The treatment of obstructive sleep apnea (OSA) has been approached in three basic ways including surgical, mechanical (continuous positive airway pressure [CPAP] and oral appliances), and weight loss. Generally, these approaches have been independent of each other and are recommended based on the background and experience of the practitioner. Once a treatment fails, then the patient must seek a different therapy independent of the previous failure. Unfortunately, the patient is ill served by this all or none approach without the benefit of a logical one based on patient preference, simplicity, compliance, cost, invasiveness, and ultimate effectiveness.
An obese patient with sleep apnea is placed on CPAP-oral appliance therapy.
Presently, insurance companies require that a patient must be first diagnosed by polysomnography (PSG) and then CPAP therapy is initiated based on criteria that are not universally accepted by the sleep community. This algorithm precludes from therapy those patients who refuse an initial polysomnogram, fall below minimum respiratory disturbance index (RDI) requirements, refuse a second PSG to titrate the CPAP, reject the CPAP at trial, stop using CPAP, or use CPAP less frequently than is necessary for symptom resolution.1 Only after failure with CPAP will most insurance companies even consider paying for any other type of therapy, particularly oral appliances or surgery.
Although CPAP has been the gold standard for treatment2 of OSA, long-term effectiveness has been limited due to problems with compliance.3-5 Complaints that limit wear include high pressure, mask leakage, claustrophobia, uncomfortable straps, aerophagia, sinus congestion, poor sleep, and issues relating to the bed partner.6 Patients who require greater pressure are known to have more complaints focused on mask leakage and pressure. Studies have shown7 that some patients with severe apnea have significant compliance problems. Much time, money, and effort have been spent to develop new masks and auto-CPAP units to address these problems. According to one source, “When accounting for sleep-time, its actual effect and use, only 50% adjusted CPAP effectiveness was observed.”8 There have even been proposals to try oral appliances or surgery first before CPAP due to the poor compliance and quality of life.9
Oral appliances are the second means of mechanically managing the airway.10,11 An appliance acts as a structural splint to hold the jaw forward, thereby preventing the soft tissue and tongue from collapsing into the airway. The newer, more fully adjustable appliances are showing results comparable to those for CPAP in many patients with severe apnea. Pancer et al12 reported that a series of 121 patients with an average RDI of 42 before therapy have an average of 12 after therapy. Gerschman has reported similar results in a series of 134 patients with before and after RDIs of 39 and 9, respectively.13 If patient preferences were considered, the oral appliance would be the primary treatment option.14 The limiting factors of RDI reduction appear to be the mechanics of the appliance, the range of motion of the mandible, and the tolerance of the patient to the optimum treatment position, especially when it reaches the limits of the range of motion. Roberts et al15 showed significant improvement in RDI when the mandible is positioned beyond maximum active protrusion by passively stretching the temporomandibular ligaments. The ideal algorithm would be to treat the patient first with oral appliances and then add CPAP as necessary when the patient cannot be managed by oral appliances alone. This is similar to the approach of cardiopulmonary resuscitation—managing the jaw position first and then ventilating as necessary. Weight loss must also be included in comprehensive treatment as well as surgery when other more conservative approaches have failed.
The following case report is the first to utilize this algorithm. The patient demonstrated both objective and clinical improvement with the use of combined oral appliance and CPAP therapy. In this study, the CPAP mask was attached to the oral appliance providing an integrated system that eliminates the straps while rigidly holding the mask in a fixed position. Potential advantages include lowered CPAP pressure, better fit, less leakage, and greater compliance. It also allows the patient to use the oral appliance independently when necessary due to problems with the CPAP.
A 53-year-old female presented to the author for evaluation for oral appliance therapy as a substitute for CPAP. At presentation, she was using an auto-CPAP set between 6 CWP and 15 CWP. Her chief complaints included mask discomfort and leakage, arousals from CPAP, fatigue, and inconvenience. She stated that she was using the CPAP 5 nights per week. She was initially evaluated at All Saints Hospital, Fort Worth, Tex—an accredited sleep center. Prior to treatment, she reported that she was fatigued, was falling asleep at inappropriate times, did not believe her sleep was restorative or restful, and was depressed. Her Epworth Sleepiness Scale (ESS) of 16 indicated severe subjective daytime sleepiness. Her husband reported that she snored loudly in all positions with witnessed apneas. She denied having any symptoms related to narcolepsy.
The patient’s medical history included hypertension, which was controlled by medication. She did not use tobacco, drank two cups of coffee daily, and drank one to two glasses of wine per night. She had a history of temporomandibular disorder and was wearing an occlusal splint. She had tried numerous diet and exercise programs but felt too lethargic to continue them.
On physical examination, she appeared obese with a body mass index (BMI) of 39 and a neck circumference of 16.5 inches. She could easily breath through both nostrils and had no complaints of allergies. She had a class I occlusion with a normal oropharynx, tongue, and soft palate.
A split-night polysomnogram was completed at the sleep laboratory. It showed an RDI of 103 with a low desaturation of 83%. She had a hypertensive response to sleep with a bedtime blood pressure of 122/80 that rose to 169/96 upon awakening. Nasal CPAP was then titrated with all respiratory impairments and snoring eliminated at 14 CWP using a soft-series mask, chin strap, and humidifier.
The patient was placed on CPAP at 14 CWP. She returned to the sleep laboratory 3 weeks later complaining of middle ear discomfort, aerophagia, dry eyes, and mask irritation, although she reported wearing it nightly. She was then placed on auto-CPAP set between 6 CWP and 15 CWP. Most of her complaints were relieved except mask irritation and arousals from the CPAP, straps, and mask. At this point her ESS was 6.
She presented to this dental office approximately 1 year later. She noted the return of some of her symptoms of OSA including sleepiness (ESS of 13) and a feeling of mental dullness on awakening. Ambulatory overnight oximetry was performed.16-19 Data indicated an increase from the original PSG in desaturation, time below 90% saturation, and low desaturation (Table 1, page 20).
A fully adjustable oral appliance was fitted and titrated to optimum position utilizing pulse oximetry (Table 1, page 20). The titration occurred over a 2-week time period with the final position set at maximum protrusion. All of her subjective symptoms were relieved including sleepiness (ESS of 5) within 2 weeks. However, after 1 month, the position exacerbated her temporomandibular symptoms. The patient was then fitted with an CPAP-oral appliance interface using shell and nasal pillows. Protrusion was set at 60% of maximum. At this position, the patient had no temporomandibular symptoms. The auto-CPAP pressure was lowered for the combination CPAP-oral appliance trial to a minimum of 3 CWP and a maximum of 12 CWP.
Software was used to evaluate the results (Table 2). The patient was asked to wear the CPAP every night for 2 weeks before the oral appliance was fitted. After 16 days of wear of the CPAP-oral appliance interface, the results were again evaluated. Interestingly, the interface became loose, which forced her to return to CPAP alone for the 3 days prior to her appointment.
After 3 months of successful wear of the combination appliance, the patient was referred to the Cooper Aerobics Institute, Dallas, for its experimental weight loss program. The program included diet management, exercise, behavior modification, group therapy, and medications as necessary. Staff physicians, dieticians, exercise physiologists, and clinical psychologists supervised the program. The patient was reevaluated with pulse oximetry every 6 months. At the end of 18 months, she had reduced her BMI to 28. At this point, she started eliminating her CPAP and wore only the oral appliance. She stated that she had more energy, was not snoring, and was normotensive without medication. She was reevaluated with overnight pulse oximetry both with and without the oral appliance.
The CPAP-oral appliance combination therapy significantly improved the objective results while enhancing the patient’s overall satisfaction with the therapy. She was highly compliant, utilizing the therapy more than 6 hours per night every night. The mean pressure was reduced from 8.8 CWP to 5.4 CWP. The average peak pressure was reduced from 13.2 CWP to 9.4 CWP. During the 3 days she returned to CPAP alone, all pressures rebounded to previous levels. Although the patient was not aware of the reduction in the pressures, she was highly pleased with the interface of the nasal pillows and oral appliance, the elimination of all the straps including the chin strap, the lack of air leakage, and the decrease in nasal irritation. She felt that her sleep was much improved, had more energy, and was not as hungry as before. She was then referred for weight management.
Over the next 18 months, she lost more than 60 pounds, and increased her lean body mass and cardiovascular fitness. Since she decided to stop wearing the CPAP and wore only the oral appliance, a reevaluation was recommended. Without the appliance, she was still spending 14% of the night below 90% saturation, and had a low desaturation of 84%. With the oral appliance set at the 60% protrusive position, she was still desaturating although greatly improved. Over the next 2 weeks she moved the position of the mandible to 95% of maximum. At this position most desaturations were eliminated (Table 1). Her temporomandibular symptoms did not return.
The treatment of sleep-disordered breathing requires a paradigm shift from a one-time diagnosis and treatment with CPAP to a strategy that manages a chronic condition over a patient’s lifetime. This requires the appropriate therapy at the appropriate time with continuous assessment at least yearly.20 Once the patient has been diagnosed with sleep apnea, then simple assessment with modalities such as pulse oximetry can determine any changes in the effectiveness of a particular therapy and, as necessary, adjustments or other therapies can be added. In this case, although both the CPAP and the oral appliance were shown to normalize a severe apneic, neither was well tolerated alone. The reasons for failure were either the excessive pressure and leakage with CPAP or the maximum protrusion of the mandible with the oral appliance. A combination therapy with a strapless CPAP-oral appliance interface effectively resolved the problems experienced by the patient. The most logical modality to treat severe OSA patients may be the use of this interface, lowering air pressure while improving leakage and comfort of the mask. Once her sleep returned to normal, she had the ability to achieve success in losing weight and ultimately eliminating the need for CPAP. She continues to be assessed every 6 months both clinically and objectively with overnight pulse oximetry, which occurs at her routine dental maintenance appointment. Studies are needed to fully evaluate this approach and treatment algorithm.
W. Keith Thornton, DDS, is a dentist at L.D. Pankey Institute, Dallas, which focuses on restorative dentistry and treatment of temporomandibular disorders and sleep-disordered breathing.
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