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Original Research: SLEEP MEDICINE |

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

Vidya Krishnan, MD, MHS, FCCP; Nancy A. Collop, MD, FCCP; Steven C. Scherr, DDS
Author and Funding Information

*From Metrohealth Medical Center (Dr. Krishnan), Cleveland, OH; Department of Medicine (Dr. Collop), Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD; and Sleep Disordered Breathing and Facial Pain Centers of Maryland (Dr. Scherr), Pikesville, MD.

Correspondence to: Nancy A. Collop, MD, FCCP, 1830 E Monument St, Room 555, Baltimore, MD 21205; e-mail: ncollop1@jhmi.edu



Chest. 2008;133(5):1135-1141. doi:10.1378/chest.07-1644
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Background: Oral appliances (OAs) 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 an OA, identify factors that predict treatment success with an 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 baseline polysomnography, were individually fit with an OA, and were instructed to titrate it at home until symptom resolution or discomfort. During follow-up polysomnography, additional titration was performed as needed. Primary outcome was successful treatment, defined as apnea-hypopnea index (AHI) <10 events per hour 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 an OA, 37 subjects (64.9%) were successfully treated with OA therapy. Of the 49 subjects for whom data were available for AHI after home titration, 27 subjects (55%) achieved successful treatment of OSA by self-titration, without need for further titration during follow-up polysomnography.

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

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