An Empowered Response: Patient-Centered Sleep Apnea Care in the Age of Teledentistry
OR: “The AASM, The AADSM and The Cheshire Cat walk into a blog…”
By David E McCarty MD FAASM (but you can call me Dave)
8 October 2025
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Alice: “Would you tell me, please, which way I ought to go from here?”
Cat: “That depends a good deal on where you want to get to.”
Alice: “I don’t much care where—”
Cat: “Then it doesn’t matter which way you go.”
— Lewis Carroll, Alice’s Adventures in Wonderland
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…“Which way ought I to go from here?”…
Illustration: Sir John Tenniel, 1865. Alice and the Cheshire Cat, from Alice’s Adventures in Wonderland by Lewis Carroll. Public Domain
Hello from the ISLE! And thanks for the Map!
Let me begin with gratitude.
Dr. Kevin Postol and the American Academy of Dental Sleep Medicine have published a piece recently in the AASM’s Montage that deserves acknowledgment. It does something important, and it does it well: it places safeguards at the center of innovation.
In an age where technology races ahead of wisdom, where commerce often outruns care, it matters that a professional society pauses, looks around, and insists on standards. The AADSM’s insistence that three essential steps remain in-person — the comprehensive dental sleep exam, impressions, and bite registration — is not a small thing. These are guardrails born of experience, and they protect patients from very real harms: poorly fitting devices, temporomandibular joint injuries, dental occlusal shifts, and—presumably—therapy that quietly fails.
There is wisdom in this. And it should be said plainly: the academy is right to name these steps as irreplaceable.
But as Lewis Carroll reminds us through the Cheshire Cat, maps and guardrails are not the journey. A map without a destination is just a decorated sheet of paper. The Cat’s sly smile points us toward a truth that resonates here: even the safest path to nowhere in particular could still lead to irrelevance. The missing question is the same Alice asked: Which way ought I to go?
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What the AADSM Gets Right
Before I move into critique, I want to linger on what this piece does well. The article gets three things undeniably right:
It affirms the role of qualified dentists — trained professionals who can evaluate the dentition, craniofacial structures, TMJ, and occlusion with precision. This is vital, and it is true.
It identifies essential in-person safeguards — places where technology cannot yet substitute for hands-on, embodied professional skill. That’s true for dentistry, but it’s also true for medicine broadly. (One hopes medicine pays attention here.)
It acknowledges technology’s promise while resisting the temptation to surrender fully to it. That balance is rare in a culture intoxicated by speed and scale.
On these counts, the AADSM has modeled something worth emulating.
And yet…there’s something…missing…
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What’s Missing: The Seeker
I’ll start with this: Dr. Postal’s piece presents oral appliance therapy (OAT) as the assumed destination, a way of making the “vending machine” concept of care safer, within a dental dispensary system.
You might say it’s framed very much from the “silo” of dental care. The diagnosis has been assigned, and the decision to proceed with therapy was arrived upon elsewhere, presumably in a conversation involving the patient’s medical provider.
The point is, from the “Dental Vending Machine” perspective, the patient’s role in the journey is left unspoken. The goal of therapy (also unspoken) is presumably “to control the Sleep Apnea”—whatever that means—which (of course) means different things to different stakeholders in this situation, which is a nice recipe for confusion leading to systematic over-titration of whatever therapy is being used. In other words, when the goals of therapy are unclear, it's more likely that the therapy will be advanced to the point of harm.
When all you have is a hammer, every problem begins to look like a nail.
Folks, this is what I’m talking about when I use the term “label-based care”…the diagnosis label becomes the north star; the device itself becomes the journey. The patient is carried along, strapped into the apparatus by their ICD-10-code, their only task to comply.
What’s missing? Why does this leave me cold?
What’s missing is the traveler. The seeker with a destination in mind.
Without the patient’s voice, therapy risks becoming technically correct but experientially irrelevant or even downright harmful. And when therapy is irrelevant to the lived goals of the patient, adherence falters and trust dissolves.
Our smiling Cheshire Cat would call this out for what it is: wandering without a destination, a careful map leading to anywhere, possibly nowhere that matters to anyone.
And if the seeker remains absent long enough, the problem compounds — not just in silence, but in systemic drift…
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The Disaster in the Making
Here is where the real disaster lurks.
When dentistry talks about “Sleep Apnea,” it is often talking about a label that serves billing, compliance, and professional identity. Medicine does the same thing with CPAP. Both silos share this reflex: treatment flows from the label, not from the person.
This creates a conveyor belt of care. Patients are ushered along, examined, fitted, billed, monitored. Everyone feels they are doing their job, and yet patients quietly drift away quietly left behind, their needs unmet. The problem isn’t malice. It isn’t even incompetence. It is simply this:
The system forgets to ask: Where do you want to go?
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The Five Reasons to Treat: True Destinations
This is where the Empowered Sleep Apnea project offers a reframing. We don’t start with the label. We start with the “WHY?”.
There are only five reasons to treat Sleep Apnea.
Not three.
Not one.
FIVE.
On our ISLE OF SLEEP APNEA (get it? It’s a Dad Joke! I Love Sleep Apnea…tee hee!), we built a whole monument for ‘em, these FIVE REASONS, with a great place to stop and get pie and coffee. The point here: the conversation is the key, as each patient discovers their own very personal Reasons to Treat:
RISK – long-term health and survival.
SNORING – the noise, the relationships, the dignity of silence.
SLEEP – the felt quality of sleep itself.
WAKE – the restoration of alertness, energy, cognition.
COMORBIDITIES – hypertension, atrial fibrillation, metabolic dysregulation, depression, and beyond.
These reasons are not just clinical abstractions. They are destinations. They answer the Cheshire Cat’s question: Where do you want to get to?
…a patient who says, “I want to stop snoring so my marriage improves,” is choosing SNORING as a destination….
…a patient who says, “I need to stay awake for my shift work,” is pointing toward WAKE…
…a patient who fears stroke or heart disease is aiming to make strides against RISK…
When we start here, we invite the patient into the story. Suddenly, care is not about compliance with a device. It is about pursuing goals that matter. Oral appliance therapy may be one of the tools — but only one—in a much larger conversation.
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Patient-Centered Conversations
Imagine a different script.
Instead of:
“You have Sleep Apnea. Your doctor says we need to fit you with an oral appliance. Here are the steps.”
We hear:
“You have Sleep Apnea. But let’s pause. Tell me what matters most to you. Let’s talk! Is it risk reduction? Quieter nights? Feeling rested? Sharper at work? Controlling your blood pressure? We have tools. Let’s choose the right ones for your reasons. Perhaps my oral appliance is one of them…”
Want to know what patient-centered care looks like? This is it. It looks and feels different because the goals are co-discovered and co-created, not pre-determined.
A map that merely marks hazards is a warning poster, but you can’t find where you’re going just by knowing what to avoid.
A map that’s designed to interact with a patient’s aspirational goals, however…that’s something else indeed!
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Teledentistry Through a New Lens
Now, bring this back to teledentistry.
From a patient-centered perspective, telehealth is not primarily about whether impressions or bite registrations can be done virtually. Those are important safeguards, yes. But the real promise of teledentistry is this: it can open the space for conversations that center the patient’s goals.
Imagine rural patients, or overburdened caregivers, who can’t make multiple trips to a clinic. Imagine the chance for them to tell their story from home, in comfort, with dignity. That conversation — the upstream “why” — is perfectly suited for telehealth.
Teledentistry should not only be about protecting the appliance. It should be about protecting the conversation.
Dentists are uniquely trained to evaluate teeth, jaws, TMJ, occlusion. That is true. But what makes them indispensable is not merely their technical skill. It is their capacity to bring the patient’s goals into alignment with therapeutic possibilities. It is their sacred and indispensable role as the learned provider of sage advice about health and healing. It’s about knowing their own capabilities.
A dentist who only safeguards bite registration is half a clinician. A dentist who listens for the patient’s reason to treat becomes a healer.
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What’s Missing: The Dentist as Team Member
Here’s the thing. For all its good intentions, the AADSM article still paints the dentist into a tiny, polite corner—a corner lined with neatly laminated standards and a vending slot marked “Now Dispensing Oral Appliances.”
Dr. Postol means well. He’s arguing for safety, for professionalism, for not letting the Wild West of mail-order mandibular advancement run off with our patients. But the way the argument’s framed… it still sounds like a trade guild defending its tools, not a team member fighting for its place in the larger story of healing.
It’s the language of the craftsman, not the clinician. And that’s tragic, because the dentist is a clinician—a doctor of the craniofacial airway, a biomechanical whisperer of bone and soft tissue. Yet in Postol’s map, the dentist’s job is mostly to guard the physical steps, to make sure the impressions are accurate and the bite is safe. In that script, the dentist isn’t part of the care team; they’re just the person who makes the widgets fit.
Come on, Life-Fans! We can do better than that!
Modern technology is begging us to. Intraoral scanners, digital bite registrations, and CBCT imaging can beam a patient’s oral landscape halfway across the country in seconds. This means the dentist can be part of real-time care teams—collaborating with physicians, sleep techs, integrative clinicians—working together toward a shared understanding of the why behind the how.
When dentistry insists on standing apart, clinging to “in-person only” as the last frontier of safety, it risks missing the point of the map entirely. Safety matters, but safety isn’t a destination. It’s a guardrail. The journey is coordinated care—the patient’s destination clearly marked on the map, every provider reading from the same chart.
The Cheshire Cat would raise an eyebrow here. Because a map that prizes safety but forgets the seeker’s goal? That’s a map that can’t lead you anywhere. The real work now is to bring the dentist back to the table where the maps are drawn—to hand them a compass, pour them some coffee, and say, “Welcome, doc. We’ve been waiting for you.”
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A Call for Integration
This is where the silos could learn from one another. Physicians, dentists, technologists, payors: all need a shared language that begins with patient goals. The Five Reasons to Treat paradigm offers one such lingua franca.
It allows medicine and dentistry to meet on common ground:
…the physician who worries about atrial fibrillation and hypertension (RISK, COMORBIDITIES)…
…the partner who worries about the roar of snoring (SNORING)…
…the commercial driver who simply wants to stay awake at the wheel (WAKE)….
…the schoolteacher who wants to sleep through the night (SLEEP)…
These are not siloed categories, to be individually addressed by specialists…they illustrate the very humanity of the journey we share with our patients.
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Conclusion: Maps, Destinations, and Agency
The AADSM is right: teledentistry must have safeguards. Oral appliances must be fitted with rigor. Dentists must remain central to care.
But let us not confuse safety with sufficiency. Guardrails without a compass can still leave us hopelessly lost.
The compass for a patient-centered healthcare journey is the patient’s “why,” a practical unpacking of which is the Five Reasons to Treat.
If we can bring this language into the silo — if we can remind dentistry and medicine alike that care begins with the patient’s reasons, not the profession’s tools — then innovation becomes not just safer…but more meaningful.
The AADSM has drawn a careful map.
For that, gratitude is due.
But as Alice reminds us through her dialogue with the Cat, the point of a journey is not the map itself, but where it leads. In Sleep Medicine, the destination must belong to the patient: their risks, their snoring, their sleep, their wakefulness, their comorbidities.
With that compass in hand, the map of safeguards finds its true purpose.
Without it, as the Cat warns, it doesn’t much matter which way we go.
Kind mojo,
Dave
David E. McCarty MD FAASM
Boulder, Colorado
8 October 2025
Further Reading:
Postol, K. (2025, September 4). Teledentistry in dental sleep medicine: Innovation with safeguards. American Academy of Sleep Medicine.