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									Dental Public

Robert R. Rogers, DMD                    Dental sleep medicine: Coming of age
                                         During the past decade, a number        ing; normal oxygenation; and rest-
Abstract                                 of critical issues have evolved and     ful, refreshing sleep. Treatment
Millions of people worldwide suffer      coalesced to create a new med-          modalities include weight reduc-
diminished quality of life due to the    ical/dental sub-specialty that has      tion, positional therapy, reduction
effects of sleep-disordered breathing    captured the attention of physi-        of alcohol consumption, positive
(snoring and obstructive sleep           cians, dentists, patients, and com-     airway pressure, surgery, and oral
apnea). The worst cases can be           mercial interests. Today, managing      appliances. At present, no single
life-threatening. Recently, the          sleep-disordered breathing (SDB)        method is universally effective
medical and dental professions have      with oral appliances is supported       and tolerated; therefore, medical
partnered to provide essential relief    by peer-reviewed research and ac-       sleep specialists have turned to an
for many of those afflicted with this    cepted by many physicians and           interdisciplinary approach and
widespread malady. As medical            dentists as integral to the treatment   called upon specially trained den-
sleep specialists reach out to include   mix.1,2 Concurrently, educational       tists to play an important role in
dentists on the “sleep team,” it is      opportunities are available for         the screening and treatment of
incumbent on the dental professional     physicians and dentists through         SDB. The past 10 years have seen
to have sufficient education and         many venues, including an inde-         a proliferation of “sleep disorders
training. Presently, there are a         pendent academic academy. In ad-        dentists,” while the term “dental
multitude of opportunities and           dition, numerous commercial man-        sleep medicine” has come to de-
venues available to the dentist who      ufacturers are joining the fray by      scribe the unique arena that part-
may have an interest in this             providing a multitude of appliance      ners physicians and dentists in the
burgeoning new field. However,           types while insurance carriers have     battle against snoring, upper air-
caution is required during the           begun to provide coverage for this      way resistance syndrome, and ob-
learning experience because different    therapy with increasing frequency.      structive sleep apnea (OSA).
sources of educational material may         SDB is characterized by repeat-         It is incumbent on the aspiring
not be congruent with legal or           ed episodes of upper airway nar-        sleep disorders dentist to appreciate
professional ethics.                     rowing and obstruction during           the medical implications of SDB
                                         sleep, resulting in upper airway        and attain the proper education in
Received: May 1, 2001                    resistance, snoring, apnea, inter-      sleep medicine and oral appliance
Accepted: May 10, 2001                   mittent hypoxemia, and sleep dis-       therapy. It has been increasingly
                                         ruption.3 There are numerous eti-       recognized that the sequelae of
                                         ologic factors involved in this         OSA cause disability from patho-
                                         malady, both of a functional and        logic sleepiness and cardiorespira-
                                         an anatomic nature. The primary         tory complications.5 In addition,
                                         functional factor is the physiologic    therapy with oral appliances, espe-
                                         decrease in tone of the upper air-      cially mandibular repositioning de-
                                         way muscles during sleep that           vices, has been associated with side
                                         causes the walls of the pharynx to      effects—most notably, an altered
                                         collapse. Anatomic factors are nu-      occlusion—that concern the astute
                                         merous and varied but ultimately        practitioner.6,7 The sleep disorders
                                         associated with a reduction in the      dentist must coordinate and blend
                                         diameter of the naso, oro, and/or       education, experience, and ethics
                                         hypopharyngeal sections of the          into new protocols and procedures
                                         upper airway. These may include         for maximum benefit to patients
                                         nasal obstructive lesions, tonsilar     and the profession.
                                         and uvular hypertrophy, macro-             This is easier said than done.
                                         glossia, retrognathia, and a caudal     The educational venues available to
                                         positioning of the hyoid bone.4         dentists interested in this new field
                                            Therapies to manage SDB ulti-        are numerous and seem to offer
                                         mately are aimed at altering or         varied slants on the subject—some
                                         eliminating factors predisposing to     appropriate, some suspect. Com-
                                         upper airway collapse in an effort      mercial entities selling oral appli-
                                         to allow for quiet, regular breath-     ances in the dental marketplace

are the most visible source of          upper airway resistance syndrome,       before participating in the treat-
information through workshops           and the various degrees of OSA.         ment of SDB with oral appliances.
and frequent advertising in profes-     How each is diagnosed is particu-       Most often, the fabrication, fitting,
sional journals. Many times it is       larly important and the dentist         and adjusting of oral appliances
here that the novice first enters the   should have a firm grasp on the         are limited to the practice of den-
realm of dental sleep medicine.         meaning of polysomnographic             tistry and fall outside the legal
    Practically speaking, this repre-   data, including apnea/hypopnea in-      practice of medicine. In this re-
sents an excellent entry point since    dices, sleep architecture, and oxy-     gard, physicians should recognize
it is quick, easy, and often provides   gen saturation. Other diagnostic        the liability they assume if they
accurate, ethical information.          tools such as the Multiple Sleep La-    engage in placing and managing
However, this is not always the         tency Test, the Maintenance of          oral appliances themselves.
case. In some instances, the com-       Wakefulness Test, and the Epworth          For dentists, the caveat relates to
mercial concern will present mate-      Sleepiness Scale should be familiar     diagnosis, which must take place
rial that deviates from accepted        to the dentist. Most importantly,       prior to appliance usage. While
medical protocol because it tends to    the sleep disorders dentist must ap-    most jurisdictions describe the
enhance sales. This can lead to im-     preciate the medical protocol           practice of dentistry with very
proper therapy for patients and le-     which dictates that all patients        broad definitions, there do not ap-
gal complications for the dentist.      must be evaluated and formally di-      pear to be any that specifically in-
    Practitioners must tread cau-       agnosed by a medical sleep special-     clude the diagnosis of disordered
tiously among the educational           ist prior to any definitive interven-   sleep within the scope of the prac-
venues and seek out a variety of        tion by a dental professional.          tice of dentistry. Additionally, if a
sources so that an accurate view of        In addition to sleep medicine, a     dentist prescribes an oral appliance
the “big picture” can be attained.      thorough knowledge of oral appli-       to treat a symptom such as snoring,
The American Academy of Sleep           ance therapy is necessary. An un-       this plan of treatment, without a
Medicine (formerly the American         derstanding of upper airway             complete diagnostic evaluation,
Sleep Disorders Association)            anatomy and physiology, appli-          may create significant exposure for
(507/287-6006,         ance design and variation, clinical     the dentist. In a case such as this,
offers a vast array of objective        procedures, troubleshooting, and        a treatment that alleviates the
information compiled by sleep           follow-up are but a few of the top-     symptom of snoring may serve to
physicians and has produced a           ics the dentist needs to master in      mask a more serious condition and
position paper that can serve as        his or her endeavor to provide          discourage the patient from seek-
the scientific basis for therapy        quality care in this growing field.     ing a more effective treatment for
with oral appliances.2 In addi-            Following recognition and appre-     the disorder, perhaps resulting in
tion, the Academy of Dental             ciation of the medical and dental re-   dangerous consequences for the
Sleep Medicine (724/935-0836,           quirements inherent in the practice     patient and potential legal liability pro-            of dental sleep medicine, one other     for the practitioner.
vides the serious practitioner with     critical element remains—the legal         The fact that an individual is li-
objective material that is based on     perspective. From this standpoint,      censed to perform a procedure does
current research and is congruent       two main concerns arise: compli-        not singularly insulate the practi-
with the accepted medical model.        ance with local licensing require-      tioner from liability for negligent
    Presently, properly trained den-    ments and issues of professional lia-   conduct. In terms of the negligence
tists are in high demand by both        bility. Because of the nature of oral   formula, healthcare practitioners
physicians and patients and play an     appliance therapy, certain aspects of   have a preexisting duty to their pa-
important role in the treatment of      treatment fall within the scope of      tients to provide medically appro-
SDB. Consequently, the sleep disor-     practice of physicians and certain      priate care that a practitioner in
ders dentist is expected to have an     others fall within the scope of prac-   good standing would provide. This
appropriate background in sleep         tice of dentists.                       is referred to as the “standard of
medicine and oral appliance therapy.       Licensing laws differ in each ju-    care.” Physicians have been found
    While an overall appreciation of    risdiction but all have laws that       to have violated the standard of
sleep medicine as a discipline is re-   define the scope of practice of li-     care when, for example, they did
quired, the specific area of SDB de-    censed health professionals within      not acknowledge the limitations of
mands more in-depth knowledge.          that area. Both physicians and          their own abilities and, as a result,
The dentist should be very familiar     dentists should be aware of the         failed to refer patients to an appro-
with the continuum of snoring,          limitations of their own jurisdiction   priate medical specialist.

                                                                           GENERAL DENTISTRY/JULY-AUGUST 2001 399

    In the context of SDB, any            Author information
healthcare professional who diag-         Dr. Rogers is the founding and past presi-
noses or attempts to treat this mal-      dent of the Academy of Dental Sleep
ady has a duty to do so with a med-       Medicine. He currently is the Director of
ically appropriate level of care. It is
absolutely critical for the dentist to    Dental Medicine for St. Barnabas Med-
recognize that diagnosis based on         ical Center in Gibsonia, Pennsylvania.
physical observation and patient in-
terview alone certainly would not         References
satisfy the standard of care if the           1. Schmidt-Nowara W, Lowe A, Wie-
level of care ordinarily possessed        gand L, Cartwright R, Perez-Guerra F,
and used by members of the pro-           Menn S. Oral appliances for the treat-
fession in good standing in the di-       ment of snoring and obstructive sleep ap-
agnosis of SDB would have includ-         nea: A review. Sleep 1995; 18:501-510.
ed the administration of a                    2. American Sleep Disorders Asso-
polysomnogram (overnight sleep            ciation. Practice parameters for the
study).                                   treatment of snoring and obstructive
    Likewise, physicians must be          sleep apnea with oral appliances.
aware that they are neither legally       Sleep 1995;18:511-513.
nor medically qualified to proper-            3. Guilleminault C, Eldridge FL,
ly manage appliance construction,         Dement WC. Insomnia with sleep ap-
fitting, and titration or the inher-      nea: A new syndrome. Science 1973;
ent concerns of tooth movement,           181:856-858.
temporomandibular joint dysfunc-              4. Hudgel DW. The role of upper
tion, and occlusal discrepancies.         airway anatomy and physiology in ob-
                                          structive sleep apnea. Clin Chest Med
Summary                                   1992;13:383-398.
A physician or dentist who exceeds            5. Guilleminault C, Tilkian A, De-
the scope of a professional license       ment WC. The sleep apnea syndromes.
risks civil and criminal liability.       Annu Rev Med 1976;27:465-484.
Additionally, one who practices               6. Bondemark L. Does two years’
within the scope of licensure but         nocturnal treatment with a mandibular
does not satisfy the standard of care     advancement splint in adult patients with
applicable to a given procedure also      snoring and OSAS cause a change in the
risks liability. It becomes obvious       posture of the mandible? Am J Orthod
then that treatment of SDB with           Dentofacial Orthop 1999;116: 621-628.
oral appliances must be a team ef-            7. Clark GT, Sohn JW, Hong CN.
fort. Diagnosis falls into the realm      Treating obstructive sleep apnea and
of medicine while management of           snoring: Assessment of an anterior
the oral appliance dwells within          mandibular positioning device. JADA
that of dentistry. If each practition-    2000;131:765-771.
er performs within the scope of li-
censure and standard of care, pa-
tients will be more likely to receive
effective treatment and legal liabili-
ty will be minimized.


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