Achieving Long-term OSA Stabilization Despite CPAP Intolerance with Oral Appliance Therapy

Sal Rodas shares the story of a patient who was CPAP intolerant but found relief from OSA with ApnoDent sleep appliance.

by Sal Rodas, MBA 

Continuous Positive Airway Pressure (CPAP) therapy continues to be considered the gold-standard treatment option for patients that suffer from obstructive sleep apnea (OSA).

However, there have been studies published in the refereed literature suggesting that oral appliance therapy is an equivalent alternative for patients that suffer from mild to moderate OSA. Some of those studies highlight the benefits of using oral appliance therapy over CPAP because patients find oral appliances more convenient and comfortable, resulting in better compliance.

Compliance is an essential factor that patients should be made aware of when presented with therapy options. Studies have shown that CPAP intolerance can be as high as 60%. Despite studies showing how effective CPAP addresses OSA, it should be noted that this efficacy possibly comes at the cost of driving patients not to wear CPAP long-term.

Like CPAP, oral devices are for managing and not curing OSA and will require patients to wear the devices long-term.

Therefore, consideration of effectiveness vs. efficacy of therapy should be analyzed when considering an ideal treatment for the patient.

Clinical Case

The following case, courtesy of Dr. Joseph Yousefian in Bellevue, WA, showcases an effective and practical protocol to address CPAP-intolerant patients and demonstrates an effective option with oral appliance therapy.

The patient presented to the practice with an ideal bite after orthodontic/equilibration treatment, as noted in the post-treatment photographs (Figure 1).

Figure 1: Post orthodontic/equilibration treatment, extra and intraoral photographs. Courtesy: Joseph Yousefian, DMD

During the visit, the patient indicated he had been diagnosed with OSA and was prescribed the use of CPAP to manage his condition. However, the patient explained that he had not been using his CPAP. Therefore, a sleep disordered evaluation was performed on the patient that revealed symptoms of severe sleep bruxism, excessive daytime sleepiness, and snoring. The patient also complained of having chronic pain in the jaw and masseters, especially when waking up in the mornings. He reported gaining over 10 pounds in the last few years and the presence of hypertension which was not responsive to his daily medication.

Figures 2A-2B: A. The ApnoDent® sleep appliance. Courtesy: ApnoMed, Inc. B. Intraoral photos with the ApnoDent sleep appliance. Courtesy: Joseph Yousefian, DMD

The patient was referred to complete an in-lab polysomnogram (PSG) since it had been a long time since his previous sleep study.

The results of the PSG indicated the presence of severe OSA with an apnea/hypopnea index (AHI) of 43.1/Hr and respiratory disturbance index (RDI) of 44.8/Hr. The PSG also indicated a REM dominant OSA with an AHI of 58.6/Hr. The minimum SaO2 was 89.0% with a mean SaO2 of 98.8%. The sleep efficiency was calculated at 93.4%.

Despite his severe OSA, the patient refused treatment with CPAP and was referred back to Dr. Yousefian’s office to be treated for his OSA and masticatory/temporomandibular joint disorders (M/TMJD). His treatment was initiated with bedtime use of the ApnoDent®, an FDA-approved oral appliance (Figure 2) designed to manage his bruxism, M/TMJD issues, snoring, and OSA.

An efficacy test was performed after four weeks of ApnoDent® use; the sleep test results indicated a reduction of AHI to 1.9/Hr with SpO2 nadir of 91%. The Mean SaO2 was 94.7%, and the sleep efficiency was 93.4%

The patient started his 2-year supervision phase and continued to use the ApnoDent with a lower clear retainer at bedtime.

In the post-treatment phase, he was seen annually for clinical monitoring of his M/TMJD and OSA issues. His annual check in the fourth year revealed that his bite was still very stable with Shimstock still holding all the posterior teeth. He presented an absence of bruxism and M/TMJD symptoms as long as the patient wore the ApnoDent. The patient described waking up refreshed daily, that he has not gained any more weight, and his blood pressure is back to normal with no need for medication.

Figure 3: Four years post-treatment extra and intraoral photographs. Courtesy: Joseph Yousefian, DMD


As noted in this case, oral appliance therapy can be an effective alternative to CPAP, even in cases where the patient has been diagnosed with severe OSA.

The use of the novel ApnoDent device was ideal in this case because the device did not cause any of the known side effects that traditional dental sleep appliances cause: posterior open bites, joint discomfort, or unintended tooth movements, allowing the patient to successfully wear the device long-term.

While CPAP remains the gold standard, educating patients on intolerance rates is essential to help patients make an informed decision about their treatment options. In this case, monotherapy was ideal for the patient. However, there are opportunities also to treat severe OSA patients with combination therapy, where CPAP and an oral appliance are worn together to help the patient be more successful and compliant with their treatment.

After reading about the new ApnoDent sleep appliance, check out this article by Dr. John Remmers on a polysomnographic test that examines a patient’s breathing while using an adjustable MPDA.

Sal Rodas is the Executive Director for the Foundation for Airway Health and a member of the American Dental Association’s Children’s Airway Screener Taskforce. Mr. Rodas has over 20 years of professional senior level executive experience. Throughout his career, Sal has been innovating solutions and leading companies in the medical and dental sleep industry designed to help practices grow.

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  4. Sutherland, K., Phillips, C. L., & Cistulli, P. A. (2015). Efficacy versus effectiveness in the treatment of obstructive sleep apnea: CPAP and Oral Appliances. Journal of Dental Sleep Medicine, 02(04), 175–181.
  5. Tong, B. K., Tran, C., Ricciardiello, A., Donegan, M., Chiang, A. K., Szollosi, I., Amatoury, J., Carberry, J. C., & Eckert, D. J. (2020). CPAP combined with oral appliance therapy reduces CPAP requirements and pharyngeal pressure swings in obstructive sleep apnea. Journal of Applied Physiology, 129(5), 1085–1091.
  6. Virk, J. S., & Kotecha, B. (2016). When continuous positive airway pressure (CPAP) fails. Journal of Thoracic Disease, 8(10).

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