Those who suffer from Obstructive Sleep Apnea (OSA) but can’t tolerate wearing a continuous positive airway pressure (CPAP) device may breathe a sigh of relief – with the blessing of their physician.
An increasing number of sleep physicians are embracing oral appliances to treat OSA. The level of clinically validated research that is being produced indicating oral appliance efficacy continues to grow. With this clinical validation comes an increase of physicians recommending oral appliances to CPAP-intolerant apnea sufferers, and in some instances as a first line treatment for mild and moderate cases.
As an example, we encounter such a patient who had never heard about oral appliances, yet had endured uvulopalatopharyngoplasty (UPPP) surgery with its painful recovery, plus a deviated septum correction. After that, the longtime sleep apnea sufferer unsuccessfully tried more than 10 CPAP masks and various CPAP settings and pressures, and several second opinions from various sleep physicians.
By the time this same patient ended up in the office of Kent Smith, DDS, the relentless snoring and sleep apnea had not gone away. Fatigued and anxious for a solution, the middle-aged man gladly sat for an oral appliance impression courtesy of Smith, a Dallas-based dentist who owns 21st Century Dental along with a sleep arm of the business called Sleep Dallas.
This patient’s unfortunate odyssey comes down to a resounding failure to communicate, and it is one of the things that Smith and a growing number of sleep-focused dentists are trying to change. “This patient ends up in my office as the equivalent of road kill,” laments Smith. “Unfortunately, he has not had anyone pointing him in the direction of oral appliance therapy until recently. I am shaking my head and feeling sorry that he has not had some kind of relief.”
Prior to the referral to Smith, Jones had seen three sleep physicians. It was not until the fourth—Nabeel Farah, MD—that oral appliances came into the picture.
As owner and founder of Sleep Medicine Consultants of North Texas, Dallas, Dr. Nabeel Farah actively looks for capable dentists, not hesitating to send patients when the situation is appropriate.
With the various treatment modalities for OSA out there, Dr. Farah does not engage in “turf battles” with dentists or attempt to pigeonhole apnea sufferers in a preferred modality, rather cooperation is his philosophy. CPAP, surgery, and oral appliances, and weight loss all share a spot at the table, and recommendations differ depending on each patient’s needs and the severity of their OSA.
When comparing CPAP to oral appliances, particularly in mild to moderate cases, Dr. Farah works with patients to find the right option. “Patients probably have a preference for oral appliances in the mild to moderate range,” he notes. “I always give the option, and oral appliances can be a good first-line option in mild to moderate cases. Sometimes I recommend oral appliances even in severe cases, usually when patients have failed in the past with CPAP. Some treatment is better than no treatment. If the patient can’t tolerate CPAP, then an oral appliance can make an improvement.”
For Kent Smith, Dr. Farah represents a segment of the medical field that is particularly tuned in to the possibilities of oral appliances. Many physicians, however, are not quite there. “I think the majority of physicians are just beginning to learn about oral appliance therapy, and probably are not as familiar yet with oral appliances as they are with CPAP therapy,” says Smith. “Even sleep centers are much more familiar with CPAP, so patients typically end up with a CPAP machine. Oral appliance therapy has not been mainstream for that long, but it is growing as more dentists and physicians become aware and research emerges showing efficacy”
Dr. Smith believes that some sleep physicians simply have a bias against oral appliances, and that some are even content to refer patients for surgery before contemplating oral appliances. “I know that the American Academy of Sleep Medicine does not share that stance,” says Smith. “They suggest oral appliances prior to surgery. But it’s a fact that there are some sleep physicians who will never think of oral appliances—even for mild patients or primary snorers who would not qualify for CPAP.”
According to Dr. Smith those dentists who continue to pursue continuing education will ultimately see the light, although it may take time. “As the field evolves, we will continue to see more oral appliances,” he says. “The problem is that even some dentists may insist on protecting their turf. However, there are more than enough patients with sleep disordered breathing. Even if all we treated were the CPAP-intolerant patients, we would be very busy.”
The patient has had several follow up visits with Dr. Farah and Dr. Smith and reports remarkable improvement in terms of his symptoms. He reports that his day time sleepiness (which was affecting his work performance) has improved dramatically and his wife is happy because he no longer snores. Objective resolution of his OSA was determined with a repeat sleep study several months after the patient was at a stable distance on his oral appliance. His went from moderate OSA before the appliance to normal after the appliance and is very satisfied with his treatment.
Relationships and Communication
The key to forging solid working relationships with physicians is treating patients successfully, but how does a physician meet a qualified dentist in the first place? In Dr. Farah’s situation, he contacted representatives from SomnoMed (makers of The SomnoDent appliance) who put him in contact with Dr. Smith.
Once contact is made, the rest depends on results and communication. Dr.Smith sends update letters to all the physicians he works with. Success breeds success, and correspondence keeps all parties up to date. “It is incumbent on me to let them know how we treated the patient and what is going on with him,” says Smith. “If I never get back to Dr. Farah and let him know what we did with the patient, he can’t let the PCP know.”
Building trust among physicians often starts with sound research. These days, the literature backing up oral appliances is mounting. And with the development of the SomnoMed MATRx (pending FDA approval), physicians who are still unsure will be able to have confidence in the efficacy of the SomnoDent. SomnoMed MATRx (pending FDA approval) “is analogous to a CPAP titration. For the first time, we are providing a means of predicting whether patients are suitable for oral appliance therapy. If they are, we can help determine optimal protrusive distance for their SomnoDent once they return to their SomnoMed dentist for further titrations” says Ralf Barschow, CEO of SomnoMed.
Clinically Validated Solutions
When sleep physicians send patients to Kent Smith, 98% of the time they rely on him to choose a particular brand of oral appliance. Smith uses several different kinds of appliances in his practice. Smith does, however, consider the SomnoDent from SomnoMed as his appliance of choice. “That is my favorite,” he admits. “I don’t have stock in the company or any financial stake in it, but for me it has proven to be my go-to appliance in most situations.”
It all comes down to: will patients actually use it? “I want the appliance with the best compliance, and through trial and error, that one appears to be the SomnoDent,” says Smith. “I would hope that at some point in the near future, all of the different health professions will learn to work together to truly get the patient treated, without being as territorial as we seem to be right now. If we honestly have the patients’ best interests in mind, we will educate them about all of the different therapies, and we will find what is best for each patient.”
The SomnoDent® is a custom-designed oral device that has been the subject of numerous stringent, independent, evidence-based studies that satisfy the need for safe and effective OSA treatment. The SomnoDent has a number of design features such as a streamlined design with minimal bulk, which maximizes lingual space, reduces gagging, and offers a comfortable treatment with a compliance rate of over 87% all night (Am J Respir Crit Care Med Vol 163. pg 1457-1461, 2001).
Facilitating the physician/dentist relationship such as the one between Dr. Kent Smith and Dr. Nabeel Farah is something SomnoMed takes very seriously. Their presence at the annual Associated Professional Sleep Society Meetings is where many of these introductions take place. SomnoMed Dentists are who attend meet with oral appliance friendly physicians.
Respect for oral appliance therapy remained high at last year’s APSS meeting in Minneapolis, echoing an inevitable trend that only seems to get stronger. With SomnoMed’s continued efforts on creating symbiotic relationships between physicians and dentists, more OSA sufferers will be treated. Ralf Barschow, CEO of SomnoMed says “Patients are confident they are receiving the highest quality oral appliance treatment out there. That confidence brings them back into treatment, which improves compliance—and improves their lives.”
Kent Smith, DDS, founder of SleepDallas and 21st Century Dental, Dallas TX