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    How to stop an epidemic: The rise of sleep apnea

    Sleep disorders are on the rise—some experts even call it an “epidemic” in the united states. And while Cpap machines are still the most commonly prescribed solutions, oral appliances are gaining steam as treatment options. So how is dentistry adapting to this revenue stream—and how is dentistry saving lives?

    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.

    Related reading: Study finds obstructive sleep apnea causes complications in dental implants

    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.” 

    Trending article: A good night's rest: Why sleep apnea treatment is critical

    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.” 

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    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.


    Next: How treating sleep apnea can save lives—and increase your revenue.


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