Since I was first introduced to Oral Appliance Therapy (OAT) to manage obstructive sleep apnea (OSA) I have continuously heard the Mantra, “CPAP is Gold Standard Therapy for OSA”. At this years American Academy of Dental Sleep Medicine Conference a number of the Guru’s that have guided this field to where it is today discussed the subject “Mean Disease Alleviation” (MDA), demonstrating that when both “adherence” and “Effectiveness” are considered mathematically, OAT actually comes out slightly ahead; imagine that!
I was first exposed to the concept of MDA in 2000 when Grote et al (Eur Respir J) demonstrated mathematically that the true efficacy of CPAP is about 50%. I suppose, the recent ability to accurately document adherence in an objective manner has helped to more accurately establish MDA for OAT. After all, it is easy to be skeptical about the very high adherence rate to OAT. The naysayers have been silenced!
CPAP is well tolerated and usually close to 100% effective for approximately 33% of patients, another 33% struggle with CPAP for years wearing it only part of the night or perhaps only when they feel so tired that they put it back on after many nights of not wearing it, and finally, approximately 33% of patients cannot tolerate or absolutely refuse to use CPAP. HOW can this be considered a GOLD STANDARD THERAPY?
However, let’s not let this go to our head. OAT cannot treat everyone satisfactorily either. We also need to keep in mind that some patients can ONLY be adequately managed with CPAP, in essence saving them from a tracheostomy!
Quite frankly, no one has the “Magic Bullet”. So rather than continuing to propagate the fallacy that “CPAP is Gold Standard Therapy for OSA” it is time that we actually start treating patients with the respect they deserve. Physicians and Dentists involved in this area of practice need to stop competing for these patients and work together to find the most effective and efficient manner to deal with their problem. A Pilot study published in Sleep Breath (2011 Ali et al) demonstrated that 10 patients that could not tolerate CPAP and had inadequate resolution of their OSA with OAT were ALL adequately controlled with a combination of their appliance and their CPAP at a lower pressure. Now, were talking, 100% success! This sounds more like a Gold Standard approach than what we’ve been hearing for the last 20 years.
So, perhaps more discussion should revolve around how Physicians and Dentists can work collaboratively together to best help these patients. Quite frankly, I don’t think it is difficult to envision 100% success in managing these patients if we consider the following three options, CPAP alone, OAT alone, CPAP and OAT together.
CPAP-OAT combined allows the patient many options, they can wear both all night, they start with both and take the CPAP off when they have had enough, they can start with their appliance and put CPAP on in the later part of the sleep period when their apnea may be worse during REM sleep or they can start with CPAP and put their appliance on when they feel the need to take their CPAP off. Quite frankly, any increase in Effectiveness or Adherence will increase over all Efficacy.
Of course, add to this weight loss, positional therapy, surgery etc and there is no reason to have anyone inadequately treated. I suggest that for many, the Gold Standard Therapy may in fact be “Harmonized Therapy”. We all know the tools at our disposal, let’s start working together to truly achieve 100% management of this issue for each and every patient we treat.
John Viviano DDS D ABDSM
REPRINTED FROM: SleepScholar.com