June 18, 2013
Mr. Glenn Parker
Texas State Board of Dental Examiners
333 Guadalupe St.
Austin, Texas 78701
Re: Proposed rule 22 TAC § 108.12, dental treatment of sleep disorders
Dear Mr. Parker:
The Texas Medical Association (TMA) is a private, voluntary, nonprofit association of Texas physicians and medical students. TMA was founded in 1853 to serve the people of Texas in matters of medical care, prevention and cure of disease, and improvement of public health. Today, our maxim continues in the same direction: “Physicians Caring for Texans.” TMA’s diverse physician members practice in all fields of medical specialization.
On behalf of more than 47,000 member physicians, the Texas Medical Association (TMA) appreciates this opportunity to review and offer comments on proposed rule 22 TAC 108.12, published in the May 24, 2013 issue of the Texas Register, pertaining to dental treatment of sleep disorders.
TMA provided two previous letters to the Texas State Board of Dental Examiners (TSBDE), dated January 22, 2013 and April 25, 2013, urging the board to adopt a policy prohibiting the diagnosis and independent treatment of sleep apnea by dentists. TMA generally supports the proposed rule because it is consistent with the statutory scope of practice of dentistry. TMA has some concerns with the proposed rule, however, and provides the following comments in that regard.
Section 108.12 (a)
This section provides a statement that a dentist “may diagnose, treat, operate, or prescribe for a disease, pain, injury, deficiency, deformity, or physical condition of the human teeth, oral cavity, alveolar process, gums, jaws, or directly related and adjacent masticatory structures.” (emphasis added). Although this statement may appear consistent with section 251.003, Occupations Code, which provides the scope of practice of dentistry, it is not completely accurate and could therefore be misleading. Section 251.003(a)(2)(C) provides that a dentist may diagnose, treat, operate on or prescribe for a disease, pain, injury, deficiency, deformity, or physical condition “of the human teeth, oral cavity, alveolar process, gums, or jaws.” It does not add that a dentist may diagnose “directly related and adjacent masticatory structures.” Providing different language in the rule from that in statute would be confusing and could be misinterpreted to expand the scope of dentistry. The Dental Practice Act clearly establishes the scope of practice of dentistry, which need not be repeated in the rules, and TMA therefore recommends that subsection (a) be removed.
Section 108.12 (c)
TMA agrees that a sleep disorder is a medical condition, and any dental treatment for a sleep disorder must therefore be done in collaboration with a qualified, Texas licensed physician. TMA is concerned with the second portion of this proposed subsection, which reads: “The dentist shall ensure that the patient has been evaluated by the physician for a sleep disorder in compliance with the Texas Medical Practice Act and Texas Medical Board rules, and is being monitored by the physician for potential complications of the sleep disorder.” This language would not only impose an undue burden on a dentist, but it would require knowledge beyond the scope of a dentist’s training or license. A dentist cannot know if a physician is acting in compliance with the Medical Practice Act and Texas Medical Board rules, because a dentist does not practice medicine or have medical training. It would be inappropriate for a dentist to oversee, monitor, or judge a physician’s treatment of a patient. TMA therefore recommends that the second sentence of proposed subsection (c) be struck.
Section 108.12 (d)
This proposed section states that a dentist “should” screen a dental patient for a sleep disorder. TMA recommends that this be changed to “may”, such that the proposed rule would allow a dentist the option (“may”) of screening for a sleep disorder rather than making it a recommendation (“should”). By recommending in rule that dentists screen for sleep disorders, the board creating tacit requirement on all dentists to screen for a medical disorder, regardless of whether they have the knowledge or interest in making such screenings. TMA recommends that the word “should” be replaced with “may,” thus allowing dentists to screen for the disorder without encouraging or recommending it.
In the Medical Practice Act, “practicing medicine” means, “the diagnosis, treatment or offer to treat a mental or physical disease or disorder or a physical deformity or injury by any system or method…” Sleep apnea is a medical disorder, which if untreated or misdiagnosed, can cause increased risk of heart attack, stroke, high blood pressure, arrhythmias, or heart failure. It is beyond the scope of practice of dentistry in Texas to diagnose a medical disease or disorder, including a sleep disorder, or to independently treat such disorder once diagnosed. On December 7, 2012, the American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) issued a joint policy statement on the issue, clearly asserting that the diagnosis of obstructive sleep apnea and the prescription of the appropriate treatment must be made by a qualified physician who is trained in sleep medicine. Once diagnosed by a physician, the physician may prescribe treatment that includes treatment by a qualified dentist for oral appliance therapy or oral surgical therapies.
The proposed rule shows that the TSBDE is in support of these principles--that although dentists shall not diagnose or independently treat patients for sleep disorders, dentists and physicians can collaborate in the treatment of sleep disorders.
TMA appreciates the board’s efforts in its rulemaking on this issue, and the opportunity to provide comment on the proposed rules. If you have any questions or comments, please feel free to contact TMA staff, Andrea Schwab, JD, CPA at 512-370-1337.
Stephen L. Brotherton, MD