For Sleep Apnea Patients, Combination Therapy Can Be the Best of Both Worlds

By Peter Blais, RPSGT

Combination therapy is a fairly new paradigm that is starting to gain more interest for both sleep physicians and sleep dentists who are treating obstructive sleep apnea (OSA), according to Warren Boardman, DDS, an American Board of Dental Sleep Medicine diplomate. Boardman practices at Ridgewood Dentistry in Ridgewood, NJ, where he has treated hundreds of OSA patients.

Combinations of treatment can be multifocal, involving oral appliances, CPAP, positional therapy, EPAP, and surgery, Boardman says. However, the most popular approach is an oral appliance and CPAP together. This combination still maintains a conservative approach that allows each therapy to reach maximum effectiveness while minimizing side effects, Boardman says.

Although CPAP continues to be considered the gold standard for the treatment of OSA, its low compliance rate hampers its true effectiveness. On the other hand, oral appliance therapy enjoys a high compliance rate but may not be as effective as CPAP in parameters like oxygen desaturation index or apnea hypopnea index in moderate to severe OSA patients.

The combination of these therapies can bring together the best of both worlds, Boardman says. The usual adverse side effects of CPAP (namely, high-pressure intolerance) and oral appliances (specifically, extended protrusion) can be minimized, Boardman says.

Each therapy works in sync with the other, allowing for a decreased CPAP pressure and reduced mandibular protrusion to treat the patient. This translates into more comfort for the patient and thus a more effective treatment therapy, Boardman says.

The sleep physician will make the initial decision to utilize either CPAP or an oral appliance. If the recommended treatment cannot normalize AHI or compliance, the decision should be made to try combination therapy, Boardman says.

A mechanism for finding the correct combination can be to treat the patient with an oral appliance to its most effective-yet-comfortable position, and then add CPAP in a sleep lab setting (using a CPAP titration protocol) to finalize the treatment pressure.

Another method may be the utilization of an AutoPAP for a few weeks after oral appliance fabrication. Then a final study should be conducted in the sleep laboratory for affirmative verification of treatment success, Boardman says.

Limitations and ultimate success for combination therapy will depend on the patient being able to tolerate these therapies, Boardman says. If failure of CPAP is from claustrophobia or any other non-pressure-related issue, then those issues will still persist in combination therapy. The same is true for oral appliance side effects. If failure is due to excessive saliva or a continued sensitivity of the teeth or jaw, then combination therapy will be poorly tolerated as well.

Boardman

Insurance concerns, he says, are always at the forefront of any therapy and may be the most limiting factor for proceeding with treatment. However, it should be noted that these therapies are medically necessary and are usually covered by most insurance carriers, Medicare, and Medicaid. The insurance issue that is most prevalent is the out-of-pocket patient portion or deductible. It may be that the therapy is a covered benefit but the deductible may be higher than the actual cost of the therapy. Therefore the procedure becomes partly or fully funded by the patient. It is always best to check with the insurance carrier prior to treatment so all parties are on the same page.

“In conclusion, combination therapy is an excellent approach for treating OSA by exploiting the benefits of oral appliance and CPAP therapies while minimizing their shortcomings. Combinations of oral appliance and positional therapy and oral appliance and surgery can also be very successful for the very same reasons,” Boardman says. “The medical community has utilized combination approaches in many other fields of treatment without reservation and it is only appropriate that this philosophy be extended to sleep medicine.”