It’s clear that the availability of oral appliance therapy (OAT) is a successful form of treatment for patients with obstructive sleep apnea (OSA). The availability of OAT helps dental sleep medicine specialists treat patients suffering from mild to moderate sleep apnea. However, OAT isn’t always the best form of treatment for patients. If OAT doesn’t produce the results dental sleep medicine specialists are looking for in the treatment of sleep apnea, combination therapy might be an improved option for providing relief.
Table of Contents
Combination Therapy for Sleep Apnea Treatment Success
Combination therapy is the use of oral appliance therapy in tandem with another form of treatment for sleep apnea. One option I typically use is OAT with ventral only ablation therapy (VOAT). VOAT is a newer approach created by a local physician in Atlanta, GA, Dr. David Dillard. Together these treatment options can further help in improving the treatment of obstructive sleep apnea in qualified patients. It is important to note that if OAT doesn’t work, VOAT might and vice versa. In these cases, Dr. Dillard and I often collaborate to provide dual treatment for our patients. While you might not have the same option for treatment available in your community, there are other combination therapy options available.
Ventral Only Ablation Therapy (VOAT) and OAT
VOAT surgery is a new approach to radiofrequency ablation of the tongue that has improved success rates over similar treatments. Previous radiofrequency ablation (RFA) procedures approached the tongue from a dorsal (top surface) aspect of the tongue. However, the VOAT procedure approach is from the bottom surface for a less painful and better outcome. With this procedure, patients have an 80% chance of improvement.
As a result, many patients don’t require a CPAP machine to improve their sleeping patterns. The VOAT procedure is quick and requires minimal sedation and treatment sometimes takes only 30 seconds.
Through the availability of combination therapy, OAT and VOAT give patients the benefits of both individual treatments. Many patients are CPAP non-compliant, and the combination of VOAT and OAT helps patients experience improved results.
Utilizing CPAP and OAT
Another combination therapy approach is through continuous positive airway pressure (CPAP) therapy. CPAP therapy is highly effective in treating obstructive sleep apnea, but it is limited by poor adherence to therapy. The combination of a nasal CPAP and OAT can provide another option for CPAP-intolerant patients with incomplete response to OAT.
In a 2011 study, ten patients with residual apnea/hypopnea events on mandibular advancement devices (MADs) who were intolerant to CPAP therapy were examined. The combination of MAD and nasal CPAP was well tolerated by all participants. Compared to utilizing CPAP therapy alone, the optimal pressure required to eliminate all obstructive events on the combination therapy was reduced from 9.4 to 7.3 cm. The combination therapy was also effective in reducing daytime sleepiness.1
Drug-Induced Sleep Endoscopy (DISE)
The mandatory diagnostic workup for OSA is through polysomnography (PSG). An up and coming adjunct diagnostic procedure is drug-induced sleep endoscopy (DISE), which is a dynamic, safe, easy-to-perform technique that visualizes the anatomic sites of snoring or apneas. DISE looks at the airway with a scope to see at which level obstructions are taking place. DISE guides the making of a tailor-made treatment plan in individualized cases.
A study of 100 patients who were eligible for sleep surgery or mandibular repositioning appliance (MRA) underwent PSG and DISE. As a result of this study, multilevel collapse, complete collapse, and a tongue-based collapse were statistically associated with higher apnea-hypopnea index values. The result of this study helps healthcare professionals to understand the pathogenesis of OSA and the associations between PSG outcomes and DISE results while assisting in the creation of patient-specific treatment options.2
Another study further displayed DISE’s influence on the location of treatment. As a result, the change in success rates of non-CPAP therapy in OSA and snoring might be possible.3
DISE also plays a role in determining if implanted upper airway stimulation (UAS), which consists of a respiration sensor, a programmable implanted pulse generator, and stimulating electrodes, is an effective tool in the treatment of OSA. A study of 21 OSA patients who underwent DISE before implantation of a UAS system revealed a significantly better outcome for these patients. The absence of palatal collapsibility during DISE may help to predict therapeutic success with UAS therapy.4
Body Position and OSA
Patients can experience improvement through their body position. A study of 30 male patients examined time spent on their side versus time on their back while sleeping. For 24 of the subjects, the apnea index was found to be twice as high during time spent sleeping on their backs than when they slept in the side position. This difference is reliable and inversely related to obesity. Five patients meeting diagnostic criteria for obstructive sleep apnea on an all-night basis fell within normal limits while in the side position, which suggests sleep position adjustment may be a viable treatment for patients who are not obese.5
Weight Loss and OSA
Therapeutic effects of weight loss was evaluated in 15 patients suffering from moderately severe OSA. As these patients decreased their body weight, the frequency of apnea fell significantly in non-rapid-eye-movement sleep. Weight loss also led to a decline in the mean oxyhemoglobin saturation during the remaining episodes of sleep apnea.
Patients also experienced improved sleep patterns with a reduction in stage I sleep and a rise in stage II sleep. Of the nine patients with the most marked fall in apnea frequency, daytime hypersomnolence decreased. In patients who didn’t lose weight, there were no significant changes in sleep patterns. The results from this study showed that moderate weight loss alone could alleviate sleep apnea, improve sleep architecture, and decrease daytime hypersomnolence.6
Combination therapy can involve CPAP, OAT, a change in sleep position, DISE as a guide to determining treatment, or even weight loss. It can also be any other upper airway surgical procedure in combination with OAT. The key is to identify the level at which treatment is failing. Once we visualize where the failure is, with or without OAT, a better-targeted approach can be created to improve treatment outcomes.
The newer procedures listed above are not the gold standard of care for sleep apnea, but they are upcoming treatments that may be promising. Remaining open and committed to finding the right treatment for patients, including combination therapy, has provided common ground to work with physicians and co-referrals. Communicating with physicians is the key to a successful dental sleep medicine practice, and combination therapy allows dentists to keep that line of communication open.
Mayoor Patel, DDS, MS, RPSGT, D.ABDSM, DABCP, DABCDSM, DABOP, serves as a board member with the American Board of Craniofacial Dental Sleep Medicine, American Board of Craniofacial Pain (ABCP), American Academy of Craniofacial Pain and the British Society of DSM. He also has taken the role as examination chair for the ABCP. Having a limited practice to Craniofacial Pain and DSM, Dr. Patel utilizes his experience and expertise to help dentists across the country excel within their dental practices. As Clinical Education Director with Nierman Practice Management, Dr. Patel develops up-to-date curriculum for their sleep apnea and craniofacial pain programs. To register for a seminar, contact Nierman Practice Management through Contactus@dentalwriter.com or 800-879-6468.
1. El-Solh, Ali A., et al. “Combined oral appliance and positive airway pressure therapy for obstructive sleep apnea: a pilot study.” Sleep and Breathing 15.2 (2011): 203-208.
2. Ravesloot, Madeline JL, and Nico de Vries. “One hundred consecutive patients undergoing drug-induced sleep endoscopy: Results and evaluation.” The Laryngoscope 121.12 (2011): 2710-2716.
3. Eichler, Corlette, et al. “Does drug-induced sleep endoscopy change the treatment concept of patients with snoring and obstructive sleep apnea?.” Sleep and Breathing (2013): 1-6.
4. Vanderveken, Olivier M., et al. “Evaluation of drug-induced sleep endoscopy as a patient selection tool for implanted upper airway stimulation for obstructive sleep apnea.” Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 9.5 (2013): 433.
5. Cartwright, Rosalind Dymond. “Effect of sleep position on sleep apnea severity.” Sleep 7.2 (1984): 110-114.
6. Smith, Philip L., et al. “Weight loss in mildly to moderately obese patients with obstructive sleep apnea.” Ann Intern Med 103.6 Pt 1 (1985): 850-5.
Stay Relevant with Dental Sleep Practice
Join our email list for CE courses and webinars, articles and more..
Dental Sleep Practice is a leading dental journal and publication for obstructive sleep apnea case studies, dental continuing education, and more. Subscribe to Dental Sleep Practice today!
Each one-hour virtual webinar moderated by MedMark Media is equivalent to one continuing education (CE) credit. Credit is available to all who register for the webinar and successfully complete a ten-question quiz through our publication’s online system.
Registrants can attend the webinar live at the specified date and time by using the GoToWebinar join link provided by email from any device with an internet connection. Using a laptop or desktop computer is recommended for best viewing the presentation. If you are using a mobile phone or tablet, we recommend using the GoToWebinar app instead of the web browser to improve ease of use for the webinar’s platform. Registrants will also have access to watch the replay at their own convenience through a link emailed to them within 24 hours of the specified live date and time which is hosted on our publication’s website.
If registrants would like to ask a question or receive further clarification, they can type their questions or comments in the question box of the webinar system. The moderator reminds the attendees multiple times before and after the presentation to use the question box. Questions are addressed at the end of the presentation for at least ten minutes. If any questions come in that are not able to be answered live in the time available, we give the question along with the registrant’s email address to the presenter for them to follow up directly.
Registrants will have to either sign in (previous webinar attendee) or sign up (first-time webinar attendee) for our CE quiz system on our publication’s website. Registrants of all CE webinars are allowed this account free of charge. The ten-question quiz is linked on the replay page below the video as well as available directly through the CE dashboard once the registrant is logged in.
Once the quiz is successfully completed, there is a button to download a PDF of the certificate. A copy of the CE certificate is also emailed to the address on file for the CE account. To ensure the deliverability of emails about CE credits, please:
Check the spam/junk folder in your email account for the email.
Set subscriptions@endopracticeus.com in your email platform.
If the registrant is having trouble accessing either the live webinar, replay, CE quiz or certificate we are available to help by email, chat, and phone. We can provide simple steps with screenshots on how to navigate to and complete the Webinar CE quizzes.
Legal disclaimer: Webinar expires 2 years from the live date. The CE provider uses reasonable care in selecting and providing accurate content. The CE provided, however, does not independently verify the content or materials. Any opinions expressed in the materials is those of the presenter and not the CE provider. The instructional materials are intended to supplement but are not a substitute for the knowledge, skills, expertise, and judgment of a trained healthcare professional.