You suspect OSA. What next?

You suspect OSA. What next? By Dr. Kate Christian Much like we screen patients for oral cancer, it is our duty to screen patients for sleep related breathing disorder (SRBD) as part of our comprehensive and annual exams. In fact, in 2017 the ADA put out a policy statement turning this into the standard of care. Some common surveys for this are the STOP BANG and the Epworth Sleepiness Scale. In addition to obesity and hypertension, dentists are able to spot other risk factors such as retrognathia, scalloped tongue, very narrow arches and enlarged tonsils. However, once you suspect SRBD, what should your next step be? I’ve seen suggestions of either pulse oximetry or home sleep testing out of your office. This method can be full of legal and ethical pitfalls. These tests are not as accurate as an in-lab sleep study (PSG) and often under-report the patient’s condition, therefore I believe they are not the most appropriate first step. Additionally, if someone tests negative on a home screening test at the dentist, it is then very hard to get them to move forward to the PSG. If they do suffer from SRBD, you could be left open to liability for failure to refer; worse, if you make a diagnosis of primary snoring based on one of these tests you are now practicing medicine. The ADA policy states, “These patients should be referred, as needed, to the appropriate physicians for proper diagnosis.” Where to refer is a common question: you have three main options. You can refer to their primary care physician. While some medical insurers require this, it is often inefficient and may be another barrier to getting a study. Unless it’s required or the patient has a very close relationship with their PCP, I would skip this step. Your next choice is an ENT. This is a common first referral if the patient is a child. Some ENTs will take out tonsils and adenoids on symptoms alone, but most will require either a history of chronic infections or a positive sleep study. Your final referral choice would be directly to a sleep doctor. Ideally this would be someone who could meet with your patient face to face (either in person or via telemedicine) before creating an official diagnosis. This fulfills even the strictest insurance criteria and makes sure that the full scope of sleep disorders are considered. Reach out to your local sleep doctors and get their referral form. A simple fax with a summary of what you are seeing and their Epworth and STOP BANG scores is all that’s needed to get the ball rolling. We’re lucky in King County that we have numerous resources, from big hospital-based sleep clinics to independent full sleep labs, to full telemedicine options. If you need help finding resources in your area, I can work with you to find options near you. An annual screening with a STOP BANG and just a few questions is going to make sure you are practicing to the current standard of care and will save lives! You’ll be amazed at the transformations you will see in people’s attitude/demeanor/general health and wellbeing after they’ve started getting a good night’s sleep. Performing a STOP BANG test and providing a referral are simple steps you can take to make a major impact in not only your patient’s sleep, but their lives. Suddenly you’re not “just” their dentist…you’re the person who improved their quality of life.

KATHARINE CHRISTIAN DMD Diplomate of the ABDSM

Let us help your patients with Sleep Apnea Dedicated sleep practice We deal directly with insurance companies Complex and hard cases such as Oral Medicine and TMD are our specialty