Editor’s intro: Dr. Zelk shows how the use of hybrid therapies allows sleep dentists to offer patients access to a combination of the many forms of treatment currently available.
In nearly 20 years of practice in sleep disorders, I’ve seen transitions from PSG to HSAT, from all-CPAP to more inclusion of OA therapy for patients of all levels of diagnosis. But now, I believe the next evolution in OSA treatments will be hybridized practice and hybridized therapies.
In 2005, I wrote about combining different sleep specialists together in one location and coined the label “hybrid therapies.”1 Soon afterward, I had the opportunity to form a hybrid practice model with Richard Moore, DDS, ABDSM, as dental director – I became the medical director of Sleep Medicine Group in Portland, OR and Vancouver, WA. The hybrid practice model was successful due to our efforts lobbying insurance companies to recognize home sleep testing (HST) for OSA. To thrive, we also found it necessary to deliver care in a medically-managed oral appliance therapy protocol for OSA.
Local success with this model led to a national campaign to train dentists in oral appliance therapy and gave us access to other sleep specialists to introduce them to hybridized therapies such as oral appliance/CPAP, oral appliance/upper airway surgery, oral appliance/nasal dilation, and oral appliance/side sleep therapy or weight loss management.
After over 15,000 oral appliance patients and many hundreds of Hybrid Positive Airway Pressure (HPAP) patients, we are convinced the foundation of airway support is to stabilize the mandible and add treatments to achieve the best outcomes, with optimum adherence to therapy as a major outcome goal.
I recently have had several positive patient outcomes combining Bongo Rx and oral appliance therapy. Notably was one very severe OSA patient (96/hr AHI) with sub-optimal oral appliance treatment after he failed CPAP.
Follow up testing showed he still had severe OSA with OA alone (61/hr AHI) but needed CDL clearance. Typically we would attempt HPAP (oral appliance with CPAP), but that would take months of time that he did not possess. We chose a trial of Hybrid-EPAP therapy, which reduced his 96 AHI to 2.5. Best of all, he tolerated wearing the EPAP (Bongo Rx) with his oral appliance, unlike his previous CPAP experience.
When compared head-to-head with PAP, OAT has been found to be as effective in many parameters except AHI reduction.2 With new therapies coming to market like the genioglossal nerve stimulator, (cNEP), novel TRDs, oral negative pressure, soft palate stiffening procedures, myofunctional therapy, maxillary development platforms, hybrid-EPAP and possibly future hybrid auto-EPAP therapies, I look forward to a sleep community brought together by the hybrid practice treatment of OSA.
1. Zelk J. Taking a bite out of SDB. Sleep Medicine Reviews. 2005;8: 25-26.
2. Phillips CL, Grunstein RR, Darendeliler MA, Mihailidou AS, et al. Health Outcomes of Continuous Positive Airway Pressure versus Oral Appliance Treatment for Obstructive Sleep Apnea. AJ AM J Respir Crit Care med. 2013;187(8):879-887