In a recent position statement, the American Academy of Sleep Medicine and the American Medical Association argue that only licensed physicians are qualified to order and interpret home sleep apnea tests.
In May of this year, the American Academy of Sleep Medicine (AASM) got the American Medical Association (AMA) on board to try to block dentists and other non-licensed-physician healthcare practitioners from using home sleep apnea tests (HSAT) to diagnose obstructive sleep apnea (OSA). According to the AASM article announcing its advocacy of this initiative, the position statement is meant to “defend the scope of practice of physicians and advanced care providers who manage patients with obstructive sleep apnea from encroachment by dentists and other practitioners, who are not trained or qualified to diagnose a medical disease.”
So how long has this resolution been in the works? AASM president Douglas Kirsch, MD, says it has been on their radar for quite some time. “In recent years, questions about the dentist’s role in the treatment of sleep-disordered breathing have been raised by dental boards in states such as Texas, Georgia, and Colorado,” he says. “The AASM has been working with members in these states, and with their state medical societies, to ensure that dental boards consider the medical perspective when evaluating the scope of practice of dentists.”
Kirsch adds that to make this perspective readily available to both dental boards and medical boards in every state, the AASM developed the position statement and introduced a resolution in the American Medical Association House of Delegates. The AMA declined to comment on this article, referring the reporter to the AASM.
Dentists might be wondering if the resolution is intended to be interpreted that at no time should they be using home sleep testing. Is screening allowed before sending the patient to a physician if the HSAT result is positive? How about titration before sending the patient back to the sleep lab for an efficacy check? Kirsch says no, and that all testing should be done by a licensed physician.
“It is the position of the AASM (and the AMA) that ‘ordering and interpreting objective tests aiming to establish the diagnosis of OSA or primary snoring constitutes the practice of medicine.’ Only a medical practitioner who is licensed to practice medicine should use a home sleep apnea test to evaluate a patient,” he says. “Therefore, a home sleep apnea test should not be used by a dentist as part of a clinical evaluation.”
Kirsch notes that despite their position, it’s important to emphasize that the AASM has no authority over the practice of dentistry.
Keith Thornton, DDS, ABDSM, a Dallas, Texas-based dentist and inventor of numerous devices that treat sleep-related breathing disorders including the TAP, says, “I think it is sad and unfortunate that the AASM has opted to pursue their approach on sleep related breathing disorders (SRBD) by legally accusing dentists of practicing medicine without a license. Certainly, their action has upset many dentists and the House of Delegates of the American Dental Association for advocating a restriction on the scope of the practice of dentistry. Professional practices, including medicine and dentistry, are regulated by state law, which is ultimately determined by state legislatures.”
When asked if advocating in this way will alienate physicians from dentists, AASM’s Kirsch says professional collaboration between dentists and physicians is most effective when their roles and responsibilities are clearly defined. “The AASM encourages qualified dentists to work closely with a board-certified sleep medicine physician at an AASM-accredited sleep center to provide high quality, patient-centered care for individuals who have sleep-disordered breathing,” he says.
The outcome of the position statement desired by the AASM, says Kirsch, is for every patient with suspected OSA to be accurately diagnosed and effectively treated. He adds, “Achieving this outcome will require effective collaboration between sleep physicians, other licensed medical providers, and qualified dentists, each practicing within the boundaries of their scope of practice to provide exceptional patient care.”
Some clinicians advocate from a different viewpoint. “My recommendation,” says Thornton, “would be for the AASM to recruit the 180,000 practicing dentists to work together to screen and treat patients with uncomplicated SRBD….Patients need all the help they can get in managing this public health problem.”
Dillon Stickle is associate editor of Sleep Review.
It seems shortsighted and not patient-centered to limit who can identified one of the millions of people at risk of this life-threatening condition.
The focus really needs to shift away diagnosis to effective treatment of OSA.
The use of a properly fitted oral appliance is clearly one appropriate therapy.
Read my series of blog posts on the end of sleep medicine for more on this topic.
I applaud Mr Grandi for taking his position. In my professional opinion, there is absolutely no reason why healthcare providers who are trained in OSA, screening techniques and appropriateness of HSAT should not be able to order this simple and valuable test. The next step, of course, must me that the test is interpreted by a boarded sleep physician who can partner with their dental colleague to guide therapy.
Are we not trying to tackle this epidemic? Why the AASM would continue to maintain their archaic and disappointing position befuddles me and I have voiced my concerns about this to several board members.
While it is true that dental sleep training and sleep dentistry have been referred to as “The Wild Wild West” implying that less than rigorous training, supervision and careless practices are out there but we all know of training programs based on rigorous didactic and thorough practical experience are out there as well. And we all know of the charlatan courses promising the dentist unrealistic and undeliverable expectations. There are many well qualified and well trained sleep dentists out there who we should embrace because there simply are not enough sleep physicians in the US to put a significant dent in this epidemic.
What the AASM should be doing is not putting up road blocks to effective diagnosis but rather they should work with dental sleep providers and other healthcare providers in a collaborative manner to solve this problem.
It is time for providers across all areas of expertise weigh in on this because the well trained sleep dentists (and patients) are being inappropriately restricted from effective practice (and care).
Well said Dr. Surkin. You are absolutely correct.
Its hard to justify that dentists that are boarded by the AADSM which was under the AASM would not be considered sufficiently trained to order and interpret an HSAT, at minimum for assessment of treatment outcomes. If the AASM were to carve out a role for boarded dentists, it would increase the number who go through the rigorous studying and testing.
The AASM is employing a self-serving initiative to protect it’s existence. They (AASM) are needlessly competing with the AAST and APT by implementing a credential of their own – RST. This is just another ploy to isolate and control sleep medicine to physician’s only.
From one who deals with OSA, I wouldn’t go to a dentist or orthodontist for treatment or diagnosis. I wouldn’t go to a sleep specialist for dental care. That’s why we have specialists
This is totally ridiculous. There is no one down the throat more than a dentist. A dentist never interprets a sleep study. That is done by board certified physicians which is right. And many physicians want to fabricate the oral appliance, which most have no experience in doing. Dentists do a great job of evaluation get the patient and then ordering a HST if necessary. This is done with a snoring scale and a daytime sleepiness scale. Dentists save a lot of lives by practicing dental sleep medicine in their practices. Everyone knows that physicians automatically prescribe Cpap and the compliant rate on a Cpap is less than 50%. A dentist can keep those patients from falling through the cracks and help them with their sleep apnea problems.
The main reason physicians do not want dentists ordering HST is a money issue. They cannot bill for the study themselves. The physician feels like he is losing revenue. I have worked with both in my professional career and the dentist does a better job of managing his patient with sleep apnea.
Let’s do what is best for the patient. Both parties are qualified to help their patients battle sleep apnea. And I know some that work together. What the AASM and the medical board is doing is totally wrong and mostly about lost revenue.
Why lump INTERPRETING a HSAT together with ORDERING an HSAT for a patient suspected of having OSA? Dentists can prescribe opiates for pain management and they can’t screen and order a diagnostic test for a serious and deadly chronic condition? Dentists that I know don’t want to make a DIAGNOSIS, they want to ORDER a simple diagnostic test and let an MD do the DIAGNOSIS. The AMA and AASM need to get their priorities straight and think of their physician members and their collective guiding maxim: Primum non nocere – DO NO HARM (to the patient, not the earning capability of your members).
This can’t work! I have told patients they need a sleep study, and some say their plan requires them to see their PCP first.
And in 2 recent cases, the primary care provider said my patient didn’t need a study.
Both were in their 60’s, loud snorers, and etc had had heart attacks.
I ordered a study by myself, again the proposed rules, and the sleep doc diagnosed severe OSA, and cardiac issues.
I sent them both to their cardiologists with the sleep doc’s report.
I do NOT diagnose, but I have an HST and use it when needed.
I do not work in the US so I do not really know it’s system, although I suppose these problems are similar everywhere.
I think non-trained dentists should not be cleared to perform this type of home screening tests and even discuss therapeutic options. But clearly, non trained physicians should not either. I do not see why we should not add every health professional available to identify all these people who is at a great risk.
Even primary care physicians should screen for sleep apnea, not only by means of questionnaires but also home testing.
Let’s cooperate and not fight against each other. We will get better results. Let’s focus on regulating the quality of the training and certification.
To say this ruling is to improve patient care is ridiculous. The goal, under the guise of improving the health of this nation, is nothing more than protection of income.
Both physicians and dentists have abused the field of sleep in an attempt to gain more income.
The person being hurt is the patients in need of care. The most recent estimate of need is one billion plus people.
Needless suffering is not what medicine should be protecting.
CPAP is a failure far more often than a success and requires considerable expense. After 10 years few initial users continue.
Is this a treatment?
How can medicine ask dentists to ignore their 8 years of medical training? Would you rather have an medical auxiliary with far less training be allowed to practice sleep medicine?
The answer is…we should work together, the magnitude of this disease process needs more participation of dentists!
The tipping point has already been reached and physicians can no longer control the delivery. Patients are demanding more and better care.
The action is like the little boy putting his thumb in the dike.
Dentistry is IN sleep treatment………….. all that medicine now has to do is assist the patient in getting into a treatment that they will follow.
Given that most dental providers see patient regulary it is unfortunate that the AASM is not seeing the opportunity here. Finally, if the AASM were to FOLLOW their own guidelines this would no longer be a discussion.
I am a very satisfied Inspire patient who experienced both CPAP and an oral device prescribed and manufactured by a dentist and both measures were unsuccessful treating my Obstructive Sleep Apnea. In fact, the dentist never showed any regard for sleep study data. I stand on the side of letting practitioners specially trained in this field be those who treat patients.
Here is a copy of an email from a company recruiting dentists to perform sleep tests to diagnose OSA.
From an email from “Dental Sleep Masters” recruiting dentists
Question#5- How can I justify the expense of your program?
Answer- I usually answer this question with a question of my own. If I could give you a business plan that led to as many as 20 patients a month –or more—all of whom will be reimbursed an average of $3,000 dollars each, what would that be worth to you? What if I told you this system will continue to grow and grow for years, what would it be worth then? The simple reality is, the price for what you get is a steal. When you couple that with the amazing financing program (no payments for 3 months while you are setting up your program and really low interest rates for 36 months after) we have been able to put together, you’re able to get full access to the
entire DSM program for close to three thousand dollars per month. That’s less than two oral appliances. Plus one of our new services literally hands you patients. As we mentioned above, Brandon Hedgecock was literally handed 35 patients within his first month of joining –all of whom are approved for full payment at $4000 or more (and is now set up for years). What would that be worth to you?
I see so many CPAP failures (ie. non-compliance), and all their sleep physician says to the is “wear your CPAP”…he offers no alternative treatment advice such as an oral appliance. So how does the AASM/AMA approach this 40-50% failure rate?? Just let the patients die???
This is a subject that I’ve been reeling about for the past several years now since I changed careers and starting my life over at the age of 27 when I experienced a “life changing, limb threatening” skiing accident where I nearly lost my leg, ended up having ten major knee surgeries, didn’t know if I’d ever walk again and couldn’t for over two years, then a total knee arthroplasty was completed in 2010 and if it weren’t for the compassion, competence, personal understanding, kindness, faith in me, and exceptional skills as an orthopedic trauma surgeon who entered into the healthcare industry for all of the right reasons just as I did, I wouldn’t be alive today. I state this because when I decided to make the drastic career change because I realized that I could now put myself in the patients shoes and see both ends of the spectrum with the utmost clarity and If it weren’t for me taking charge and being my own advocate as well, I’d be in big trouble today but I learned all of these things and understand just how critical it is to be an “out of the box thinker” when it comes to treating each patient as an individual by taking a multifaceted approach and not even thinking about “money” when it comes to doing what is right for the patients livelihood. My father was an experienced Pulmonologist for nearly forty years when I went back to school and became a Respiratory Therapist and a Sleep Disorders Specialist all the while working and learning from my dad sitting in with hundreds of patients during their visits, asking him a million questions, sitting through his talks and learning more about Pulmonary Disorders in an hour with him than I did all throughout school. Upon completion of Respiratory School in 2012, I decided to work for a durable medical equipment company to learn the business end of the field as I knew that after what I had experienced with my own health, I had the ability to truly have an impact on peoples quality of life and the last thing on my mind was dollar signs. I quickly learned that very few of the companies Respiratory Therapist’s had any training in sleep medicine nor did they understand much about Respiratory Care either and although at the time I was not credentialed in sleep, because I cared about people, worked hard, and had great passion, my compliance rate for patients on positive pressure therapy within 6 months was around 85%. I saw a tremendous disconnect between the sleep lab and the dme and a field that was failing miserably because there was no patient management or follow up care done after the titration study when the patient was sleeping in their own bed for longer periods of time throughout the duration of several weeks to even months sometimes. I was scolded because I spent too much time with the patients despite my compliance rate being far greater than any other therapist at this company or dme in the area and the sad part was that I really knew very little about the “other end of the spectrum” which was of course sleep medicine and diagnostic studies for it. Nobody there instructed me on the inner workings of the newer PAP devices, how critical humidification was for the patient, interface fit and seal, or gradual, systematic pressure titrations in order to fine tune the equipment for each individual patient. I had one friend who managed a sleep lab for several years and was a manufacturer respresentative at the time who was really the only kind, competent, honest, person around whom I could trust and was of any help to me at the time.
After ten short months, I got so frustrated with the greed, arrogance, lack of compassion, and downright incompetence of the majority of the company and their crooked ways that I quit and worked full time at a hospital while still working for my dad and doing other independent contract work as well. This was in the summer of 2013 when home sleep testing was becoming more prevalent and I learned a fair amount about it from the rep friend of mine. I knew that if I could help as many people achieve compliance as I did not knowing sleep medicine at the time, I imagined what I could do if I became credentialed in sleep as well and I knew that the only way I could help people and do the job right is if I could figure out some way to do not just the sleep study like everyone else but all patient initiation and management on PAP therapy from start to finish myself instead of doing what nearly everyone else did and sending the patient off to a dme where they were given a 20 minute instruction on how to use CPAP, a brief mask fit, and sent on their way with baseline pressure settings that were far from accurate in most cases due to poor sleep quality during the titration and typically an underestimated study result to boot due to “first night effect” in the sleep center. Long story shorter, I began the business in November of 2013 and put my ideas into place, I did all of my own direct marketing, I worked 80 hours a week for two years, had four jobs at once, but within less than one year, the local hospital sleep lab who’s compliance was horrible, essentially shut down and with the help of a few kind souls including my father, I did what my friend informed me of something nobody else in the state had ever accomplished all the while working three other jobs, taking care of my family, and finally becoming a person I was proud to become and choosing a field that I was meant to be in now.
At the time, Medicare’s local coverage determination stated that my father as a pulmonologist, another boarded sleep physician who we had interpreting some of the sleep studies, and myself as a respiratory therapist and a sleep disorder specialist met all of the qualifications to do what we were doing which was helping hundreds of people and saving the healthcare system millions of dollars. We were then sent a Record from BCBS of Michigan stating that “because my dad hadn’t taken his sleep board exam” despite having been grandfathered in as a Pulmonologist, we could no longer perform or interpret any home sleep studies unless we had a boarded sleep doctor doing so only which was NOT required at the time if you were a Pulmonologist, or a Neurologist. I also had spoken with 5 or 6 different people at each insurance company who stated that we were clear and good to go with what we were doing. Mind you, there were hundreds of family practice providers doing the sleep studies illegally and billing the technical component of them and in some cases interpreting them as well in the state at the time. My dad spoke with the CEO of BCBS who was a family physician at the time and said that they followed Medicare guidelines which we had sent them and the language was clearly stated on our qualifications being accurate. I suspect that this had something to do with politics with the hospital and their deep pockets messing with us and at that point I was furious to say the least. We had to fight so hard just to do the right thing for the patients I wanted to give up I was so pissed off at the time because BCBS also stated on their record that “in March of 2016 you must be accredited with the American Academy of Sleep Medicine” only in order to perform any home sleep studies and at that time I was working on ACHC accreditation in fact 6 months into the application. I had 7 months now to decide what to do and my dad was in the midst of retiring so I chose to restructure everything, pay a fortune for AASM accreditation, complete the 7 month application process, and finally do our site visit in November of 2015 which was rigorous but we passed with two provisions we had to redo and send back in but were finally granted full accreditation as of January 8th 2016, just two months prior to the March deadline and we became the first and still the only AASM Accredited “Independent Home Sleep Apnea” testing company in Michigan and remain among less than ten in the country to this day.
Shortly after I became accredited I had a local dentist approach me and inquire about working together however he was planning on performing the home sleep studies, billing the technical component of the test as a dentist with nobody with any training in sleep medicine instructing the patient on usage of the device, no accreditation obviously, and essentially wanted to us to do what we knew to be highly illegal and aid them in simply scoring the tests for them and getting an interpretation to diagnose sleep apnea. They were then going to give every patient a Mandibular Advancement Device and wanted my dad to write the prescription for it. I couldn’t believe what they were asking I later found out who told them that they could legally bill the technical component of the study which was a dishonest crook I personally knew who made a few thousand dollars during the dental seminar that he spoke at that weekend. I am not the type to rat someone out and after the rigorous, brutal, expensive, tenacious, process that I had just completed in order to achieve what enabled us to continue to conduct business the right way when now many board certified sleep doctors were unable to do these studies at all I was appalled and of course told them no. To this day, however they are still doing these sleep studies and have not been caught yet. I have had several other dentists who have been patients of mine personally and they were honest, advocates of mine, one in particular who tried and failed CPAP a few years prior however I was able to help him become compliant very easily doing things the right way. He was adamantly against MAD’s and said that they caused bad “jaw protrusion” in many cases and I personally have only seen one actually decrease a patients AHI down from 30 to 15 once but ironically there was more hypoxemia with the appliance in versus without it and this patient did develop severe “jaw protrusion” from the MAD and is now compliant on CPAP and is benefiting immensely. There’s more to this story I’ll just say “you reap what you sow.” Every patient that I’ve seen who’s come in with an MAD, I’ve had perform the home sleep study two nights with the MAD in and two nights with the MAD out and ironically (in all honesty out of at least 15 patients) the number of apneas was either higher with it in or identical with the MAD in versus out.
I’m a very open minded individual and after experiencing all that I have with my own health throughout the past twelve years, I’m a firm believer in taking a multifaceted approach and treating each patient as an individual. I nor any physician I work with is certainly not opposed to anyone trying an “MAD” if they’ve tried and failed CPAP first considering it’s the “gold standard treatment” of obstructive sleep apnea and let me tell you that my compliance rate on PAP patients including fixed CPAP, Auto-Pap, Bi-Pap S, Bi-Pap ST, and Bi-Pap ASV has been 100% now for the past 24 months which happened to be nearly 600 patients because I’ve dedicated my life to this field for the past 8 years and I ensure that every one of our patients achieves optimal therapeutic benefit on positive airway pressure therapy as well. This has taken thousands of one on one clinical time with patients and understanding that what works for one certainly does not for all in terms of the manufacturer of the PAP device which I’ve found Respironics to be of immense benefit when fine tuning pressures, observing actual breathing waveforms along with snoring events, airflow limitation, periodic breathing, in addition to apneas, hypopneas, and of course the different types of events as well.
This is a long story I’ve been wanting to share for a long time now and anyone who wants to argue my case with me, I’ll show you all of the proof you need to see that there is a much better way to this and it’s art along with science but also it takes a lot of time, attention to detail, asking the right questions to the patient, and knowing what you’re doing which has taken me years of experience to get to this point and this is simply a system that has failed for years due to everything that I’ve mentioned here and a hundred other stories I could tell you about that have shocked the hell out of me. Thanks for reading if you did.