Download January 29, 2016 Illinois Division of Professional Regulation Jay

January 29, 2016
Illinois Division of Professional Regulation
Jay Stewart, JD, Executive Director
Medical Licensing Unit
320 W. Washington St., 3rd Floor
Springfield, IL 62786
Dear Mr. Stewart,
On behalf of the board of directors of the American Academy of Dental
Sleep Medicine (AADSM), I am writing to bring to your attention our
concern that some physicians are providing non-custom oral appliances
for the treatment of obstructive sleep apnea (OSA), which is clearly suboptimal patient care for this chronic disease. As the leading professional
membership society in dental sleep medicine, the AADSM represents
more than 3,000 dentists who are committed to reducing the burden of
snoring and OSA through collaboration with our physician colleagues.
An estimated 25 million adults in the U.S. require treatment for OSA, a
chronic medical disorder that is associated with deleterious medical
conditions such as hypertension, stroke and congestive heart failure. The
primary treatment option for adults with OSA is continuous positive
airway pressure (CPAP) therapy. According to the clinical practice
guideline published jointly by the AADSM and the American Academy of
Sleep Medicine (AASM) in 2015, physicians should consider prescription
of oral appliances for adult patients with OSA who are intolerant of CPAP
therapy or prefer alternate therapy.1 The guideline also suggests that a
qualified dentist use a custom, titratable appliance over non-custom oral
devices when oral appliance therapy is prescribed by a sleep physician.
This recommendation delineates two important aspects of optimal care for
the provision of oral appliances.
First, qualified dentists are the provider of choice for oral appliance
therapy. The expertise of a dentist is especially important because oral
appliances can be associated with health risks such as intraoral gingival,
palatal, or dental soreness; temporomandibular joint (TMJ) dysfunction
syndrome; obstruction of oral breathing; and loosening or flaring of lower
anterior teeth or general tooth movement. Therefore, the clinical guideline
suggests that qualified dentists provide oversight of oral appliance therapy
1
Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical
practice guideline for the treatment of obstructive sleep apnea and snoring with oral
appliance therapy: an update for 2015. J Clin Sleep Med 2015;11(7):773–827.
to survey for dental-related side effects or occlusal changes and reduce their incidence. A
qualified dentist who has technical skill and acquired knowledge in dental sleep medicine can
minimize these health risks and ensure that patients with OSA receive the highest quality of
therapeutic care. The guideline also suggests that adult patients treated with oral appliance
therapy for OSA return to their dentist for periodic office visits. The ongoing role of the dentist is
essential to monitor patient adherence and appropriate device calibration while evaluating the
health of the oral structures and integrity of the occlusion.
The clinical practice guideline for oral appliance therapy, which was based on a systematic
review of the evidence, also establishes that custom, titratable appliances are superior to noncustom oral appliances, which are commonly known as “boil and bite” devices. An oral
appliance that is custom-fit by a qualified dentist reduces sleep apnea severity and increases
oxygen saturation to a greater extent than a non-custom device. Furthermore, the AADSM
definition of an effective oral appliance states that, “An oral appliance is custom fabricated using
digital or physical impressions and models of an individual patient’s oral structures. As such, it is
not a primarily prefabricated item that is trimmed, bent, relined or otherwise modified.”2 In
contrast, non-custom oral devices are primarily prefabricated and usually partially modified to an
individual patient’s oral structures. These prefabricated oral appliances tend to be bulky and illfitting, resulting in difficulties retaining the device on the oral structures, which diminishes the
ability of the appliance to maintain a stable mandibular protrusive position during sleep and may
increase patient discomfort.
1
By clarifying that oral appliance therapy should be provided by a qualified dentist after it has
been prescribed by a physician, the clinical practice guideline that was developed jointly by the
AADSM and the AASM supports increased teamwork between physicians and dentists to
achieve optimal treatment for OSA patients. This collaboration is undermined, and patient care
suffers, when some physicians practice outside these recommendations by providing inferior,
non-custom “boil and bite” devices to patients who have OSA.
On behalf of the AADSM, I urge you to notify your licensees that the provision of an oral
appliance by a physician is an unacceptable patient care strategy. To discuss this issue further,
please contact AADSM Executive Director Jerome Barrett at (630) 737-9705.
I thank you for taking these comments under consideration.
Sincerely,
Kathleen Bennett, DDS
President 2
Scherr SC, Dort LC, Almeida FR, Bennett KM, Blumenstock NT, Demko BG, Essick GK, Katz SG, McLornan PM, Phillips KS, Prehn RS, Rogers RR, Schell TG, Sheats RD, Sreshta FP. Definition of an effective oral appliance for the treatment of obstructive sleep apnea and snoring. Journal of Dental Sleep Medicine 2014;1(1):51.