Should Oral Appliances be considered the gold standard for mild to moderate sleep apnea and CPAP the alternative

A recent article (abstract below) in “Curr Treat Options Neurol. 2009 Sep;11(5):358-67.” describes sleep apnea as “major public health problem that afflicts 9% of women and 24% of men 30 to 60 years of age. It is highly treatable, but when untreated, it has been associated with (but not necessarily linked to) increased probability of cerebral and coronary vascular disease, congestive heart failure, metabolic dysfunction, cognitive dysfunction, excessive daytime sleepiness, motor vehicle accidents, reduced productivity, and decreased quality of life.” It also describes CPAP as the Gold Standard of treatment. This must be called into question and held up for examination. It is established fact from publshed stuies that the majority of patients reject CPAP therapy and even those who use it average only 4-5 hours a night 4-5 nights a week. It appears the gold standard is somewhart tarnished and may in fact be fool’s gold.

The article describes techniques to increase CPAP utilization “Measures to increase compliance with PAP therapy include medical or surgical treatment of any underlying nasal obstruction, setting appropriate pressure level and airflow, mask selection and fitting, heated humidification, desensitization for claustrophobia, patient and partner education, regular follow-up with monitoring of compliance software, and attendance of support groups (eg, AWAKE).” Even with all of these interventions still leave us with less than 50% utilization. In addition, patients with sleep apnea most frequently die of heart attacks and strokes in the early morning hours after the average user has already discarded the machine and mask.

The article then goes on to consider surgical techniques as the second phase of treatment. ” Patients with significant upper airway obstruction who are unwilling or unable to tolerate PAP therapy may benefit from surgery. Multilevel surgery of the upper airway addresses obstruction of the nose, oropharynx, and hypopharynx. A systematic approach may combine surgery of the nose, pharynx, and hypopharynx in phase 1, whereas skeletal midface advancement or tracheotomy constitutes phase 2. Clinical outcomes are reassessed through attended diagnostic polysomnogram performed 3 to 6 months after surgery.”

Also all well and good. The majority of patients with mild to moderate sleep apnea do well with oral appliances. See http://www.ihatecpap.com Studies repeatedly show much higher compliance (hours and days used) with oral appliances so why are appliances not considered the gold standard for this group of patients and CPAP and surgery the alternative tretments. Billions of dollars are at least a part of the problem. Research is controlled by the CPAP and diagnostic equipment maufacturers. A second cause is double dipping with doctors or family members owning CPAP companies. While the majority of companies are legitimate there are also many dubious arrangements to escape STARK laws and laws against self referral. Medicare has recognized that there is financial abuse and have made use necessary for payment. This ill not only reduce medical costs for medicare but will also put an increased onus on CPAP compliance. CPAP should still be considered as a first line treatment for severe apnea but even among patients with severe apnea compliance does not improve.

Surgery is extremely expensive, often carries high morbidity and results are often marginal.

Changing treatment protocols to make oral appliances the first line treatment for mild to moderate sleep apnea is a move that is overdo. If appliances are not successful we can still try less well tolerated CPAP and surgery or do combination therapies.

I do not expect this to happen. I HATE CPAP was banned from meetings of the AADSM and AASM. A past president of the AADSM when presented with the fact that the website www.ihatecpap.com was saving lives responded that it was “irrelevant” The I HATE CPAP! site promotes the principles of the AASM and ADSM but it steps on the toes of deep pockets.

PUBMED ABSTRACT below:
Treatment options for obstructive sleep apnea.
Abad VC, Guilleminault C.

Christian Guilleminault, MD, DBiol Stanford Sleep Medicine Clinic, 450 Broadway Street, Pavilion C, 2nd Floor, Redwood City, CA 94063, USA. cguil@stanford.edu.
Sleep apnea is a major public health problem that afflicts 9% of women and 24% of men 30 to 60 years of age. It is highly treatable, but when untreated, it has been associated with (but not necessarily linked to) increased probability of cerebral and coronary vascular disease, congestive heart failure, metabolic dysfunction, cognitive dysfunction, excessive daytime sleepiness, motor vehicle accidents, reduced productivity, and decreased quality of life. The gold standard for treatment in adults is positive airway pressure (PAP) therapy: continuous PAP (CPAP), bilevel PAP, autotitrating CPAP, or autotitrating bilevel PAP. Measures to increase compliance with PAP therapy include medical or surgical treatment of any underlying nasal obstruction, setting appropriate pressure level and airflow, mask selection and fitting, heated humidification, desensitization for claustrophobia, patient and partner education, regular follow-up with monitoring of compliance software, and attendance of support groups (eg, AWAKE). Adjunctive treatment modalities include lifestyle or behavioral measures and pharmacologic therapy. Patients with significant upper airway obstruction who are unwilling or unable to tolerate PAP therapy may benefit from surgery. Multilevel surgery of the upper airway addresses obstruction of the nose, oropharynx, and hypopharynx. A systematic approach may combine surgery of the nose, pharynx, and hypopharynx in phase 1, whereas skeletal midface advancement or tracheotomy constitutes phase 2. Clinical outcomes are reassessed through attended diagnostic polysomnogram performed 3 to 6 months after surgery. Oral appliances can be used for patients with symptomatic mild or moderate sleep apnea who prefer them to PAP therapy or for whom PAP therapy has failed or cannot be tolerated. Oral appliances also may be used for patients with severe obstructive sleep apnea who are unable or unwilling to undertake PAP therapy or surgery. For children, the main treatment modality is tonsillectomy and adenoidectomy, with or without turbinate surgery. Children with craniofacial abnormalities resulting in maxillary or mandibular insufficiency may benefit from palatal expansion or maxillary/mandibular surgery. PAP therapy may be used for children who are not surgical candidates or if surgery fails.