Letter 3, Issue 10.4

Response to “Recent AADSM Protocol Update: A Step Forward, or Backward?”


Standards for Practice Committee of the American Academy of Dental Sleep Medicine: Mitchell Levine, DMD (Chair)1 ; Michelle K. Cantwell, DMD2 ; Kevin Postol, DDS3 ; David B. Schwartz, DDS4
 1Saint Louis University Center for Advanced Dental Education, St. Louis, MO; 2Wellspan Health, Pulmonary and Sleep Medicine, York, PA; 3Gateway Center for Sleep Apnea and TMJ Therapy, Ballwin, MO; 4Dental Professionals, Skokie, IL

We are appreciative to Dr. Viviano for expressing his thoughtful concerns with the recent publication, Dental Sleep Medicine Standards for Screening, Treatment, and Management of Sleep-Related Breathing Disorders in Adults Using Oral Appliance Therapy: An Update.1 True advancement in a field only occurs when people with varying perspectives can respectfully discuss their opinions. Dr. Viviano suggests “that the status quo has failed us dentists and this AADSM guidance has been written with the best intention.”  While we applaud this observation, we also feel it is important to recognize that the status quo has failed some patients.

Providing optimal patient care is the focus of these standards. There are 43 million people in the US with undiagnosed and untreated OSA.2 As we developed this update, we considered how dentists might improve access to streamlined, affordable care. There are countless patients who have been diagnosed with OSA by a medical provider and have either abandoned CPAP or may have chosen an oral appliance as a first-line treatment, if given the opportunity. When physicians and other medical providers (including dentists) empathetically explain the need for management of sleep apnea, including each of the reasonable treatment options, the patient should be able to make an informed decision on how to manage their condition and then obtain that treatment from the most appropriate provider without additional hurdles. The intent of our updated guidance was not to strain physician-dentist relations, complicate insurance reimbursement, allow a dentist to initiate the management of a medical disorder without a physician’s oversight, or to open the door to abuse. Rather, our primary purpose was to provide greater guidance and clarity in the quickly evolving field of dental sleep medicine. Ideally, board-certified sleep medicine physicians would manage the diagnosis and care of all OSA patients. In reality, there are simply too few board-certified sleep physicians to meet the needs of patients with undiagnosed and untreated OSA - and there are now more than two thousand qualified dentists who desire very much to collaborate with physicians to stem the tide.3 To be sure, there are dentists and physicians for that matter, who are motivated more by financial return than managing their patient’s health. Thankfully, neither are in substantial number, and frankly, obtaining a physician prescription for an oral device does not mitigate that concern. Patients who have been diagnosed by a licensed medical provider and desire an oral device should not have to return to the medical provider to seek solutions which may lie elsewhere. To that end, the qualified dentist remains committed to not only communicating with patients’ health care providers but being an active care provider in collaboration with our medical colleagues. If a patient has been diagnosed by a licensed medical provider and desires an oral appliance as their treatment, it is appropriate for the dentist to provide treatment as expeditiously as possible. The longer a patient waits to receive treatment the more potential danger the patient may experience, which is why the AADSM firmly supports this model as a step forward.  Of course, communicating with a patient’s healthcare providers throughout treatment is an important step in providing optimal care, which is why the standards continuously discuss having a collaborative relationship with our medical colleagues.

The dentist prescribing an appliance by no means removes the medical provider from the patient treatment pathway. Rather, it better recognizes the time sensitive need of the medical provider at critically necessary points, ideally improving outcomes for the patient. This is a truly interdisciplinary model for healthcare in the 21st century that focuses on putting the needs of our patients first.


Levine M, Cantwell MK, Postol K, Schwartz DB. Response to “Recent AADSM protocol update: A step forward, or backward?”. J Dent Sleep Med. 2023;10(4).


  1. Levine M, Cantwell M, Postol K, Schwartz D. Dental sleep medicine standards for screening, treating, and management of sleep-related breathing disorders in adults using oral appliance therapy. J Dent Sleep Med. 2022;9(4)
  2. Benjafield AV, Ayas NT, Eastwood PR, et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis. Lancet Respir Med. 2019;7(8):687-698.
  3. Watson NF, Rosen IM, Chervin RD. The past is prologue: the future of sleep medicine. J Clin Sleep Med. 2017;13(1):127–135.


Submitted in final revised form October 3, 2023
Address correspondence to: Mitchell Levine, DMD; Email: mlevine@aadsm.org


The authors report no conflicts of interest.