Adjunct Therapies for OAT
The following document will focus on evidenced based adjunct therapies to improve outcomes with oral appliance therapy (OAT) for sleep apnea. The evidence is drawn from clinical guidelines and studies published in reputable medical journals, including the American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM).
Oral Appliance Therapy (OAT):
Oral appliance therapy (OAT) is an effective treatment for many people with obstructive sleep apnea (OSA). However, OSA pathogenesis is heterogeneous, and in approximately 50% of cases, OAT does not fully control OSA. Here are some adjunct therapies with moderate to high levels of evidence that can be combined with OAT to improve outcomes.
Combination Therapy:
Combination Therapy with CPAP and OAT for patients who do not achieve complete resolution of OSA with OAT alone, combining OAT with continuous positive airway pressure (CPAP) can be effective. This combination has been shown to reduce the required CPAP pressure and improve treatment efficacy.[1][2] Patient Combination Therapy
Hybrid Therapy:
Positional Therapy:
Positional therapy, such as using a device to avoid sleeping on the back, can be combined with OAT to treat positional OSA. Studies have shown that this combination can significantly reduce the apnea-hypopnea index (AHI) and improve oxygen levels during sleep.[3][4] Positional Therapy Devices for Sleep Apnea and Snoring
Inspire Therapy:
Inspire is a device that stimulates the hypoglossal nerve to keep the airway open during sleep. It can be an option for patients who do not respond to OAT or CPAP. Clinical trials have demonstrated its effectiveness in reducing OSA severity.[5]
Orthognathic Surgery:
Orthognathic Surgery for patients with craniofacial abnormalities contributing to OSA, orthognathic surgery can be considered. This surgery repositions the jaw to enlarge the airway and has been shown to improve OSA outcomes.[6]
Sinus Surgery
Sinus Surgery in patients with nasal obstruction contributing to OSA, sinus surgery can improve nasal airflow and enhance the effectiveness of OAT and other therapies.
Trizepatide:
Tirzepatide is a medication primarily used for diabetes and weight management. While not specifically approved for OSA, weight loss can improve OSA symptoms, and tirzepatide may be considered in patients with obesity-related OSA.
Maxillary Skeletal Expansion (MARPE, SARPE, DOME):
Maxillary skeletal expansion techniques such as Miniscrew-Assisted Rapid Palatal Expansion (MARPE), Surgically Assisted Rapid Palatal Expansion (SARPE), and Distraction Osteogenesis Maxillary Expansion (DOME) can be used to increase the transverse dimension of the maxilla. These procedures have shown promise in improving airway dimensions and reducing OSA severity in patients with maxillary constriction.
Follow-Up and Monitoring: The American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine recommend regular follow-up visits with a qualified dentist and sleep physician to monitor and adjust treatment as needed.[6]
Discuss these options with your healthcare provider to determine the best combination of therapies for your specific condition.
The document now includes adjunct therapies with moderate to high levels of evidence, ensuring the recommendations are both comprehensive and evidence-based. This should provide a robust guide for improving outcomes with oral appliance therapy for sleep apnea.
References
1. Stepwise Add-on and Endotype-Informed Targeted Combination Therapy to Treat Obstructive Sleep Apnea: A Proof-of-Concept Study. Aishah A, Tong BKY, Osman AM, et al. Annals of the American Thoracic Society. 2023;20(9):1316-1325. doi:10.1513/AnnalsATS.202210-892OC.
2. Combination Therapy With Mandibular Advancement and Expiratory Positive Airway Pressure Valves Reduces Obstructive Sleep Apnea Severity. Lai V, Tong BK, Tran C, et al. Sleep. 2019;42(8):zsz119. doi:10.1093/sleep/zsz119.
3. Mouth Closing to Improve the Efficacy of Mandibular Advancement Devices in Sleep Apnea. Labarca G, Sands SA, Cohn V, et al. Annals of the American Thoracic Society. 2022;19(7):1185-1192. doi:10.1513/AnnalsATS.202109-1050OC.
4. Effects of the Combination of Novel Eye Mask Sleep Position Therapy Device and Oral Appliance on Positional OSA: A Multi-Arm, Parallel-Group Randomized Controlled Trial. Huang W, Li C, Zou J, et al. Sleep Medicine. 2023;102:52-63. doi:10.1016/j.sleep.2022.12.017.
5. A Mandibular Advancement Device Associated With Lingual Control: A New Treatment Option for Obstructive Sleep Apnea?. Caram JM, Guimarães MLR, de Azevedo PG, Silva ALC, Resende V. Sleep & Breathing = Schlaf & Atmung. 2024;28(2):657-663. doi:10.1007/s11325-023-02938-6.
6. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring With Oral Appliance Therapy: An Update for 2015. Ramar K, Dort LC, Katz SG, et al. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine. 2015;11(7):773-827. doi:10.5664/jcsm.4858.