SLEEP APNEA SURGERY LESS EFFECTIVE THAN ORAL APPLIANCES!
Obstructive Sleep Apnea is routinely treated with CPAP which is considered the gold standard despite dismal results in patient compliance studies. A new review in Medical Clinics show surgical alternatives have mixed results and low cure rates.
A new paper in Medical Clinics of North America (see PubMed abstractt below) by Holty and Guilleminault recognizes that poor compliance with CPAP is a reality and considers surgical alternatives. CPAP is still considered the “Gold Standard” for obstructive sleep apnea treatment in spite of poor compliance because it is highly effective. The problems is many patients report “I HATE CPAP”. The surgery with the finest results is Maxillo-Mandibular Advancement that is typically performed by Oral and Maxillofacial Surgeons. This dental surgery was more successful the surgeries performed by otolaryngologists. Soft palate surgery including UP3 or Uvulopaltoplatopharyngealplasty only cured apnea in a measly 16% of patients and partial surgical success of 50%. UP3 surgery is known to have a high morbidity rate and some patients actually have worse apnea due to scarring of the tissues of the airway.
Dr Ira L Shapira is a Chicago dentist and founder of the website http://www.IHATECPAP.com that touts the many advantages of oral appliances and Dental Sleep Medicine in treating Sleep Apnea. He is always clear to point out that CPAP is the “Gold Standard” of treatment but has been banned from having a booth at national sleep meetings do to the fact that his website name is considered politically incorrect. “I was actually told by a past president of the Academy of Dental Sleep Medicine” says Dr Shapira “that the use of the word “Hate” was so repulsive that even the fact that the website was saving patients lives was irrelevant.”
The American Academy of Sleep Medicine agrees with Dr Shapira that CPAP has serious compliance issues and has accepted oral appliance therapy and Dental Sleep Medicine as a first line treatment of mild to moderate sleep apnea and as an alternative to CPAP for severe sleep apnea when patients do not tolerate CPAP. The majority of patients , in fact, do not tolerate CPAP. Oral Appliances are well tolerated and studies have shown that most patients offered a choice prefer oral appliances to CPAP.
Patients preferences have had only a small effect on the prescribing habits of physician over the last several years in spite of the National Sleep Foundation declaring that “ORAL APPLIANCES ARE A THERAPY WHOSE TIME HAS COME”. This may be do to the fact that many physicians profit directly or indirectly from owning DME’s that supply CPAP therapy to patients. This is not a bad situation as long as physicians recognize that the majority of patients will fail to comply with CPAP therapy. Physicians then has an ethical alternative to refer patients for alternative therapy. Because Oral Appliances are very successful especially for mild to moderate sleep apnea it now obviously the ethical responsibility of responsible physicians to refer patients for Oral Appliance therapy. The landscape is changing and DMEs and Oral Appliance manufacturers are beginning to work together. Dr Shapira predicts exponential growth in the utilization of Oral Appliance Therapy which most insurance companies now cover.
Surgery has marginal effectiveness at its best and therefore should be resrved only for patients who fail both CPAP and Oral Appliance Therapy according to Dr Ira L Shapira the Chicago dentist who founded I HATE CPAP LLC. Dr Shapira expects that insurance companies will begin to deny coverage for surgical treatments for sleep apnea until after Oral Appliance Therapy has been tried. The first choice of surgical procedures should be Maxillo-Mandibular Advancement due to its higher success rate. Dr Shapira recommends that Maxillo-Mandibular Advancement should only be done following oral appliance titration to determine the extent of advancement necessary for successful surgical treatment.
Unfortunately physicians are not always comfortable referring to dentists so they automatically refer to physicians even though therapy will probably not be as effective as an oral appliance.
Dr Shapira is a pioneer of Dental Sleep Medicine and was a Visiting Assistant Professor at the Sleep Disorder Center at Rush medical School under the tutelage of Dr Rosalind Cartwright who is unquestionably one of the All-Time greats in Sleep Medicine along with Dr Guilleminault. Dr Cartwright is primarily responsible for most of the early research into oral appliances as well as positional therapy. Her contribution to Dental Sleep Medicine represents only a sliver of her entire body of sleep research. However, Dr Cartwrights first articles about oral appliances for treating sleep apnea did not bring her accolades but rather scorn. History has proven that Dr Rosalind Cartwright’s work with oral appliances may be some of the most important medical research in the last several decades. While not as sexy as other research her oral appliance research will probably do more to improve the lives of sleep apnea patients than any other researcher in sleep medicine.
Approximately 10,000 unique patients visit www.ihatecpap.com every month and Dr Shapira looks forward to working with DME companies wishing to break into this exciting field. The website has recently undergone a facelift. The majority of dentists who participate in joint marketing efforts with I HATE CPAP LLC sign three year contracts.
Dr Shapira treats sleep apnea patients at his general dentistry practice, Delany Dental Care Ltd www.delanydentalcare.com and at the offices of Chicagoland Dental Sleep Medicine Associates, http://www.chicagoland.ihatecpap.com/. Patients across the US can find Sleep Apnea dentists in their area in the find a dentist area of I HATE CPAP’s website. If there is not a dentist in your area you may use the website contact form and the I HATE CPAP team will assist in find a sleep apnea dentist.
To contact Dr Shapira call toll free 1-8-NO-PAP-MASK
Med Clin North Am. 2010 May;94(3):479-515.
Surgical options for the treatment of obstructive sleep apnea.
Holty JE, Guilleminault C.
Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, VA Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304, USA. [email protected]
Obstructive sleep apnea (OSA) is a prevalent condition characterized by repetitive airway obstruction during sleep with associated increased morbidity and mortality. Although CPAP is the preferred treatment, poor compliance is common. Patients intolerant of conventional OSA medical treatment may benefit from surgical therapy to alleviate pharyngeal obstruction. Case series suggest that maxillomandibular advancement has the highest surgical efficacy (86%) and cure rate (43%). Soft palate surgical techniques are less successful, with uvulopalatopharyngoplasty having an OSA surgical success rate of 50% and cure rate of 16%. Further research is needed to more thoroughly assess clinical outcomes (eg, quality of life, morbidity), better identify key preoperative patient and clinical characteristics that predict success, and confirm long-term effectiveness of surgical modalities to treat OSA.
Dr Ira L Shapira is an author and section editor of Sleep and Health Journal, President of I HATE CPAP LLC, President Dato-TECH, and has a Dental Practice with his partner Dr Mark Amidei. He has recently formed Chicagoland Dental Sleep Medicine Associates. He is a Regent of ICCMO and its representative to the TMD Alliance, He was a founding and certified member of the Sleep Disorder Dental Society which became the American Academy of Dental Sleep Medicine, A founding member of DOSA the Dental Organization for Sleep Apnea. He is a Diplomate of the American Board of Dental Sleep Medicine, A Diplomat of the American Academy of Pain Management, a graduate of LVI. He is a former assistant professor at Rush Medical School’s Sleep Service where he worked with Dr Rosalind Cartwright who is a founder of Sleep Medicine and Dental Sleep Medicine. Dr Shapira is a consultant to numerous sleep centers and teaches courses in Dental Sleep Medicine in his office to doctors from around the U.S. He is the Founder of I HATE CPAP LLC and http://www.ihatecpap.com Dr Shapira also holds several patents on methods and devices for the prophylactic minimally invasive early removal of wisdom teeth and collection of bone marrow and stem cells. Dr Shapira is a licensed general dentist in Illinois and Wisconsin. He has recently founded a new website www.ihateheadaches.org to promote Neuromuscular Dentistry as a safer and effective treatment and prevention therapy of Migraines, Chronic Daily Headaches and Tension-Type Headaches as well as Temporomandibular (TMJ, TMD) Disorders.