John Viviano DDS D,ABDSM
Clinical Director at Sleep Disorders Dentistry Research and Learning Centre
The American Academy of Sleep Medicine (AASM) just published an update to the use of Positive Airway Pressure (PAP) to manage Obstructive Sleep Apnea (OSA) JCSM, Vol. 15, No. 2 Feb 15, 2019. These devices are commonly referred to as CPAP and APAP, the first being continuous airflow and the later having the ability to sense the required airflow and adjust accordingly. Of course, when a patient is able to wear their PAP all night, the outcomes are stellar, with most patient’s experiencing complete elimination of their OSA. So, for those patients, PAP is GREAT! But, there is something really important missing in these guidelines…
Well, the guidelines do not address the Elephant in the room. A Frost and Sullivan Report commissioned by the AASM in 2016 found that of the 5.9 Million Americans diagnosed with OSA, only 60% were adherent to CPAP, leaving 2.4 million unmanaged. Making matters worse, a study of 2,687 patients followed for 7 years did not experience the protection from cardiovascular accidents expected from their CPAP wear; this study found that patients wore their CPAP for an average of 3.3 hours per night New Eng J Med 2016; 375: 919-931. The moral of the story here is not that PAP does not work. PAP DOES WORK! But, you need to wear it all night, and it is well established that only about 1/3 of patients wear their PAP all night long, leaving the other 2/3 either sub-optimally managed, or unmanaged!
So how is it that guidelines can continue to refer to PAP as a Gold Standard Therapy and dismiss the other therapies, relegating them to the fine print, when it is documented to only be effectively helping 1/3 of the diagnosed patients? Hmmm???
Low rate of adherence is problematic
The guidelines discuss “Patient-Centered” care, “in which an individual patient’s specific health needs and desired health out-comes are the driving force behind all health care decisions”, which sounds promising. However, the guidelines then go on to discuss the usual and customary approach which has simply not worked to date; we’ll change the pressure level, we’ll try a different mask, we’ll add humidification, we’ll try Auto instead of Continuous PAP, etc. But don't take my word that this approach hasn't worked, here's the proof, a comprehensive systematic literature review of (1994– 2015) of 82 CPAP studies found that “The rate of CPAP adherence remains persistently low over twenty years’ worth of reported data…This low rate of adherence is problematic, and calls into question the concept of CPAP as gold-standard of therapy for OSA.” Rotenberg et al. Journal of Otolaryngology - Head and Neck Surgery (2016) 45:43.
The Elephant in the room
Yet, the new PAP guidelines do not address this problem at all! What’s the definition of insanity again? Oh right, continuing to do the same thing and expecting a different result! I am actually not trying to be funny here. This is not a laughing matter; I am deeply troubled by the lack of legitimate guidance these guidelines provide physicians for patients that cannot tolerate wearing PAP. It’s time we meet the Elephant in the room head on, and come up with truly Patient-Centric guidelines, that will not leave a good percentage of diagnosed patients either sub-optimally managed or unmanaged altogether.
What’s Missing? I say a “Patient-Centric” approach to the management of OSA is missing; currently, we have a “Treatment-Centric” approach, that focuses on simply “One Therapy”, that is missing the mark by a long shot!
If you struggle with OSA or are having difficulty with your PAP, ask your Dentist about the Oral Appliance Alternative. If you are a Dentist not yet involved in the management of Breathing Related Sleep Disorders, it's time to look into it. Your patients will thank you for it.