Consensus on “Combination Therapy” the Pursuit of Better OSA Therapy Outcomes

(Mark Abramson, Kent Smith, Shouresh Charkandeh, Keith Thornton, Arthur Feigenbaum, Steve Marinkovich, Jason Tierney, Steve Carstensen, Tony Soileau, Lee Surkin, Steve Lamberg, Dennis Marangos, Shari Katz, John Viviano) The LinkedIn Discussion Group, “SleepDisordersDentistry” has just completed an open discussion on “Combination Therapy” the Pursuit of Better OSA Therapy Outcomes. Here is a consensus for all to ponder.

What was asked,

“When one combines “Outcome and Adherence” for any singular OSA therapy, the result often falls short of the mark. However, the combination of “Multiple Therapies” often yields results far surpassing those obtained with any singular approach. Share your protocols regarding the use of combination therapy, which combination of therapies you select for specific patient phenotypes, and other combination therapy suggestions that help optimize your therapy outcomes…”

What was said,

Adjunctive therapies discussed for combination with an Oral Appliance (OA):

Positional Therapy to avoid supine sleep or facilitate airway function

Nasal aids to facilitate nasal breathing

Taping Lips Together to train patients to breathe nasally

  • 3M Micropore tape (Amazon)

Nasal surgery to facilitate nasal breathing

  • Turbinate Reduction

Palatal Implants to stiffen soft palate

CPAP

  • Used Simultaneously
  • Hybrid

 

I’d like to start off by expressing my surprise that there was so little discussion on the benefit of combining weight loss with oral appliance therapy. Shari Katz touched on weight loss, and I have presented her insightful comments in closing below. We are all aware of the relationship between AHI and weight, and that the literature demonstrates a reduction in AHI with successful weight loss. So, I am certain that weight loss is routinely discussed with our patients and perhaps this current discussion revolved more so around things we can do as clinicians. Nevertheless, I wanted to put weight loss out there as a consideration before discussing anything else. Although weight loss is likely the most difficult adjunctive therapy to implement successfully, there should be a constant effort on our part to have our OSA patients normalize their weight.

Regarding surgery, in support of conservatism, it was suggested that nasal aids should be tried before considering nasal surgery. However, in stark contrast, Tony Soileaucombines OAT, physiotherapy for head and neck musculature to ensure trigger point release and Turbinate Reduction routinely, claiming results that surpass CPAP outcomes.

Steve Carstensen shared an inexpensive Positional trick that has worked for many of his patients, “I recommend raising the head of the bed – we suggest patients simply put a 2×4 under the frame at the head of the bed. Have no pre/post data about it, but patient feedback is good, and they really like the low cost”. Steve also cautions patients about using too thick of a pillow, especially in supine position.

Steve Lamberg discussed the use of 3M Micropore tape to have the patients tape their lips together for the sleep period, explaining that this is merely like training wheels to train them to nasal breathe rather than mouth breathe. This tape is easy to use and very inexpensive. He buys boxes and gives out rolls. (Amazon)

For heavy bruxing patients that wear CPAP, Dennis Marangos provides maxillary deprogrammer appliances with an anterior ramp that keeps the mandible forward, especially helpful for those patients with expensive dental work to protect.

Regarding the combination of an OA and CPAP, most clinicians found that patients do not readily accept this option. However, a number of clinicians (including myself) have successfully combined these therapies to obtain a better outcome. Shouresh Charkandeh mentioned that he has some patients that use both devices, but not at the same time. For instance, using CPAP at home and travelling with the OA.

Kent Smith explained his protocol when combining these therapies, “I have found that rarely do patients want to use both OAT and PAP, but when they do, it works well. I used to be concerned that they would vent, but as patients use CPAP, they usually keep their tongue at the top of their palate to seal off the air, so my concerns were ill founded. We get the OA maximally calibrated, then have them do a CPAP titration in the lab with OA in place”.

Mark Abramson shared that the basic premise of the OASYS appliance is actually a combination of nasal and pharyngeal therapy, which includes tongue positioning on the palate. Regarding true Hybrid Therapy, Mark also explained that Jim Addiego of OASYS and Dream Systems has created a connection to attach the TAP PAP or CPAP PRO to the OASYS or Herbst or other appliance that makes it removable so that the patient can remove it for travel or camping. He also shared that John Bixby has a collection of data involving patients who had failed CPAP and did not respond to oral appliance therapy. They were fitted with the OASYS with CPAP Pro and then retested with PSG titration. He found that their CPAP pressure was reduced by 40% and that they were all able to tolerate the therapy with the Hybrid combination of OA and CPAP. 

The inventor of Hybrid Therapy, Keith Thornton shared the following with us, “I would agree with Kent, OAT and PAP, as individual approaches combined don’t work well. However, hybrid therapy using a maxillary stabilized mask works extremely well. The biggest problem with all masks and reason why most are discontinued is leakage. Once the mask is stabilized by an upper tray, there is virtually no leakage. The MyTap-PAP nasal pillow mask that only has the upper tray and is fitted by the patient has been very well received. As Mark Abramson mentioned above, the TAP-PAP has been attached to several different appliances with great success. This is true hybrid therapy. We are now checking with the FDA about regulatory issues with using this with appliances other than the TAP. In a retrospective study by Essick, 70% of failed CPAP patients became compliant with a TAP-PAP. Also, take a look at Ron Prehn’s article in the recent JPD on custom masks and compliance which he presented at the AADSM”.

 http://www.thejpd.org/article/S0022-3913(15)00675-7/pdf

Shari Katz made a very good point about an OA being a journey for some patients,

“After patients have experienced some success with OAT, they often become receptive to the idea of increasing aerobic exercise and/or weight control. Aren’t each of you beginning to see OSA management to be more of an ongoing process instead of giving the patient a therapy that they either pass or fail? As an example, I have had patients that were pretty good responders, but many months (years?) later, they were able to easily handle further protrusion and become successful. OR a couple of months later, they were willing to try using their CPAP over their OA to see if they noted a little more improvement”

So, I suppose we can consider passage of time to be “adjunctive therapy”, highlighting one of the major differences between the use of CPAP and an OA, although we all try our best to obtain optimum outcomes with our initial attempt to calibrate an OA, sometimes, that process is simply the beginning of the Journey to Wellness! We must all work hard to have “OA resistant” physicians understand this difference.

Once again, I would like to thank all those clinicians that took the time to participate in this discussion, this consensus article is intended to provide guidance for those that are new to this area of practice and also to provide valuable insights for those of us that have been at this a while. I look forward to your participation in futureSleepDisordersDentistry LinkedIn discussions.

John Viviano B.Sc. DDS Diplomate ABDSM

John Viviano B.Sc. DDS Diplomate ABDSM

John Viviano B.Sc. DDS Diplomate ABDSM; from Mississauga ON Canada,obtained his credentials from U of T in 1983, he provides conservative therapy for snoring and sleep apnea and Sleep Bruxism in his clinic, Limited to the Management of Breathing Related Sleep Disorders. A member of various sleep organizations, he is a Credentialed Diplomate of the American Board of Dental Sleep Medicine, and has lectured internationally regarding management of Sleep-Disordered Breathing and the use of Acoustic Reflection. Dr Viviano has also conducted original research, authored articles and established protocols on the use of Acoustic Reflection for assessing the Upper Airway and its Normalization. For more info or to contact Dr Viviano click:
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