Treatment options such as oral appliance and CPAP therapies are keeping SDB at bay.
The specialty of sleep disorders medicine, recognized officially by the American Medical Association in 1996, has continued to grow tremendously. Many sleep disorders that were recently unfamiliar are now known as common terms in the average household. The specialty has been revolutionized by new procedures, diagnostic technologies, and treatments. Equally, advances are occurring at an unprecedented rate into the 21st century because of the continued improvements in comfort measures research, reliability of instrumentation, delivery of therapy, and responding to patient concerns as practitioners.
Inherent in the youth of this specialty are the seemingly diminutive steps of innovation that result in significant impact. In no area of this specialty is this more evident than in the treatment of sleep-disordered breathing. An example of this is the application of valuable compliance programs for CPAP. There is no debate that CPAP therapy has changed the landscape of modern medicine. The art of patient education, coupled with innovations in delivery of treatment, more varied options for treatment, and combinations of alternative treatment modalities, continues to improve patient acceptance and adherence to prescribed interventions.
In many research articles, it is commonly reported that long-term compliance for sleep apnea patients nationally averages 50% to 60%.1 Higher compliance is seen by integrating sleep diagnostic centers and durable medical equipment dispensing services that include comprehensive CPAP support, such as is done at Sleep Health and Wellness NW in Portland, Ore, where reported compliance rates approach 94%.
Despite this advancement, there remains a segment of the patient population that historically does not tolerate CPAP therapy well. Patients with mild and moderate sleep apnea are one vulnerable population. Other persisting factors that contribute to the resistant patient population in relation to long-term compliance are: lack of improvement in daytime functioning as a reinforcing drive for long-term use, severe OSA sufferers without excessive daytime sleepiness (EDS), high treatment pressures, mouth leaks, persistent pressure sores, persistent nasal congestion, epistaxis, rhinorrhea, complaints of dry mouth, aerophagia, chest discomfort, sinus discomfort, claustrophobia, and bed partner intolerance.1-8
It is well documented that targeting each of these complaints individually will lead to CPAP therapy success. Those measures include CPAP mask desensitization; new and more compact, travel-friendly CPAP units that are not so obtrusive and cumbersome; heated humidification; medically treating nasal anatomic obstruction; as well as surgical options. Instituting ramping times and trialing auto-titrating CPAP and bilevel PAP for patients with complex comorbidities and uncomfortably high treatment pressures are useful as well. It is clearly supported that consistent and frequent follow-up from the medical provider for this patient population does have a clear positive impact on long-term use.2
Follow-up for patient adherence and acceptance is a team effort. By having strong medical leadership and a well-trained allied health care team available to teach CPAP adaptation, many of the barriers to preventive therapy such as CPAP can be successfully removed. Other attributes include practice sessions for CPAP use, acclimation to the mask only, and wearing the unit on ramp pressures while napping or for short sedentary periods. Short-term institution of hypnotics is an effective adjunct for desensitization for the 2- to 4-week critical period of fragmented sleep due to the novelty of the therapy. Of course, addressing specific complaints is paramount. This should be combined with cognitive therapy to address misconceptions about ones sleep state and to educate the patient on the benefits of treating SDB. Review of consequences attributable to untreated OSA is effective as well.2 All this said, if patients feel their quality of life is severely impacted, none of these measures are likely to be effective.9-11
This introduction leads me to the objective of this article: interventions will not be accepted by the patient unless adequate review of alternative options is performed. The review of optional treatments should include the pros and cons, limitations in efficacy, or possible lack of certainty regarding outcomes of treatment. Lastly, easy access to and availability of specialist referrals are needed. Here at Sleep Health and Wellness NW, we have strategically aligned our group of sleep disorder centers with board-certified sleep specialists in a diverse range of primary specialties. Those include an otolaryngologist, pulmonologist, and neurologist who are all certified by the American Board of Sleep Medicine. Within this network, the close collaboration and convenient access to a specialist, such as a mid-level provider that is on-site, can quickly clarify appropriate treatment for the patient, and have been a tremendous advantage in expediting treatment.
In our network, we have a dentist who is a member of the Academy of Dental Sleep Medicine. He is readily available to consult on oral appliance therapy for OSA, and is also applying hybridized CPAP and mandibular advancement oral appliances. Our dental sleep specialist and medical sleep specialists confer regularly, which keeps the network up-to-date in both specialty arenas.
There is a large sector of the medical sleep community that is not readily accepting of the dental appliance option for patients who are intolerant to CPAP. Much of this can be readily attributed to the vast array of dental appliances in the market; the last count of FDA-approved medical devices was around 707. The more influential factor, likely, is the dearth of dental sleep board-certified practitioners available to each local sleep laboratory or center. One ground-breaking measure in this arena is the active collaboration of sleep disorder medical directors and local or regional board-certified dental sleep specialists. By acting in this manner, these pioneering sleep communities are breaking down misconceptions, driving collaborative efforts, improving CPAP and oral appliance success rates, and innovating hybridized therapies.
A Collaborated Effort
In communities where this sort of collaboration is performed, the barriers to insurance coverage are quickly eroding secondary to combined efforts. Options for successful treatment of patients with SDB are exponentially more varied, and the speed of diagnosis to final successful treatment application is drastically accelerated. In our network, many patients who would have been lost due to excessive treatment pressures have been maintained and referred early in the process for oral appliance and CPAP therapy, resulting in decrements of pressure often as low as 75% of initial titration pressures. This frequently is achieved without advancing the mandible and simply maintaining the rest position of the mandible, thereby restricting mandibular range of motion and eliminating genioglossus prolapse.5 Other combinations available to our patients are oral appliance therapy (OAT) with directed palatal surgery; palatal pillars (theoretically); and phase II surgeries.12,13 Not to forget conservative treatments that include weight loss, avoidance of sedatives and alcohol, positional therapy, and medical therapy or surgical intervention for nasopharyngeal obstruction.3 Lastly, we offer in-office application of temporary OAT for patients who are concerned about possible suboptimal response to OAT. This is a cost-effective adjunct for those patients with mild to moderate OSA who are unwilling or unable to travel with their CPAP units or may want a trial on an inexpensive OAT before pursuing more permanent devices.
One action that has significantly impacted our understanding of OAT has been the in-servicing of the Academy of Dental Sleep Medicine practice parameters for the effective application of OAT with our network providers. This has resulted in higher statistical compliance with treatment for OSA and greater patient satisfaction due to a more complete and thorough understanding of the treatment options available.
Standards of Care for an OAT Referral Process
Our dentist with training in OAT is familiar with the various designs of appliances. He can determine which one is best suited for the patients specific needs. Our dentist works closely with our providers as part of the medical team in diagnosis, treatment, and ongoing care. Determination of proper therapy is made by joint consultation of our dentist and providers. Initiation of OAT can take from several weeks to several months to complete. Our dentist continues to monitor treatment and evaluate the response of the patients teeth and jaws. He actively updates and refers the patients back for medical follow-up as clinically indicated.
Standards for treatment are:
- Patients with primary snoring or mild OSA who do not respond to, or are not appropriate candidates for, treatment with behavioral measures such as weight loss or sleep-position change.
- Patients with moderate to severe OSA should have an initial trial of nasal CPAP, due to greater effectiveness with the use of oral appliances.
- Patients with moderate to severe OSA who are intolerant of or refuse treatment with nasal CPAP. Oral appliances are also indicated for patients who refuse treatment or are not candidates for tonsillectomy and adenoidectomy, craniofacial operations, or tracheostomy.14
Ongoing care, including short- and long-term follow-up, is an essential step in the treatment of SDB with OAT. Follow-up care serves to assess the treatment of the SDB, the condition of the appliance, and patient response to OAT, and to ensure its comfort and effectiveness.
Advantages of OAT
OAT has several advantages over other forms of therapy including:
- Oral appliances are comfortable and easy to wear. Most people find that it takes only a couple of weeks to become acclimated to wearing the appliance.
- Oral appliances are small and convenient, making them easy to carry when traveling.
- Treatment with oral appliances is reversible and noninvasive.14
Side Effects of OAT
Our patients who decide to combine or simply undertake OAT are well aware of the potential side effects, which include, but are not limited to:
- tooth discomfort
- jaw or gum discomfort
- excessive salivation
- TMJ pain or dysfunction
- loosening of teeth
- tooth-position change
- jaw-position change
- space opening between the posterior teeth.8,9
Many of these symptoms are amenable to daily exercises, which may include the use of a leaf gauge or, at the polar end of management, orthodontic therapy. These potential side effects can be monitored by the patients primary dentist.
In September 2002, a 42-year-old female patient came in for a sleep test via polysomnography (PSG). She was snoring and had frequent nighttime awakenings. She had undergone septoplasty in July 2002. Her height was 66 inches, she weighed 265 pounds and had a body mass index (BMI) of 41.5, and her neck circumference was 45 cm. A Beck depression scale score of 8 and Epworth Sleepiness Scale (ESS) of 21/24 were obtained. The ESS score was consistent with pathologic somnolence. She was not hypertensive, and her medications were limited to fluticasone propionate nasal inhaler/spray and fexofenadine for seasonal allergies. Her chief complaint was severe daytime somnolence and unsafe driving in the morning to work. The diagnostic portion of the PSG revealed severe OSA with an oxyhemoglobin saturation nadir of 74%. Her AHI was 99.7 with the longest event at 49.3 seconds (a follow-up home study showed excellent agreement).
The CPAP titration was successful, resulting in objective measurement of improved control of SDB and improved sleep architecture. The patient soon began to fail CPAP therapy despite close follow-up. She would remove the mask unconsciously and, despite months of effort, was unable to maintain compliance with treatment goals.
She was referred back to an ENT surgeon who evaluated and scheduled the patient for uvulopalatopharyngoplasty (UPPP) and adenotonsillectomy. Her oral airway was a Mallampati Class 2. The patient subsequently heard of the orthotic management of OSA and sought consultation regarding this option prior to the surgery date. After collaboration between the ENT surgeon and Rich Moore, DDS, a trial of OAT was agreed on to assess possible response prior to surgical intervention.
The OAT titration took place over a period of several months, utilizing patient symptom profile assessment, home study evaluation, and gradual mandibular advancement to achieve optimal results. The RDI was reduced to 8.7 with an oxyhemoglobin saturation nadir of 89% for a total of less than 1% of total sleep time.
According to Moore, this response is not that unusual. He reports great successes with severe OSA patients with varied baseline physical findings. He does clarify that there is increased variability in effect and higher grades of OSA severity, which is consistent with the literature.
It is evident that the management of patients with SDB will continue to have a multitude of options. The network of multiple specialists helps to drive patient satisfaction and success in their preventive efforts.
Joseph R. Zelk, MS, FNP, BC, is clinical director, Sleep Health and Wellness NW, Sleep Lab Network, Hillsboro, Ore.
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