Med 2013;9:827–33.

SUBMISSION & CORRESPONDENCE INFORMATION

Submitted for publication September, 2014
Accepted for publication September, 2014

Address correspondence to: Kathleen Bennett, DDS, Diplomate, ABDSM, 222 Piedmont Avenue, Suite 8300, Cincinnati, OH 45219; Tel: (513) 871- 9111; Fax: (513) 467-0943; E-mail: kmbennettdds@gmail.com

DISCLOSURE STATEMENT

Dr. Bennett has indicated no financial conflicts of interest.



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