How Collaborative Care for Sleep Disorders Could Be Better

When physicians and dentists communicate well with each other, more sleep apnea patients are diagnosed and adherent to therapy.

By Jennifer Q. Le, DMD, DABDSM, CPCC

The following story is an example of what I have seen many times. It’s from a sleep disorder patient who came to me in despair. Ready to do anything to feel better, she sought consultations and self-help remedies before coming to me.

“My story began almost 5 years ago. I felt weak and tired, and I could not tolerate the stress in my job as a nurse. I would wake up with my heart racing and struggle with anxiety day after day. I went to my medical provider, who sent me for my first sleep study and eventually told me that I had mild sleep apnea. She advised me to call the sleep study provider for a CPAP machine. The CPAP blew air into my stomach, which led to painful bloating and horrible gas. Seeking alternate solutions, I found a dentist who made oral appliances, but the cost was prohibitive, and my insurance plan did not cover it.

I continued to suffer with my condition, untreated, for nearly 4 more years. I left my job, which I loved, because I felt I could no longer handle the demands. My day-to-day living situation had become nearly unbearable. I would wake up feeling like I had the flu without the fever. I would quietly dread any outing. I would cry for no reason and thought I was losing my mind.

My husband asked me to see a sleep doctor, and in my search, I found Dr Le, who turned out to be exactly what I needed. The sleep doctor I had seen previously had looked at the results of my first sleep study and insisted that I did not have sleep apnea. On Dr Le’s advice, I underwent another sleep study, which showed moderate to severe sleep apnea. Dr Le made my oral appliance almost a year ago now. In the past year, I have felt better than I could ever have expected. I now have a life I look forward to living, which all stems from a simple oral appliance and a knowledgeable, supportive doctor.”

T.J.

This is not a story about me being a hero. It is a story of why collaborative medicine is both crucial and severely lacking. I played one role in a larger picture. It is my hope that this story will motivate others, both inside and outside the medical community, to strive for a higher standard of communication and teamwork in the co-management of sleep-related disorders.

Communication

In sleep medicine, we talk about collaborative care when managing obstructive sleep apnea (OSA) patients alongside our medical colleagues. Different organizations form “collaborative working” partnerships, which can take on a variety of forms. Options range from informal networks and alliances to joint delivery of projects to full mergers. Since 50 to 70 million Americans have sleep disorders,¹ it is more important now than ever to develop a wellness management team based on one shared definition of a successful patient outcome. The single most crucial element of collaborative care is communication.

At the recent Sleep Medicine Trends 2020 conference in Tampa, Fla, organized by the American Academy of Sleep Medicine (AASM), I listened to more than 500 medical doctors as they shared their questions and concerns for the management of alternative therapies for OSA with their dental colleagues. The dialog illuminated a growing opportunity for both the medical and dental communities. As the public increasingly begins to recognize the central role of sleep in overall health, physicians and dentists can expect more patients to turn to their medical providers for remedy. The necessity for clear standards and best practices for the diagnosis and treatment of sleep disorders has grown more apparent than ever before.

As studies continue to support the effectiveness of oral appliance therapy (OAT) in the management of OSA, physicians are referring their patients to their dental colleagues for guidance in selecting alternative therapies. Several questions arise. How can a physician best determine where to send patients and what to communicate to the dentist? What diagnostic follow-up procedures are most essential to a successful patient outcome? What role should the medical provider continue to play in the patient’s management and care? How might factors such as cost and insurance coverage influence patient compliance and follow-through? How can both physician and dentist remain “in the loop” about important developments in the patient’s care?

The importance of collaborative efforts is self-evident when we accept that sleep-breathing disorders arise from disease processes that most often involve comorbidities. They have been linked to an increased risk of conditions such as heart disease, diabetes, obesity, depression, anxiety, and countless others. Our physician colleagues must be able to trust that their patients are under management, referring back to the dental sleep medicine practitioner. They need to follow up with objective testing and further assessments of clinical findings to address the patient’s other medical comorbidities.

Co-Management

Early in my practice of dental sleep medicine, I found myself quickly humbled by the complexity of the patients who were presenting to me. There was no question that I needed to attain the most unbiased education via stringent programs to appropriately equip myself for the management of sleep disorders. Equally, I knew I would need my entire team to continually improve their education and their professional peer networks, developing key mentoring relationships in the domain of sleep medicine and OAT.

More often than not, patients sit in front of me with little to no clear understanding of their condition or the consequences of nonadherence. The patients are surprised by the effects of insufficient oxygen to their bodies and minds. They present with a list of medications, diagnoses, and outdated sleep studies, frequently frustrated and emotional about the lack of control they feel they have in their personal and work lives. More importantly, they feel they were not given options or given conflicting professional opinions.

Over the past 10 years, I have heard numerous physicians express concerns with home sleep test (HST) findings, which can underdiagnose the severity of a patient’s OSA and result in a misdiagnosis and treatment recommendation of OAT. Referring a patient back for follow-up sleep testing by a physician-monitored lab can be crucial in determining whether the patient’s OSA has been adequately managed. When physicians develop partnerships with dentists who they feel will communicate with them, this reduces the likelihood of a common “recommendation” that patients often hear: “You can just ‘Google’ a dentist that makes oral appliances.” (I doubt that same physician would suggest a patient requiring three antihypertensive medications “Google” a cardiologist.)

Dentists are familiar with patient education, through the ongoing practice of explaining disease processes and therapies. We are accustomed to using referral pads to communicate our treatment recommendations with other healthcare providers and in asking for specific assistance in the co-management of a disease process. Yet in collaborative management of sleep-breathing disorders with our medical colleagues, many of us seem to forget how to communicate effectively. We need to communicate back to our medical colleagues the progress of the sleep-breathing disorder and ask their assistance in determining whether the therapeutic outcome is sufficiently managing the breathing. Dentists may refer a patient for a sleep study as deemed appropriate by their physicians who are familiar with potential comorbidities. Qualified dentists should be able to communicate to their medical colleagues the treatment protocols they follow in the management of OSA, ask the physicians to clarify their preferences with regard to when they would like to reassess the patient, and what information they would like included in follow-up communications. Physicians can communicate, via letters of medical necessity, their preferences for mutual patient management.

Patients vary in their anatomical structures, parafunctions, psychosocial needs, and preferences in what they perceive as therapies they can tolerate. Understanding the various types of custom fabricated oral appliances and their specific benefits and limitations allows for greater predictors of appliance success in managing OSA. The process of fitting an oral appliance involves multiple office visits involving patient education and reinforcing critical patient behaviors such as oral hygiene routines and usage of AM/PM fitted repositioners. Just as patients present to their medical providers with comorbidities, these patients also present with a plethora of existing dental conditions and areas that must be closely monitored for the stability of the patient’s dentition as well as the long-term stability of the oral appliance therapy.

Finding Compatible Colleagues

I have often heard physicians express confusion in the cost differences amongst dental providers for the management of OAT. Not all appliances are created equal and not all styles of management are the same. It is important for a dentist to communicate what fees include (for example, follow-up visits, working with various types of appliances, inclusion of AM/PM positioners, warranties, and patient education). The cost of dental care for sleep disorders can vary significantly from one dentist to the next. This is due to mechanical variations in the design of the appliance itself, anatomical variations from patient to patient, and variations in parafunctions such as bruxing, jaw-clenching, and other associated movements. Follow-up care is vital, but often inconsistent. For instance, an appliance may initially show promising results, but then require additional adjustments a few weeks later. The level of dental sleep medicine training and experience in case management varies amongst dentists as well. Physicians alternately have the option of working with dental sleep medicine practitioners who are in-network with medical insurance, which is a more standardized fee.

The American Academy of Dental Sleep Medicine (AADSM) and the AASM have authored joint statements regarding best practices, guidelines, and standards for the management of OSA.² The AADSM also outlines the didactic content of its mastery program, giving the referring physician an idea of what a “Qualified Dentist” designation means. The American Board of Dental Sleep Medicine (ABDSM) oversees the credentialing process for dentists who are qualified in the field of sleep medicine. Any physician can reference the AADSM website to locate a qualified dentist by zip code (available at aadsm.org, then navigate to “For Patients,” then “Find an AADSM dentist”). Many physicians are unaware of this resource—as I recently confirmed in Tampa when I polled the physicians in the room.

Jennifer Q. Le, DMD, DABDSM, CPCC

Dentists who are committed to the practice of dental sleep medicine have access to multiple avenues of higher training and credentialing. Dentists can also consider joining nonprofit organizations such as the AADSM, thereby giving them access to guidelines, standards, research, and mentors. Physicians who find limited access to qualified dentists can share the AADSM’s resources with dentists in their local communities and create partnerships with credentialed dental sleep medicine practitioners.

The seriousness of sleep disorders, and their central effect upon all areas of patient health, cannot be overstated. The body cannot heal itself from illness or injury without regenerative sleep. Lack of sleep contributes to systemic conditions, leading to a chain of effects that cause overall health and quality of life to deteriorate. Patients and their physicians often do not recognize the role of sleep as an aggravator of other conditions until obvious symptoms appear. Treatment of sleep disorders necessitates a multi-layered management approach.

Physicians and dentists must work together to co-manage patients by screening, making appropriate referrals, and establishing clear communication protocols to help guide sleep-deprived, frustrated patients toward therapeutic options that best meet their needs. The key to a cohesive treatment plan is clear communication between providers on a patient’s wellness team. When providers work collaboratively, this empowers the patient to make well-informed decisions on a modality of therapy that they will be most compliant with resulting in better management of their sleep-disordered breathing.

Jennifer Q. Le, DMD, DABDSM, CPCC, is a dentist at Wake Dental Sleep in Raleigh, NC.

References

1. Sleep studies. National Sleep Foundation. Available at https://www.sleepfoundation.org/articles/sleep-studies.
2. Policy statement on the diagnosis and treatment of obstructive sleep apnea. American Academy of Sleep Medicine/American Academy of Dental Sleep Medicine. 7 Dec 2012. Available at https://aasm.org/resources/pdf/aadsmjointosapolicy.pdf.

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