Journal of Dental Sleep Medicine Vol. 4, No. 2, 2017 29 JDSM Study Objectives: Tis is a descriptive retrospective study about the efcacy of combination therapy using the TAP-PAP custom face mask (CFM) interface, with a literature review of combination therapy. Te purpose of this study is to determine which group of failed obstructive sleep apnea (OSA) therapies would beneft from combination therapy with the CFM. Te three failed therapies are mandibular advancement splint (MAS) monotherapy, continuous positive airway pressure (CPAP) monotherapy, and TAP-PAP CS (nasal pillows) combination therapy. Clinically, this will assist the clinician to understand the beneft of the CFM when the patient’s current therapy fails. Methods: Tere was a retrospective chart review of patients on combination therapy from 2006–2012. Te 75 patients who underwent combination therapy with the CFM were categorized into the three failed groups. OSA severity was compared between groups. CPAP and compliance were compared before and afer CFM use. A 6-year follow-up was conducted. Results: A total of 220 charts of patients undergoing combination therapy were reviewed; 75 patients were in combination therapy with a CFM. Te populations of the three groups were as follows: MAS monotherapy failed in 11 (11%), TAP-PAP CS failed in 21 (27%), and CPAP failed in 43 (57%) before the CFM was used. Tese patients had severe OSA with mean CPAP 14 cm H 2O. At 6-year follow- up, a 78% compliance rate and average CPAP of 13 cm H2O were reported. Conclusions: Tis study suggests that patients in whom CPAP monotherapy failed would beneft the most from the CFM. Te application of the CFM is for patients with more severe OSA and is well tolerated with improved compliance. Te CFM should be considered when other therapeutic methods of treating OSA have failed or when CPAP or the CPAP mask are intolerable to the patient. Keywords: combination therapy, CPAP, custom face mask, MAS, TAP-PAP Citation: Prehn RS, Swick T. A descriptive report of combination therapy (custom face mask for CPAP integrated with a mandibular advancement splint) for long-term treatment of OSA with literature review. Journal of Dental Sleep Medicine. 2017;4(2):29–36. INTRODUCTION Obstructive sleep apnea (OSA) is a common sleep disorder manifested by repetitive closure or partial closure of the upper airway causing hypoxemia, hypercapnia, and increased sympathetic activity resulting in sleep fragmentation. Te natural history of untreated OSA has been well described, including but not limited to daytime sleepiness, hypertension, cognitive impairment, metabolic syndrome, and obesity. In patients who are symptomatic (presence of excessive daytime sleepiness, cognitive dysfunction, mood disorders, insomnia, hypertension, ischemic heart disease, or cerebrovascular acci- dent) the diagnosis is established if there are fve or more sleep- disordered respiratory events/h of sleep (apneas, hypopneas, or respiratory efort related arousals). If the patient does not exhibit the previously noted symptoms, the presence of 15 or more events/h is sufcient to make the diagnosis. 1 Te severity of OSA varies from mild to severe based on a combination of clinical and polysomnographic determinants. Oral appliance therapy, specifcally mandibular advance- ment splint (MAS) monotherapy and continuous positive airway pressure (CPAP), are indicated for the treatment of mild to moderate OSA. 2 Oral appliance therapy and CPAP are equally efective for mild to moderate OSA, 3 however for patients with severe OSA, the use of MAS monotherapy is generally not recommended; instead, CPAP is typically the preferred method of treatment because of its efectiveness for treating severe OSA. 4 It is generally thought that as the number of apneas/hypopneas increase, the pressure required to main- tain upper airway patency also typically increases. As the pres- sure increases, so do the challenges of CPAP acceptance and/or compliance. With increased pressure, there is increased mask leakage, air leakage out of the mouth, and patient discomfort. 5 Standard of-the-shelf noncustom masks ofen are not efective in these severe cases. Combining CPAP therapy and oral appliance therapy with MAS monotherapy has been shown to be a tolerable and efec- tive therapeutic option. With combination therapy, many of the challenges of CPAP intolerance can be overcome, resulting in improved therapeutic outcomes. Combination therapy utilizes a standard CPAP machine to deliver positive air pres- sure through a standard nasal and/or oronasal interface in conjunction with MAS monotherapy. 6,7 Combination therapy is categorized into two types. Type 1 is CPAP therapy used with MAS monotherapy. Tere is no inte- gration of the two therapies other than both are applied to the ORIGINAL ARTICLES A Descriptive Report of Combination Therapy (Custom Face Mask for CPAP Integrated With a Mandibular Advancement Splint) for Long-Term Treatment of OSA With Literature Review Ronald S. Prehn, DDS, Diplomate, ABDSM 1 ; Todd Swick, MD 2 1 University of Texas School of Dentistry, Houston, Texas; 2 University of Texas School of Medicine, Houston, Texas http://dx.doi.org/10.15331/jdsm.6522