For those of you involved in the treatment of patients with sleep breathing disorders inclusive of Obstructive Sleep Apnea (OSA), there has been a great deal of activity on the research front to support our optimism that Mandibular Advancement Devices (MADs) are truly a viable alternative to PAP (positive airway pressure).
To reference some of these studies, a useful read would be an article recently published by a colleague of mine, Sylvan Mintz DDS, in Sleep and Breathing (2018) 22: 541-546. Though the conclusions drawn put MADs in a very positive light, reaching this level of achievement in your own practice does not come without obstacles.
Consider the following:
Knowing that patients with OSA were often hard to motivate from the outset to participate in care, and having a gut sense that many I had treated had disappeared, I recently took a look back at my listing of patients who had a MAD inserted between 2014 and 2016. What I discovered was that only slightly more than 20% had been seen in 2017 and 2018.
Though the vast majority of these patients had a sleep study that revealed the efficacy of the MAD before they disappeared, one could only wonder about their current status. Where had they all gone and why?
Concerned by these results, I contacted two colleagues who are immersed in managing sleep-related breathing disorders. Surprised by my results, they did a similar investigation of their patients who had been given MADs between 2014 and 2016.
The results: In one practice only 28% had been seen for reassessment during 2017 or 2018. In the other practice only 25% were seen. Not much better than what I had discovered.
These results certainly were not what we had hoped for, but maybe they should have been expected. In fact, a recent article concluded that the overall long-term non-adherence to MAD therapy in mild-to moderate OSA patients was high. The findings demonstrated an adherence rate of only 32% in long-term (4-11 years) MAD therapy of mild-to moderate OSA patients).
Conclusions and Thoughts
If adherence is poor over time, as suggested by the literature, and we are not seeing these patients consistently to encourage utilization, recheck their health status, and to determine if the appliance is fitted properly and titrated for efficacy (my experience and shared by others for reasons being investigated) then results with MAD may be less than anecdotally reported.
How Can We Do Better?
The use of embedded compliance chips is already in play in several of the MADs available (Dorsal Fin and Herbst). However, unlike PAP monitoring, which is done remotely without patient participation, the chips in the dental appliances must be put into a docking station to determine whether there has been consistent utilization. This puts the onus on the patient to bring the appliance into the dentist’s office.
Unlike PAP surveillance, which can lead to the threat of cancellation of lease payment by the carrier, the MAD has already been paid for. I can’t imagine any insurance carrier will demand that the dentist involved refund the money paid under the insurance contract. (Stay tuned.)
Dental Sleep Medicine oriented software can purchased, which is helpful to track patients that have engaged in MAD treatment. As with all new projects, however, you will need a dedicated employee to assume responsibility for this task, which can grow based on patient volume. Creating incentives may facilitate the success of this effort.
If your volume is sufficient already and/or if you have goals to make sleep a bigger part of you practice, you can do what I did last year: hire a Sleep Coordinator. The role of the Sleep Coordinator is to track patients but also to build relationships with the medical community, and most importantly, gather and put together the necessary paperwork to pursue an insurance-based reimbursement process – which is what the vast majority of patients want.
The bottom line: If you take on these patients you become involved in treating a medical problem that has potentially broad consequences if treated inadequately.
As a result we need to strive to get better at what we do.