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Combination Therapy and the Severe CPAP Resistant Patient

Martin Denbar, DDSGeneral Dentist

Diplomate, American Board of Dental Sleep MedicineAdjunct Assistant Professor, Texas A&M School of Medicine

12505 Hymeadow Drive #2EAustin, Texas 78750

www.austinapnea.com(512) 338-8120

What is Combination Therapy

ØWhen one or more treatment modalities are combined to control an airway.

ØFor this presentation:ØThe use of an Interface connecting a PAP device to an Adjustable

Mandibular Advancing Appliance.ØMonoblock appliances with or without an Interface does not allow for

mandibular position variability to achieve maximum therapeutic effect.

Interface Samples

TAP-PAP (CS)

Interface SamplesCPAP Pro

Interface Samples

Fusion Custom Mask

Combined oral appliance and positive airway pressure therapy for obstructive

sleep apnea: a pilot study.(No Interface is used.)

ØPressure reduction: 9.4 ± 2.3 to 7.3 ± 1.4 cm H₂O ØAHI Reduction: 11.2 ± 3.9 to 3.4 ± 1.5

CONCLUSIONS: Combination therapy of MAD and nasal CPAP is effective in normalizing respiratory disturbances of sleep apnea in selected OSA patients who are intolerant to CPAP.

Sleep Breath. 2011 May;15(2):203-8, EI-Solh AA

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Management of severe obstructive sleep apnea using mandibular advancement devices with auto continuous positive airway pressures

(No Interface used)

ØUsed a monoblock appliance(AHI) 66.8/h

ØHe could not tolerate the applied pressure of 12.7 cm of water.Reduced pressures by 33% on day 1 and 51% on day 90.

Lung India, 2015 Mar-Apr; 32(2): 158–161.

Continuous Positive Airway Pressure and Oral Appliance Hybrid Therapy in Obstructive Sleep

Apnea: Patient Comfort, Compliance, and Preference: A Pilot Study

(No Interface used.)

Conclusions: Although pressure could be lowered and hybrid therapy seems a comfortable alternative to conventional CPAP, there were no differences between both therapies regarding compliance, satisfaction, and both objective and experienced effectiveness.

Journal of Dental Sleep Medicine, Vol. 3, No. 1, 2016, Grietje E. de Vries

Combined CPAP-Oral Appliance Therapy: A Case Report

Conclusion:The most logical modality to treat severe OSA patients may be the use of this interface, lowering air pressure while improving leakage and comfort of the mask.

Sleep Review, Published on January 9, 2002, Thornton

A Case Study Involving the Combination Treatment of an Oral Appliance and Auto-

Titrating CPAP Unit(Patient made his Interface in his garage.)

ØDiagnostic PSG: AHI 85 Nadir 85%.

ØNo optimal jaw position with the oral appliance could be identified to normalize sleep respiration: AHI 40 Nadir 84%

ØWith combination of both therapies, sleep respiration was almost normalized: (At 18 months) AHI 7 Nadir 90%

ØAuto-CPAP recorded a mean pressure of 4.5 cm H20.

Sleep Breath 6:125-128, 2002, Denbar

Homemade InterfaceHybrid Therapy A case study using hybrid

therapy to treat a soon to be deployed soldier with obstructive and central sleep apnea

Baseline 11/2007: AHI 85.6 CI 16.6 11/2007 CPAP 10 cmH2O: AHI 6.2 CI 4.44/2008 BiPAP 16/12 cmH2O: AHI 0.8 CI 3.85/2010 AutoPAP Average 11.8 cmH2O: AHI 19.5 CI 26June 2010 ASV with Interface: 16 cmH2O: AHI 0 CI 0

(Deployed)Sept. 2010 Download: AHI 19.5 CI 0.5 (Negligible obstructive and central events but significant hypopneas. Major improvement in quality of life with most symptoms gone. Able to deploy overseas.)Sleepreviewmag.com , June 2012, Denbar

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Dental Clinicians’ Observations of Combination Therapy in PAP-Intolerant

Patients(Using an Interface)

Ø92 OSA patients aged 25 to 85 years (mean 55 years)ØPretreatment AHI 48.0 Post-treatment AHI 3.1 Ø70.7% compliance at 14.0 monthsØPAP/MAS-tolerant patients had remarkably fewer complaints

about the Combination Therapy than conventional PAP.ØOur expectation that the addition of MAS would cause

discomfort in masticatory muscles, TMJ, and teeth was not met.

Sleep Review, March 9, 2015, Sanders, Denbar

A Descriptive Report of Combination Therapy Custom Face Mask (CFM) for CPAP Integrated With a Mandibular

Advancement Splint for Long-Term Treatment of OSA Literature Review

(Custom Face Mask is attached to an Interface.)

Ø75 patients who underwent combination therapy with the CFM were categorized into the three failed groups.

ØTAP-PAP Chair Side (CS) failed in 21 (27%), and CPAP failed in 43 (57%) before the CFM was used.

ØAt 6-year follow-up, a 78% compliance rate.

ØConclusion: The application of the CFM is for patients with more severe OSA and is well tolerated with improved compliance.

Journal of Dental Sleep Medicine, Vol. 4, No. 2, 2017, RS Prehn

A Restorative Technique for the Severe Partial Edentulous and Fully Edentulous

CPAP-Resistant Patient (Using an Interface)

ØPretreatment AHI 33.8 ØPost-treatment AHI 3.6 ØPressures: (post-treatment) 9.8 cmH2O

ØSix weeks post-treatment:ØPressure 9.4 cmH2OØUsage 6 hours 21 minutes ØAHI 2/hr.

Journal of Dental Sleep Medicine, Volume: 04 Number 1, 1/10/2017, Denbar

Fully Edentulous Patient

Combination Therapy Benefits

ØLower pressures: My experience 25-50%ØFewer leaksØLess restrainingØCan be modified to fit a patient’s need.

ØAs a carrier only using the upper appliance converted into TMJ device for TMJ patients, quadriplegics, ALS patients.

ØAs a carrier only for mostly females with sensitive scalps due to fibromyalgia or chronic fatigue.

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Using Upper Appliance only as a CarrierWhen Should Combination Therapy be

Used and Other Thoughts

ØAny patient from moderate to severe that is PAP intolerant.

ØMy experience allows for most BiPAP patients to be converted to CPAP.

ØHave been able to control most patients that have not responded to regular PAP therapy.

ØLess predictability with mouth breathers, UPPP and LAUP.

ØSalivation can be controlled with Botox. (submandibular and sublingual salivary glands)

When Should Combination Therapy be Used and Other Thoughts

ØAlways check results with high resolution pulse oximetry along with PAP download.

ØBe aware of normal AHI from PAP download may still have a low T90 but normal desaturation indices. (Burn Pit Registry)

ØI generally use 6 or 8 cmH2O to 20 cmH2O to gain baseline with 10-15 minute ramp starting at 4 cmH2O.

ØCheck first download next day.ØAnother download 7-10 days.ØLast download 7-10 days along with HRP before refer back to

physician of record.

Who Should be Performing Combination Therapy

ØOral Appliance Therapy by itself or Combination Therapy has no place being administered by a physician or physician assistant. (Dental complications and medical liability)

ØCombination Therapy should only be administered by a highly qualified dentist trained in its use.

ØPatient must be monitored and followed until retested by the referring physician.

ØPatient must be on regular recall.

Case Presentation #1

• 44 year old male• BMI 29.7• Medical History: OSA, HBP, Diabetes• HST 1/18/2017: AHI 74 Nadir 49%• Converted to Combination Therapy 6/9/2017• AHI 2.8 Nadir: 84% (48 seconds below 90% SpO2)• Pressures 11 cmH2O

Case Presentation #2• 53 Year Old Female• BMI 32.8• Medical History: OSA, GERD, HBP, Diabetes, Thyroid Disorder,

Insomnia, Chronic Fatigue, Heart Attack 2010• PSG 1/6/2011: AHI 111 Nadir 81% Pressures 15 cmH2O• Converted to Combination Therapy 1/1/2014• AHI 3.7 Pressures 6.1 cmH2O• Patient disappeared for two years since she felt normal. Now

back on recall.

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Case Presentation #3

• 53 year old female• BMI 30.8• Medical History: OSA, GERD,• PSG 8/24/2014: AHI 91.1 Nadir 68% Pressures 16 cmH2O• Converted to Combination Therapy 10/15/2018• AHI 1.1 Nadir 88% Pressures 9.3 cmH2O

Case Presentation #4

• 37 Year Old Male• BMI 29.4• Medical History: OSA• PSG 12/19/2011: AHI 56 Nadir 67% Pressures 14 cmH2O• Converted to combination Therapy 1/24/2012• AHI .5 Nadir 86% Pressures 10.4 cmH2O

Case Presentation #5

• 39 Year Old Male• BMI 33.5• Medical history: OSA• PSG 8/28/2015: AHI 55.6 Nadir 84% Pressures 11 cmH2O• Converted 10/23/2018• AHI 2.2 Nadir 83% (T90 99.8%) Pressure 7.6 cmH2O • (His dog ate the lower appliance so I modified the upper

appliance to be a carrier only.)

What to Look for that can Impact treatment Success

• Has the patient had a LAUP or UPPP?• Resting tongue position, normal or abnormal• Swallow pattern, Normal or Reverse• Normal or forward head position denoted by side plumb line• Normal lip seal, intermittent mouth breather, obligate mouth

breather• Tongue position will impact pressures

Thank You

Questions?