Is Obstructive Sleep Apnea Treatment within the Dental Scope of Practice?

I attend many conventions and meetings throughout the year in the course of my work in sleep therapy. These meetings tend to be predominantly in the medical world, however I am starting to meet more and more dentists. I am struck by the passion of the dental community as they approach the practice of sleep. It seems that every weekend there is some kind of dental course teaching dentists about sleep medicine. The question from the medical side usually focuses on scope of practice. A series of questions emerge:

“Is OSA treatment within the scope of practice for a dentist or is it not?”

I asked an attorney friend to track down some scope of practice documents from any dental boards. It turns out that most scope of practice statements for each state board are phrased the same way. “What is not immediately clear from reading a state’s Dental Practice Act (DPA) is that they were all drafted like the US constitution to be a broad instrument,” said my attorney. “More than 100 years ago, when these documents were drafted, it was impossible to predict what the full scope of dentistry would entail. Therefore, as the constitution of the US has penumbral rights, which allows the document to evolve and grow, likewise, DPAs and scope of practice definition’s are purposefully broad to allow growth and new areas of development. Overlap with medicine was built into the definition so that each field could bring insight to the table.”

As we discussed the sale of dental materials and the responsibility of the individual practitioner, he also reported, “You should know all acts cover the sale of dental materials. This is where dental lab procedures and appliances such as oral appliances (OAs) fall in the practice of dentistry. In other words, the dentist can sell appliances, but he is legally responsible for this appliance and its ramifications.”

All DPAs are public documents and are available online. You can easily Google your state DPA. I have a few excerpts that you may find interesting. First is the “State of California Dental practice act.” (http://bit.ly/R4WW0d ). It is as follows:

Dentistry is the diagnosis or treatment, by surgery or other method, of diseases and lesions and the correction of malpositions of the human teeth, alveolar process, gums, jaws, or associated structures; and such diagnosis or treatment may include all necessary related procedures as well as the use of drugs, anesthetic agents, and physical evaluation.

Without limiting the foregoing, a person practices dentistry within the meaning of this chapter who does any one or more of the following:

(a) By card, circular, pamphlet, newspaper or in any other way advertises himself or represents himself to be a dentist.

(b) Performs, or offers to perform, an operation or diagnosis of any kind, or treats diseases or lesions of the human teeth, alveolar process, gums, jaws, or associated structures, or corrects malposed positions thereof.

(c) In any way indicates that he will perform by himself or his agents or servants any operation upon the human teeth, alveolar process, gums, jaws, or associated structures, or in any way indicates that he will construct, alter, repair, or sell any bridge, crown, denture or other prosthetic appliance or orthodontic appliance.

d) Makes, or offers to make, an examination of, with the intent to perform or cause to be performed any operation on the human teeth, alveolar process, gums, jaws, or associated structures.

(e) Manages or conducts as manager, proprietor, conductor, lessor, or otherwise, a place where dental operations are performed.

Below is another variation that comes from the  “Arkansas Dental Practice Act” (http://bit.ly/N8Lb8a ). This is a much simpler document and points out the slight variation available in the standards of practice from state to state.

(A) “Practicing dentistry” means:

  • The evaluation, diagnosis, prevention and treatment by non surgical or related procedures of diseases, disorders and conditions of the oral cavity, maxiofacial area and the adjacent and associated structures and their impact on the human body, but not for the purpose of treating diseases, disorders and conditions unrelated to the oral cavity, maxiofacial area and the adjacent and associated structures; and
  • The sale or offer for sales of those articles or services of dentistry enumerated above

(B)“Practicing dentistry” shall include, but not be limited to, the administration of anesthetics for the purpose of or in connection with the performance of any of the acts, services, or practices enumerated or described in this section

(C) Nothing herein shall be construed to prohibit a licensed physician from extracting teeth in an emergency when, in his or her considered professional judgment, it is necessary and when it is not practicable or reasonable to secure the services of a licensed dentist;

Dental Board in Hawaii  (http://1.usa.gov/LPFVlV) includes the Phrase:

“Or who engages in any of the practices included in the curricula of recognized and approved dental schools or colleges.”

UCLA, Tufts, the University of Michigan, and the University of Kentucky dental schools all notably have mini residency programs in Sleep.

After I read through this a few times, I was struck by the breadth of the coverage of these documents. The intention seems to be inclusive of medicine and other professions. Since obstructive sleep apnea is a condition that involves the tongue, tonsils, and other tissues of the oral cavity and pharynx, it seems that the treatment of OSA is well within the scope of practice for a dentist—certainly if he or she has consulted with the dental board requirement in their state.

It would be hard to deny the adjacency of the anatomic structures of the nasopharynx with the teeth, gums and alveolar process in California, Arkansas and Hawaii. We’ll assume that human biological structures transfer across state lines.

What caught my eye is the last line of the description of dental service in Arkansas. This is where the sale of articles and services is covered. In this area, it begs the question: “If managing the tissues of the oral cavity and nasopharynx non surgically with an oral appliance is within the scope of practice, what if the dentist were to choose to use a CPAP (continuous positive airway pressure)?”

CPAP is a tool that has a demonstrated success in managing the structures of the nasopharynx. Combination therapy, OA, and CPAP, is becoming more and more frequent and should be closely managed. It stands to reason that as a doctor who manages the tongue, nasopharynx and maxiofacial area, a CPAP would be a useful tool indeed. I would suspect that as a controlled device (pharmacy board in most states) the CPAP would require setup by a licensed Respiratory Therapist. However, the treatment plan designed to achieve patient compliance with an appropriate therapy certainly could be managed by a dentist.

The next question would be, “If a dentist is managing the care of a patient’s tissue in accordance with his scope of practice, what protocol would be appropriate to establish clinical success?” It would seem to me that level III home sleep testing would be appropriate for this phase of treatment due to the significant difference between the asleep and the awake airway. Certainly it could be reasonably assumed that the dentist would require feedback as to the effectiveness of his treatment before referring the patient to a sleep diagnostics facility to confirm that the patient’s OSA is well managed with an oral appliance.

To answer the initial question, “Is OSA within the scope of practice for a dentist or not?” The answer is an unequivocal “Yes.” It is important to note that diagnosis of OSA and any one of the 80+ other sleep disorders, and many co-morbid conditions, require the services of a board certified sleep physician. However, once a diagnosis of OSA is established, and the patient requires therapy, a dentist with training in sleep is certainly a great choice.

by Randy Clare

Randy Clare is managing editor of SleepScholar, Aliso Viejo, Calif.

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