CPAP is the most commonly offered treatment, and while it is effective, of great concern to clinicians is how few people are able, or willing, to use it.
A large percentage of the patients who can’t, or won’t use CPAP do not then access any other treatment for their OSA and are consequently at risk for health problems - as well as being a danger to themselves, and others, on the roads and in the workplace.
A recent study (1) from a major sleep clinic in the US confirms that large numbers of people diagnosed with significant OSA, and offered CPAP, either refuse to consider it, or are unable to adhere to it. Of 616 consecutive patients diagnosed with OSA and offered CPAP, 260 (42%) had evidence of some degree of adherence.
Of the remaining 356 patients not willing, or able to use CPAP, very few were referred for other treatments. Only ten of these patients completed surgical procedures and nine were referred for oral appliances. The authors were extremely concerned that nearly half (46%) of all patients with diagnosed OSA are not being actively treated for this condition.
According to the authors:
“Despite the known sequelae of OSA, clinicians are not treating a significant percentage of patients with diagnosed OSA. Those who fail to tolerate CPAP therapy are unlikely to be referred for additional treatment. Furthermore, there are minimally invasive options, such as oral appliances, that have been found to reduce symptoms of OSA in a manner similar to that of CPAP” .
To highlight the extent of the problem the authors compared the treatment of diabetes to that of OSA, as the incidence of both are similar.
The authors states:
“Both conditions contribute to long-term patient morbidity and decreased quality of life, and both can lead to increased mortality. Despite these similarities, according to studies only 1.2% of diagnosed diabetic patients do not manage their diabetes in some manner, while many patients in this study do not have documented treatment of their OSA”.
To address this specific problem the American Academy of Sleep Medicine produced recent guidelines (2) designating that specifically defined oral appliances need to be offered by sleep physicians to patients diagnosed with OSA, particularly if not using CPAP.
While the effectiveness of CPAP may be better than oral appliances, studies show that treatment outcomes are often similar due to the far better compliance with oral appliances.
A recent study (3) objectively measured compliance with oral appliances using embedded sensors. Of the 51 patients in the study 82% were using their appliance for an average of 6.6 hours per night at three month follow up.
There are hundreds of thousands of Australians diagnosed each year with OSA with the majority unable to use CPAP and unaware of oral appliances. There are many more who don’t even know they have OSA.
The new AASM guidelines specifically state that only a trained dentist can provide oral appliances.
This represents a great opportunity for dentists, with many rewards that come from:
Changing people’s lives with regard to quality of life and health
Enjoyable, far less physically demanding treatment than general dentistry
Increased practice revenue
If you have an interest in providing this service the first step is to choose an appropriate training program.
In choosing a program I recommend being cautious of courses put on by distributers of specific appliances, and groups selling equipment, much of which may not be necessary.
While there are courses in which the main focus is on theory, it is important that a program places an emphasis on demonstrating all the clinical steps on actual patients, as well as providing systems for diagnosis and working with a sleep physician.
Finding a mentor with experience can also be a source of great support.