Collaborative Care

This issue of Sleep and Breathing is a milestone both in the field of sleep medicine, and in the relationship of the medical and dental professional communities. It is the first time an issue of a professional journal not only has resulted from a joint effort of both physicians and dentists but also has been directed at readers of both professions. It is appropriate that sleep medicine is the arena that has precipitated this cooperative effort because the recognition and treatment of sleep- disordered breathing must be a team responsibility.

Oral appliances have become a vital part of the physician's armamentarium for the treatment of sleep breathing disorders. Because these appliances are worn in the mouth, depend on healthy temporomandibular joints, and are supported by the teeth and other intraoral structures, they should be constructed and maintained by a dentist. The sleep physician depends on a dentist to provide the appliance therapy. Once a dentist assumes responsibility for a patient with sleep-disordered breathing, he/she must also be prepared to understand a wide array of causative factors and sequelae. This involvement of dentistry in the direct treatment of a medical disorder carries with it the obligation for the dentist to study and learn about a medical specialty field.

At the same time, the dentist must depend on the physician to make medical diagnoses and assign treatments. Patients present with symptoms, not diagnoses. Although a complaint of snoring in a patient often leads to a diagnosis of obstructive sleep apnea, other issues influence the diagnostic process and the treatment with surprising frequency. Physicians with interest in sleep disorders are trained to make these distinctions. The patients should have the benefit of their expertise.

The need to interact has produced a number of interpretations on how the patient might best be served with oral appliance therapy. Different models of care include not only the collaborative paradigm described above but also the dentist who evaluates snoring patients without medical help, and the physician who makes boil-and-bite appliances without a dental consultation. The article by Neal Cooper in this issue identifies some licensing and liability concerns that arise when clinicians assume responsibilities outside their area of training and expertise. At the very least, this legal opinion should stimulate clinicians to reassess their practices in view of the regulations in their local jurisdictions. Cooper's essay supports the wisdom of the collaborative models of care that have been advocated by the Academy of Dental Sleep Medicine (formerly the Sleep Disorders Dental Society) as well as the Academy of Sleep Medicine in their respective practice guidelines.[1] [2]

It is sincerely hoped that this issue of Sleep and Breathing will mark a new level of interaction and mutual respect between the members of two professions that have but one common goal-the health and well-being of our patients.

REFERENCES

• 1 . American Sleep Disorders Association Standards of Practice Committee. Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances.  Sleep . 1995;  18 511-513
• 2 Rogers R, Lowe A. Oral appliances for the management of snoring and Obstructive Sleep Apnea-a comprehensive guide for the sleep disorder dentist.  Slide/tape sequence for the Sleep Disorders Dental Society . 1997;  51