Resmed CPAP

Wouldn’t it be Nice to Effectively Treat 100% of our OSA Patients?

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!

Resmed CPAP
Resmed CPAP

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

Resmed Narval CC
Resmed Narval CC

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 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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One comment

  1. Don’t forget surgery … minimally invasive surgery of the nose, throat, and palate have an important role either as primary treatment or adjuvant treatment for snoring and sleep apnea. There is a definite role for MMA surgery as well. And of course the recent results of the “STAR” trial using upper airway stimulation show excellent results for CPAP and OAT failures. I agree that CPAP is not the “gold standard”, I call it the “old standard”. Comprehensive treatment of sleep apnea and snoring includes surgery.

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