Special Considerations in the Treatment of OSA by Oral Appliances in Commercial Motor Vehicle Operators.
Ever since the FMCSA issued its latest updated advisor on Sleep Apnea which specifically changed previous medical advisory board recommendation on certifying CMV operators with OSA treated with oral appliances there has been discussion about Dental Sleep Medicine offering treatment programs for commercial drivers. This interest expanded when Braebon announced the availability of compliance monitoring for oral appliances . This article will attempt to give Dental Sleep Medicine professionals additional information they should consider when treating CMV operators or considering marketing to trucking companies.
DO YOU WORK IN CONJUNCTION WITH OR PARTNER WITH AN MD BOARD CERTIFIEED IN SLEEP MEDICINE?
Sleep Scholar Editor Randy Clare and frequent contributor Dr. John Viviano have both written excellent articles about the issue of whether or not treating OSA with oral appliances is within the scope of practice for a dentist or not. While this is a current controversy if you are going to treat CMV operators or persons employed in other safety sensitive occupations you WILL need to do so in conjunction with an MD board certified in Sleep Medicine. Whether this is as part of a group practice, collaborative referral agreement or other business arrangement would have to be arranged. There are several reasons for this.
- Medical Certification of CMV drivers under FMCSA NRCME program guidelines.
The current guidance from FMCSA on sleep apnea includes language that “the issue of treatment is best left to the treating healthcare professional and the driver.” Whether or not a dentist would be considered an appropriate healthcare professional to certify “current and effective treatment” would be a potential issue. In general “treating healthcare professional” in FMCSA language is a person acting within the professional scope of practice laws and holding a license to practice. Unless you have a relationship with or have checked in advance with an NRCME certified DOT medical examiner you will be sending your patients to, this can cause major issues.
Another issue will be a reluctance of DOT medical examiners to certify your patients for work unless they have paper work from an MD attesting to current and effective treatment. There will be reluctance to certify from the statements of a dentist. This reluctance will in part be due to liability concerns outlined below. DOT medical examiners want an MD and their insurance coverage on the line. They will want to avoid potential negligence allegations for accepting the opinion of a dentist possibly acting outside their scope of practice in attesting to current and effective treatment.
- Liability, malpractice, or errors and omissions insurance coverage.
John and Wanda Lindsay were traveling on I-30 when they were struck from the rear by a semi-truck driven by a driver with recently-diagnosed severe uncontrolled sleep apnea. John did not survive the crash. On June 26, 2009, a tractor trailer crashed into a line of stopped vehicles, killing seven people. Post-crash polysomnography of the driver showed an AHI of 15/hr. The driver had recently been released from the hospital with discharge recommendations that he be evaluated for sleep apnea (which he declined).
Let’s assume as a dentist you were the treating healthcare professional in either of these cases. Assume the patients were in the process of having their oral appliance titrated and had not yet reached full effective treatment. Or, even if the patient was under effective treatment the plaintiff alleges you were negligent for practicing outside your scope of practice. The Lindsay case settled for $ 3.25 million. The 2009 case settled out of court for over $ 66 million. In reality the likelihood of your being sued by your patient is slim. The liability risk will be suits from the motor carrier’s liability carrier subrogating their losses.
- Maintaining current and effective treatment during OA titration.
Another aspect of CMV driver treatment is the need to maintain effective treatment while the oral appliance is being titrated. A common approach is to maintain CPAP treatment and use the oral appliance as adjunct therapy. Use of auto-titrating pap and monitoring pap determined pressures as part of the titration process is often used. If a CMV driver is not under effective treatment they should not be cleared for work. Newly diagnosed patients will need to at least temporarily be put on CPAP while the oral appliance is fabricated and titrated. This requires working in conjunction with an MD.
TO USE COMPLIANCE MONITORING OR NOT.
The FMCSA guidance is silent on whether or not CMV drivers must use compliance monitoring. All of the major recommendations on CPAP treatment recommend to DOT medical examiners are that drivers should maintain a minimum of 4 hours 70% of the nights of use. DOT medical examiners normally want to see compliance data for the entire period of treatment. All drivers with OSA will need to be recertified by a DOT medical examiner annually. Being able to provide compliance data will greatly ease your patient’s issues or problems with recertification. DOT medical examiners will have a variety of training and experience with sleep medicine. Chiropractors are allowed to be trained and certified to perform DOT exams.
POST TITRATION SLEEP STUDY
Part of a CMV driver program oral appliance program will need to include a post titration sleep study. You will need to be able to document the effectiveness of treatment. Whether this is an HST or PSG is open.
TEMPERATURE SENSITIVE MATERIALS.
One of the early practical feedback points from truck drivers using oral appliances are issues with OA constructed with thermally sensitive materials.
DO NOT use materials or OA that would be affected by being left on the dash of a truck in the sun.
MODERATE TO SEVERE OSA
One of the major issues will be how well your patient with moderate to severe OSA is treated. Unless they are under good control showing no excessive daytime sleepiness you should have major concerns. With moderate and severe OSA being the areas of concern for DOT certification and OAT being less effective than CPAP for moderate to severe OSA this will be an issue.
MULTIPLE VISITS FOR TITRATION
Dentist need to work with drivers, especially those in the long haul over the road segment to address getting OAT titrated. Self-titration where medically appropriate needs to be considered. A long haul driver being able to make multiple office visits for titration is not a practical reality.
Dentist will be needed to work with MD’s board certified in sleep medicine to execute treatment programs for either CMV driver needing to switch from CPAP therapy or start OAT therapy in lieu of CPAP. It is exciting that oral appliance therapy is a treatment option for drivers. But, a dentist planning to work in this area needs to be aware of how what special issues will need to be addressed in developing their programs. Partnering with firms already working with trucking companies to add OAT to their treatment options may be a better approach than trying to approach trucking companies on your own.