How to stop an epidemic: The rise of sleep apnea

There’s an epidemic in American healthcare, and it’s not something that you’ll see on the news. It’s not being debated by Congress in a cleverly named healthcare act, and you won’t see red-faced pundits passionately arguing about it on a cable news program.

In fact, the only place you might have heard much about it is at a family gathering, when a parent or a sibling or a relative talks to you about a new machine they’ve just gotten. This epidemic is quite literally silent-or, rather, it’s not silent and it should be.

The rise of sleep disorders is a significant problem in the United States and around the world. “Research published by the Centers for Disease Control¹  and international organizations²  are now categorizing sleep disorders as an epidemic,” says Sal Rodas, CEO of Sleep Architects, Inc. and executive director of the Foundation for Airway Health. Obstructive sleep apnea (OSA) has already been found to have serious comorbidities, such as stroke, high blood pressure and heart disease, so the earlier it is detected and treated it, the better.

As awareness and diagnostics for OSA increase, more patients will be diagnosed, and it’s not just up to physicians to treat them. Dental sleep medicine is a developing treatment modality which has garnered increased attention in recent years, according to Rodas. And the role of the dentist in screening for and treating sleep-disordered breathing is going to become critical. 

There are two ways in which dentists can take a more active role in OSA: they can be instrumental in increasing diagnoses of dental sleep apnea and they can also serve as a resource to patients who are looking for alternatives to the medically prescribed CPAP (continuous positive airway pressure) mask. 

The alternative is the mandibular advancement device (MAD), often generally referred to as an oral appliance (OA). 

Today, CPAP masks are far more common, but due to increased awareness of oral appliances as an alternative and the lack of patient compliance with CPAP masks, that will likely change.

Research analyst Tara Shelton states that in 2020, the U.S. market will be double what it was in 2012.³  “Due to the large difference in market size and maturity, there is also less evidence supporting OAs as a first-line treatment when compared to PAP,” Shelton writes. “Only a select population will tolerate and consistently use PAP, and with increasing evidence, OAs could be positioned to consumers, clinicians and payers as a primary method of treatment for sleep apnea.” 

To demonstrate, 93 percent of OSA patients were prescribed a CPAP in 2015, while only seven percent were given an oral appliance, either to use alone or in combination with a CPAP. In 2020, it is predicted that 80 percent of patients will be prescribed a CPAP alone and 20 percent will be given an oral appliance. 

The reason oral appliances aren’t as popular yet is because they are not as predictable as CPAPs, says Dr. Steve Carstensen, DDS, co-founder of Premier Sleep Associates and founding editor of Dental Sleep Practice magazine, a publication dedicated to helping dentists learn how to understand and treat sleep apnea. Dr. Carstensen explains that physicians rely on CPAPs because it is proven to manage the problem and patients can start therapy immediately. The issue is compliance: Less than half of those prescribed to use a CPAP use it consistently. 

This is where the MAD comes in: to fill the gap in patient compliance with a more comfortable option for patients with mild-to-moderate OSA. 

“Research is supporting MAD as almost an equivalent to CPAP in many patients, but it’s not as easy for the physicians to count on it because it doesn’t work on everyone,” Dr. Carstensen says. 

While dentists can screen for it in their practices and offer alternative treatment to CPAP machines, they cannot diagnose patients-that’s up to the physician. Therefore, dentists must work with local physicians, which is another issue, says Dr. Carstensen. 

“Many physicians don’t have a dentist they can rely on, and the device depends on the skills of the dentist,” he notes. “The [MAD] is custom, whereas with CPAPs, the physician knows that the patient just has to go pick up a machine. It’s more predictable and the physician is more comfortable.” 

It’s also more work for the physician, who may end up prescribing a CPAP when MAD therapy fails. Therefore, many physicians prescribe a CPAP as the first-line treatment. 

“The more severe the diagnosis of apnea, the far more likely any physician will say to try the CPAP first,” Dr. Carstensen says. “The guidelines for mild cases state that the patient or physician can use an oral appliance as an equivalent first step. But in my experience, I get very few primary referrals for oral appliances versus ones who come through having already tried a CPAP.” 

CPAP is the ideal therapy for severe apnea patients, but the guidelines address a lack of patient compliance and now state that an oral appliance is better than nothing. For dentists, the time is right to start asking how they can position themselves as potential partners for physicians looking for alternatives to CPAP solutions.

How dental sleep medicine can save patients-and be a serious revenue driver 

Both dentists and patients can benefit from an increased awareness of sleep-disordered breathing. When dentists are looking for its signs and symptoms, they open up more treatment avenues. When patients receive treatment, their entire lives improve. 

There has been some conflict within the industry around practitioners who use dental sleep medicine to increase profits. It was that focus on profitability that kept dentists like Dr. John Flucke, DPR’s technology editor, from getting involved in the area sooner. 

I wasn’t sure if what we were doing in dentistry with sleep apnea treatment was adequate,” Dr. Flucke says. “I had a cone beam machine for a while and as I started to see more science behind it, I realized it wasn’t just something people were looking at as a profit center, which are two words people shouldn’t use in healthcare. It was about improving people’s lives.” 

For most dentists who are providing the service, revenue is an afterthought. 

“Dental sleep medicine is considered another service to add to your practice to make it more profitable, but it’s a life-and-death situation,” says Tara Griffin, DMD, of Dental Sleep Solutions in Bradenton, Florida. “We’re helping patients breathe at night and keeping their hearts healthy.” 

“There are people who have narrowed their practice to focus on sleep medicine and they are running driving practices,” Dr. Flucke says. “It’s definitely a profitable part of the practice as long as you learn to do it and do it correctly. It’s not just ordering the appliance. You need to get the proper training.” 

“The National Institutes of Health estimate that approximately 50 to 70 million U.S. adults have sleep-related disorders⁴,”  Rodas says. “Of those, approximately 18 million suffer from sleep apnea. Given the prevalence of these disorders, dentists may tap into a large source of patients that need their assistance.” 

That assistance doesn’t only come in the form of therapy for sleep-disordered breathing. Providing screenings alone is also an option. “There is no financial benefit there, but it starts a different conversation with the patient, which creates a unique experience in the office,” Dr. Carstensen says. “That gives the patient something to talk about with others, and that might build referrals.” 

But being successful with dental sleep medicine takes planning. 

“Dentists who do actual treatment have to be careful of the time involved,” Dr. Carstensen believes. “Medical insurance pays nicely for these appliances, so there is no reason it can’t be a good revenue source for the office if they plan it well. It’s important to set the right fees and control the time. The evidence for that revenue is that there are more and more practices that do only sleep medicine. If it wasn’t good revenue, we wouldn’t be able to do that.” 

Dentists can have as many sleep apnea patients as they want. “There is no end of adults to treat,” he says. 

Dr. Griffin advises that practitioners start with patient education to help reach those patients who may need to be diagnosed, as well as the patients who need to know about all of the treatment options. When patients fail to wear their CPAP mask, they should know that other options may be available. And if they suffer from sleep apnea, that may be something helpful that their dentist can tell them. 

“I think that part of our responsibility as dentists is to talk to patients and figure out if it could be something that’s affecting them without them knowing it,” says Leah Capozzi, DDS, owner of Metropolitan Dental in Buffalo, New York. 

Dr. Capozzi says that many patients who snore have never been evaluated for sleep apnea. “I think there is room for increased diagnosis,” she says. 

When patients complain about snoring or mention OSA directly, Dr. Capozzi starts the conversation about therapy options. She compares oral appliances with CPAPs and explains the risks involved to encourage compliance. She also explains that oral appliances aren’t always more comfortable than CPAPs, but it might be the lesser of two evils. “It’s still something that they’re going to have to make an effort to get used to,” she says. 

Dentists can use simple surveys to identify at-risk patients, says Dr. Carstensen. “That becomes much like taking blood pressure in the dentist’s office: We do that routinely but we don’t treat hypertension. If we do a screening and find a problem and we know where to send the patient, that’s a very good service we can provide.” 

If dentists do decide to implement dental sleep medicine in their practices, it is crucial to make sure that their treatment is not masking a bigger issue. 

“Many practitioners will make a device for patients for snoring, but the problem is that there might be something more going on,” Dr. Griffin says. “Snoring can be benign, but it’s often indicative of a bigger problem.” If you make a device for a patient who snores, you could miss the fact that they actually have sleep apnea. “I don’t want to ask patients if they snore and then respond by saying they need an airway appliance,” Dr. Flucke says. “There are a lot of diagnostic pieces that fit into the apnea diagnosis. When patients bring up snoring, I can ask questions and check things off the diagnostic checklist, do [a CBCT] scan, analyze the airway and get objective data. That science was my tipping point.” 

There are many dentists who start the process of providing dental sleep medicine and become deterred by the obstacle of medical insurance billing. The good news is that there are third-party billing services that can help. The other option is to have patients pay up front before submitting their claims to their medical insurance themselves. Most insurance, including Medicare and Medicaid, covers oral appliance therapy for patients diagnosed with sleep apnea, says Rodas. That includes the sleep studies, dental office visits and the sleep appliance. 

The future of dental sleep medicine 

According to a January 2015 Frost & Sullivan report by Tara Shelton, more clinicians will soon prefer dental appliances.⁵  Shelton also notes that the industry will see an increase in CPAPs and oral appliances being used in combination, presenting the case for increased collaboration between physicians and dentists. 

That collaboration should already be present. “The most important part is that, as a dentist, you shouldn’t be diagnosing sleep apnea,” Dr. Capozzi says. “You should make sure the patient has gone to a sleep doctor, has had a sleep test done, and has been diagnosed by a physician. Then you can work as a team with the sleep medicine provider to give the patient the best option for treatment.” 

Companies are coming out with technology that makes it easier for dentists to be champions of patients’ total wellness. Cone beam units are a big part of diagnostics. 

“The cone beam has been such an eye-opener for me,” Dr. Flucke says. “When you do an airway analysis on my machine, it literally gives you a 3D color-coded picture of the airway in red, yellow and green, so you can immediately know what you’re seeing.” 

While dentists can’t diagnose sleep apnea (or refer a patient to a sleep study lab), most states allow them to provide equipment for at-home sleep studies. “That can be a way to reduce barriers to getting a diagnosis,” Dr. Carstensen says. “A dentist works with a physician to provide the testing equipment, the physician evaluates the study, and the patient gets into therapy quicker than if they waited to have a sleep study done at a lab.” 

Some companies, such as Whip Mix, are making it easier for dentists to get involved in treating sleep-disordered breathing. At the end of last year, Whip Mix introduced the GEM and GEM Pro, a pulse oximeter that sends readings to the dental practice over the internet. It measures the patient’s SPO2 (the amount of oxygen in the blood) and heart rate. The GEM Pro also measures the patient’s bruxism, reads body position and records audio of their snoring. 

Dr. Carstensen is also involved in breaking down barriers for dentists. He is currently the principal investigator in a clinical trial of an at-home, tablet-controlled remote jaw positioner called Matrix Plus, which has yet to be cleared by the FDA. “We’re testing a patient to see if there is a jaw position that opens the airway to an ideal position,” he says. “I believe it will be a game changer for the treatment of sleep apnea because we’ll be able to identify if a patient is a good candidate for an oral appliance or not. That will help physicians have confidence that their patient is going to be treated with the best possible care.” 

Dr. Carstensen hopes to see Matrix Plus on the market this year. He asserts that the future of dental sleep medicine will be “screening by many and treatment by few.” 

Many dentists on the frontline of dental sleep medicine believe that every dental office should screen for the issue because dentists are so ideally placed to spot early signs and intervene before OSA’s comorbidities erupt. 

“The gold standard for treatment ... for obstructive sleep apnea is to artificially pry open the airway at night with air, plastic, or scalpel,” writes Barry Raphael, DMD.⁶  “But if you look at the progression leading up to obstruction, there are many, many opportunities to intervene, to change the trajectory of the disease, and to increase the quality of life.” 

Helping kids grow up healthier

The future of dental sleep medicine is brightest in the area of children’s health. 

“We’re learning that we can have an influence on kids from almost infancy through the ages of 10 or 11,” Dr. Carstensen says. “Think about a child who turns 13. Their teeth are crooked so they go to the orthodontist. If we can see that child when they’re four or five and recognize that their jaw structure isn’t growing big enough, we can influence that jaw to grow bigger. A side benefit is that the teeth will have room to grow straight, but the major benefit is that the jaw will be big enough to support a bigger airway so they can breathe well.” 

Poor breathing, especially in sleep, inhibits children’s brain development and could be connected to low daytime energy and ADHD. 

“Only dentists can influence jaw growth with orthodontic appliances that we have available today,” he says. “That’s the most important contribution to population health that dentistry’s ever had: to help these children grow up with an open airway, breathing well 24 hours a day.” 

Orthodontists don’t even have to invest in extra technologies or materials to positively impact children’s airways, he says. “We develop good tongue habits, the right shape for the jaws, and use Habit-Correctors to put nature on course,” Dr. Carstensen says. “It’s not fancy, it’s just making sure growth is directed in the right ways.” 

Other dentists are looking to identify at-risk children before they are even born. 

“It’s pretty well understood that any airway issue in adults, adolescents, or even older children that is related to the morphology of the face and jaw is usually detectable in the primary dentition, and maybe even before a child is born,” says Kevin Boyd, DDS, a pediatric dentist recognized as a leading clinician in the Chicago area for diagnosing and treating interferences to normal growth of the teeth, jaws and face. 

Dr. Boyd is currently working with multiple institutions that have dental schools in obstetric hospitals to conduct a retroactive study. 

“The proposal is to get children who are recognized as having jaws that are too small or too retrognathic and comparing the ultrasound from the hospital to see if there is a correlation in utero,” Dr. Boyd says. 

Retrognathia in early childhood is a known risk factor for sleep-disordered breathing, and if doctors can identify the malocclusion in utero, the unborn child has a better prognosis. 

“A kid with a mid-gestation retrognathic mandible will be born with it,” he says. “They don’t self-correct. We haven’t proven this, but that’s what the study is going to be about. We could potentially show in a retrospective trial how predictive the mid-gestational ultrasound was for children being worked up for pediatric work.” 

By identifying the issue in utero, Dr. Boyd hopes to encourage doctors to intervene earlier than what they had previously been taught is the ideal first age to intervene. He likens identifying and attending to the issues earlier to investing for retirement as soon as you get your first job. 

“The popular knowledge base is that if you invest early and let it grow, your retirement is set up, but if you wait too long, you have to invest too much money and you never get there,” Dr. Carstensen says. “If we invest in a child in single-digit ages, they have a lifetime of breathing well and being healthy. If we wait, then they suffer from heart diseases and diabetes and other chronic diseases that are associated with bad breathing at night time. We can’t just watch kids breathe through their mouths and listen to them sleep and not recognize that that’s not going to be a huge issue later on.” 

Despite the fact that the American Academy of Pediatrics advises doctors to ask parents about their children’s snoring, Dr. Boyd says it’s not being done. 

“The American Academy of Pediatric Dentistry came out years ago with the recommendation that every child should establish a dental home by age one, but the American Association of Orthodontics says that children should be seen at age seven,” Dr. Boyd says. “I’m thinking the orthodontists should go along with [the AAPD’s recommendation]. Certainly before the age of seven should every child be seen and evaluated for possible craniofacial morphology that might be restrictive.” 

Dr. Boyd says it is important to include general dentists in the conversation as well since they provide pediatric dental care and orthodontic services to both adults and children. But the elephant in the room, he says, is that general dentists and orthodontists are not used to providing care to children. 

“Children with less than six permanent teeth are being ignored, but that’s where we could nip the problems in the bud,” he says. “I understand that orthodontists don’t go into the specialty because they want to deal with anxious children. The idea is that orthodontics can wait until the children are older and more equipped to deal with a clinical setting, but it should be the responsibility of the orthodontist to make it a more comfortable experience for younger children so we can start treating these issues earlier.” 

However, Dr. Boyd says dentists can still play a positive role in pediatric dental sleep apnea without treating children directly. 

“I like to tell general dentists that see adults that, while they’re not treating kids, they’re treating the parents, aunts and uncles, and grandparents of kids that might benefit from this if their adult patient has a history of TMJ and airway problems,” Dr. Boyd says. 

Conducting more screenings and identifying sleep apnea in atypical candidates lays the foundation for identifying sleep apnea in children. “Many people think that sleep apnea patients are overweight or they have big necks, but many patients have it that you’d never expect to have it,” says Dr. Griffin. “Patients who grind their teeth tend to have apnea. Also, high blood pressure, heart problems, reflux, depression, anxiety and fibromyalgia tend to be associated with sleep apnea.” 

Dentists should use sleep screening questionnaires to help identify patient issues. Even patients who know about OSA may not recognize that they display common symptoms. 

How to get started

If a dentist wants to invest more in dental sleep medicine, it should be approached the same way a dentist would approach any other new treatment area, says Dr. Griffin. 

“Look for a mentor, someone who has systems in their office that allow them to do it successfully,” she says. “Notice what they’re doing.” 

Dr. Griffin took the step from being a general dentist to being a dental sleep specialist nearly a decade ago. Today her practice is focused on dental sleep medicine and TMJ dysfunction. 

“I started by screening patients in my general practice, and now I only do dental sleep medicine,” she says. “My practice is mostly referral-based from cardiologists and primary care physicians for patients who don’t tolerate the CPAP.” 

The field isn’t glamorous, but it reaps huge rewards for dentists and patients alike. 

“We get rewards when people have been treated well, whether it’s with CPAP or oral surgery, they come back to the person who helped identify the problem and express gratitude,” Dr. Carstensen says. “What an amazing reward for a patient to feel that much better because of what we did. We don’t get that a lot. We as dentists do beautiful work and focus on disease management, but people don’t love that. They love breathing better, sleeping better, working more productively and having a happier life.”   

References

1. www.cdc.gov/features/dssleep/

2. Stranges S; Tigbe W; Gómez-Olivé FX; Thorogood M; Kandala NB. Sleep problems: an emerging global epidemic? Findings from the INDEPTH WHO-SAGE study among more than 40,000 older adults from 8 countries across Africa and Asia. SLEEP 2012;35(8):1173–1181.

3. Shelton T. Vital signs: The price of a good night’s sleep: insight into the US oral appliance market. Frost & Sullivan. Industry Focus: Advanced Medical Technologies. January 2015. 

4. NHLBI (National Heart, Lung, and Blood Institute) National Sleep Disorders Research Plan, 2003. Bethesda, MD: National Institutes of Health; 2003.

5. Shelton T. Vital signs: The price of a good night’s sleep: insight into the US oral appliance market. Frost & Sullivan. Industry Focus: Advanced Medical Technologies. January 2015.

6. Raphael B. Airway Orthodontics the New Paradigm: Part 1: Addressing the Airway. Orthodontic Practice. Volume 7, Issue 3. Pages 35-39.