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An Evaluation of a Titration Strategy for Prescription of Oral Appliances for Obstructive Sleep Apnea

Metrohealth Medical Center, Cleveland, OH; Department of Medicine, Division of Pulmonary and Critical Care Medicine; Johns Hopkins University, Baltimore, MD; Department of Medicine, Division of Pulmonary and Critical Care Medicine; Sleep Disordered Breathing & Facial Pain Centers of Maryland, Pikesville, MD

ncollop1{at}jhmi.edu

Abstract

BACKGROUND: Oral appliances (OA) are first-line therapy for mild to moderate obstructive sleep apnea (OSA), and are being used with increasing frequency. Additionally, best practice of OA titration is unknown. We describe the experience of patients treated with OA, identify factors that predict treatment success with OA, and offer a protocol for OA titration.

METHODS: We retrospectively studied patients seen in a dental sleep clinic between 2002 and 2006. Patients selected for OA treatment underwent a baseline polysomnogram, were individually fit with an OA, and instructed to titrate it at home until symptom resolution or discomfort. During follow-up polysomnogram, additional titration was performed, as needed. Primary outcome was successful treatment, defined as apnea-hypopnea index (AHI)<10/hr and AHI decrease at least 50% from baseline. Logistic regression models were created to identify associations between patient characteristics and successful treatment. Overall differences in AHI at baseline, after home titration, and after final titration were compared using Kruskal-Wallis test, and post hoc comparisons were performed with sign tests, with Bonferroni corrections.

RESULTS: Of 57 subjects treated with OA, 37 (64.9%) were successfully treated with OA therapy. Of the 49 subjects for whom data were available for AHI after home titration, 27 (55%) achieved successful treatment of OSA by self-titration, without need for further titration during the follow-up polysomnogram.

CONCLUSIONS: A majority of subjects, regardless of OSA severity, are successfully treated with OA. Men and younger patients were found to be the best responders. The titration protocol for OA offers a beneficial initial-step in the treatment of OSA.

Key Words: Oral Appliance Therapy • Mandibular Advancement Devices • Obstructive Sleep Apnea