ADA policy on sleep-related breathing disorders (2017, amended 2019): screen everyone, fabricate only on a physician's referral

What it says#

The policy is two pages. It starts with definitions: sleep-related breathing disorders (SRBD) are disruptions in normal breathing patterns caused by anatomical airway collapse and altered respiratory control; the common ones are snoring, upper airway resistance syndrome and obstructive sleep apnea (OSA); OSA has been associated with metabolic, cardiovascular, respiratory, dental and other diseases, and in children with cardiovascular problems, impaired growth, and learning and behavioral problems. Dentists, it says, can and do play an essential role in the multidisciplinary care of these patients and are well positioned to identify those at greater risk; the care model is collaborative, with medicine. Custom-made, titratable oral appliances can improve SRBD in adults compared with no therapy or placebo devices, and oral appliance therapy (OAT) can improve OSA, especially in patients who cannot tolerate CPAP. Then the sentence the profession quotes: dentists are the only health care provider with the knowledge and expertise to provide OAT.

The dentist's role follows as a list. Screening is encouraged as part of the comprehensive medical and dental history, looking for daytime sleepiness, choking, snoring or witnessed apneas and for risk factors such as obesity, retrognathia or hypertension; a patient found to be at risk should be referred, as needed, to the appropriate physicians for proper diagnosis. In children, screening through history and clinical examination may pick up deficient growth and development or other risk factors, and a medical or dental referral or evidence-based treatment may be appropriate to treat the disorder or develop an optimal airway. OAT is an appropriate treatment for mild and moderate sleep apnea, and for severe apnea when CPAP is not tolerated.

The fabrication bullet, as amended in 2019, reads: when a physician diagnoses obstructive sleep apnea in a patient and treatment with oral appliance therapy is recommended through written or electronic referral, a dentist should evaluate the patient for the appropriateness of fabricating a suitable oral appliance, and if deemed appropriate should fabricate it, monitor its effectiveness and titrate the appliance as necessary. Consent should review the treatment plan, all available options, the potential side effects of OAT and the expected appliance longevity. A dentist treating SRBD with OAT should be able to recognize and manage side effects, and should monitor and adjust the appliance for efficacy as needed or at least annually; because titration affects the outcome, unattended cardiorespiratory (Type 3 or Type 4) portable monitors may be used by a dentist trained in them to help find the target mandibular position. Surgery is a secondary treatment when CPAP or OAT is inadequate or not tolerated, and a primary one only in selected cases such as concomitant dentofacial deformities. Dentists treating SRBD should keep up their training with continuing education, maintain regular communication with the referring physician and other providers about progress, and expect follow-up sleep testing by a physician to evaluate improvement or confirm efficacy, especially if symptoms or comorbidities recur.

For scale, the ADA's own topic page on OSA (last updated January 9, 2023) reports that OSA accounts for over 80% of sleep-disordered breathing cases in the US, cites an epidemiologic review with mean OSA prevalence of 22% in men and 17% in women, and a US cohort estimate of moderate to severe OSA (apnea-hypopnea index of 15 or more) of about 13% of adult men and 6% of women. The same page notes PAP adherence of 17% to 60% in the studies it cites, which is the gap oral appliance therapy is meant to fill, and it points to the ADA's July 2016 evidence brief on oral appliances.

Who it applies to#

The screening bullet reaches every dentist and every patient, adult and child, because it is written into the comprehensive history rather than into a sleep practice. The rest of the list reaches the dentist who chooses to provide OAT: evaluation, fabrication, consent, side-effect management, monitoring and annual adjustment, physician communication and continuing education.

Three things stay with the physician. Diagnosis: the policy sends the at-risk patient to a physician for proper diagnosis, and the amended fabrication bullet begins with a physician's diagnosis of OSA and a written or electronic referral recommending OAT. Confirmation: follow-up sleep testing by a physician. Surgery: a secondary option, with a primary role only in selected cases. The policy is an ADA position, not a practice act; what a dentist in a given state may do with portable monitors, and under whose order, is a state-law question the policy does not answer.

What changed#

Between 2017 and 2019 the House of Delegates rewrote one bullet. The 2017 text said that when oral appliance therapy is prescribed by a physician through written or electronic order for an adult patient with obstructive sleep apnea, the dentist should evaluate and, if appropriate, fabricate an oral appliance. The 2019 text (Trans. 2019:270) says that when a physician diagnoses obstructive sleep apnea and treatment with OAT is recommended through written or electronic referral, the dentist should evaluate, fabricate, monitor its effectiveness and titrate the appliance as necessary. The "adult patient" qualifier dropped out of that bullet, the physician's act is framed as a diagnosis plus a referral rather than an order, and monitoring and titration became part of the fabricating dentist's job in the same sentence. Every other bullet is unchanged word for word.

Against common practice, the policy's line is the referral. An office that fabricates a mandibular advancement device on a snoring complaint alone, without a physician's diagnosis, is outside the policy; so is one that fabricates and never sees the patient again.

Where the source is#

The link under the title is the ADA's PDF of the policy as adopted by the 2017 House of Delegates; the amended text (Trans. 2017:269; 2019:270) is the PDF the ADA links from its obstructive sleep apnea topic page, also listed above. Both are two-page public documents. The prevalence and adherence figures are from the ADA topic page, which cites its own sources, and the July 2016 evidence brief is a 23-page ADA PDF.