In June of 2021, much of the obstructive sleep apnea (OSA) community was upended by the recall of continuous positive airway pressure (CPAP), bilevel positive airway pressure, and mechanical ventilator devices by Philips Respironics. This voluntary recall occurred in the sleep industry alongside the COVID-19 pandemic, which brought its own series of supply chain disruptions, creating a “perfect storm” for the CPAP industry. One year later, availability challenges persist for CPAP users, and this has been further exacerbated by safety issues with magnets that have affected medical devices in the recent CPAP Philips mask recall.
Oral appliance therapy (OAT) is a proven, effective treatment option for OSA that should be discussed with all patients. This is even more true during the CPAP shortage, as oral appliances are readily available and can be delivered in approximately three weeks. OAT can be used to treat all levels of OSA severity and has been proven to reduce apnea-hypopnea index and improve OSA co-morbidities, such as blood pressure, fatigue and fatigue-related accidents, and cardiovascular mortality. OAT is covered by Medicare and most commercial insurances.
When sleep physicians refer patients for OAT, one of the most important aspects to consider is clear communication and collaboration with dentists who have the training necessary to offer a continuity of optimal patient care.
What is a qualified dentist?
Dentists are well-versed in oral biomaterials to manage dental occlusion and masticatory function. However, treating OSA requires additional education to understand sleep physiology and the pathophysiology of sleep-related breathing disorders. The dentist should be well-versed in the mechanics of oral appliances to ensure the appropriate appliance is selected for each patient. Furthermore, the dentist must have demonstrated proficiency in clinical strategies to minimize and manage any potential side effects. When referring patients for OAT, sleep physicians should seek qualified dentists who have this appropriate training. The dentist should understand the role of collaborative care with other healthcare providers.
The American Academy of Dental Sleep Medicine (AADSM) has defined qualified dentists as AADSM Qualified Dentists, American Board of Dental Sleep Medicine (ABDSM) Diplomates, and ABDSM International Certificants. These designations all require the successful completion of all or certain components of the AADSM Mastery Program.
The AADSM Mastery Program is a comprehensive, unbiased, evidence-based training program offered by both the AADSM and accredited dental schools. The AADSM Mastery Program is divided into two parts. Mastery 1 is approximately 50 hours of didactic and clinical education and provides a foundational overview of the practice of dental sleep medicine. Mastery 1 students are required to have a valid dental license, maintain professional liability insurance, and pass a standardized examination administered by the AADSM and are awarded the designation of “AADSM Qualified Dentist.”
Dentists who seek additional training in dental sleep medicine continue with the AADSM Mastery Program and take Mastery 2. Mastery 2 is 60 hours of didactic and clinical education. As part of the program, dentists are required to complete a series of clinical competencies. Students who complete the entire program are eligible to sit for the certification examination offered by the ABDSM.
Dentists who successfully complete the ABDSM examination are recognized as ABDSM Diplomates. The ABDSM takes many steps to ensure that ABDSM Diplomates have achieved the gold standard of excellence in dental sleep medicine. The ABDSM uses a testing model built on three principles: test standardization, criterion-based testing, and equitable difficulty over time. The examination is developed in conjunction with a testing company to ensure the ABDSM is utilizing best practices and complying with recognized professional standards.
The ABDSM tests on a standardized knowledge base organized into core content areas. All candidates are tested using the same proportion of questions from each content area, and the content focus does not vary from one applicant to another. The ABDSM’s examination is criterion-based, which is a proven model for delivering accurate, fair, and consistent results. The ABDSM compares each candidate’s test performance to a predetermined standard rather than using arbitrary standards that are not based on research (for example, 60%-70% correct answers) or normative standards (e.g., grading on a curve). This predetermined standard is set by the ABDSM to establish the foundational competencies an individual must have to provide excellent patient care.
The ABDSM’s criterion-based testing approach means that all candidates are held to the same standard of competence. Examination content, by nature, consists of some material that is more difficult than other materials. The ABDSM’s test development methodology includes a measure of the difficulty of each question that could appear on the exam. The minimum passing test score may change from exam year to exam year based on the aggregate difficulty of the questions included in the exam. Unlike normative pass/fail standards that alter the passing point based on the performance of different groups of candidates, the model used by the ABDSM only adjusts the passing criteria based on the inherent difficulty of the exam itself. This mitigates concerns about skewed test results over time due to “easier” or “harder” versions of the test.
Finally, the ABDSM requires maintenance of certification to ensure that Diplomates remain current in their knowledge of dental sleep medicine. The ABDSM requires Diplomates to earn CE on an ongoing basis and verifies this through an annual CE audit process. As such, Diplomates need to earn 25 credit hours every two years.
Competencies of a qualified dentist
AADSM Qualified Dentists and ABDSM Diplomates have demonstrated competency in the following areas:
- Basic sleep physiology, including the pathophysiology of SRBD
- Dentist and team member roles in managing SRBD
- Evidence-based therapeutic options and an awareness of emergent treatments and technologies for SRBD
- Comorbid nature of OSA and temporomandibular disorders and treatment effects from OAT on the temporomandibular joint (TMJ), dental occlusion, and related structures
- Screening and risk assessment of SRBD
- Comprehensive, DSM-focused medical/dental examination and history, including relevant imaging
- Understanding objective sleep testing and other complementary assessments
- Gathering and synthesizing information from sleep medicine patients to appropriately screen patients and establish a treatment plan, including: OA selection, device fitting and calibration, long-term care, and management of potential side effects. These decisions should take into consideration patient values and preferences.
Learning and Improvement
- Clinical practice and decision-making guided by evidence-based principles
- Continuing education
- Reflective practice and personal growth
- Identifying opportunities to standardize, simplify, and improve quality of care
- Ethical principles, including billing and coding practices
- Accountability and team training with adherence to applicable state and federal laws and regulations
- Subjective, Objective, Assessment, and Plan (SOAP) note documentation, maintenance of treatment records, and protection of patient information
- Collaborative model of interdisciplinary care
- Informed consent
Interpersonal and Communication Skills
- Effective patient communication
- Barrier and bias mitigation
- Interprofessional and team communication
Finding a qualified dentist
The AADSM maintains a list of AADSM Qualified Dentists, ABDSM Diplomates, and ABDSM International Certificants at www.aadsm.org/oat_for_osa. This web page also provides additional resources about OAT including evidence briefs, template referral forms, and a free CME webinar providing more information about how OAT and working with a qualified dentist can help improve OSA outcomes.
Mitchell Levine, DMD, MS, D.ABDSM is the president of the American Academy of Dental Sleep Medicine and a diplomate of the American Board of Dental Sleep Medicine. Dr. Levine is also an associate professor of orthodontics at St. Louis University.
Jennifer Le, DMD, D.ABDSM is the president of the American Board of Dental Sleep Medicine. Dr. Le has a private practice in Raleigh, North Carolina dedicated to dental sleep medicine.
Source: Sleep Lab Magazine Sept/Oct 2022