TITRATION END POINT; WHAT
STANDARD OF CARE ARE YOU
STRIVING FOR?
APRIL 29, 2015 JOHN VIVIANO B.SC. DDS DIPLOMAT E ABDSM LEAVE A COMMENT
AS PRESENT ED ON SLEEPSCHOLAR.COM
When I first became involved with Sleep Disorders Dentistry circa 1995, I remember feelings of
frustration regarding the lack of an objective way to establish the titration endpoint of an oral
appliance.During that era, as Dentists, we would have to wait until the in-lab sleep study results
revealed how effective our titration efforts were. With experience, we’ve learned that titrating
through subjective feedback alone often results in under-titration of an oral appliance. Since
these early days, we have come a long way, this journey involving the use of various literature
validated questionnaires, measurement of variables closely associated with sleep apnea such as
nocturnal oxymetry and more recently, what I believe to be thecurrent titration standard of
care; the “Home Sleep Test” (HST). There simply is no other more dependable way for a
Dentist to evaluate the efficacy of their titration end-point than through the use of aHST.
One common practice regarding appliance titration has involvedtraining and allowing the in-lab
sleep technician to fine tune titration of an oral appliance a Dentist has made. Pre the
affordable and reliableHST era, perhaps this made sense, but not today. This protocol is a bit
like the Wedding Cake you ordered arriving with the Icing dispenser on the side so you can
put the names on the way you wish? Madison Lee’s Cakes of New York, NY would never
consider letting someone else put the icing on one of their cakes. After all, they are
professional’s and are extremely proud of their work! If we expect to be treated like
professionals, we should be absolutely on top of our game and return the patient back to the
referring physician with the appliance optimally titrated along with objective verification of our
efforts. Presently, there is no better way to do that than with an HST. In-lab testing is expensive
and often not covered by insurance; it should be reserved for initial diagnosis and for
confirmation of treatment. The HST is useful to the treating Dentist to titrate or calibrate the
oral appliance for maximum effect before the final in-lab sleep study is used to confirm
efficacy of the appliance titration.
In 2015, affordable, reliable and easy to use HST’s make it possible to objectively check, modify
appliance titration when necessary, and objectively recheck how well titration efforts
are
working; while the
patient sleeps in their own bed, in the manner they are accustomed to sleeping. The information
deemed with an HST is also helpful when dealing with residual supine related apnea. Body
position is critical to the treatment of a Sleep Apnea patient with an oral appliance. Too often
patients with positional apnea are left at a risk of being untreated in supine position. Once
revealed by an HST, it can be dealt with by either further advancement, placement of elastics to
prevent mouth opening while supine or simply avoiding supine sleep in the event you have
already exhausted all other possibilities. Why should we wait to hear from an in-lab sleep study
conducted in a medical facility that our titration is incomplete, exposing the patient to
unnecessary in-lab diagnostics and ourselves to the risk of under-titrating the patient? Sleep
Disorders Dentistry has come a long way since 1995; one could argue that being able to easily
obtain this level of accurate information, repeatedly and as required, is one of the greatest
advancements in this field.
As a side note, the relationship between Sleep Apnea and Sleep Bruxism has been receiving a
lot of attention as of late. As our understanding of this relationship increases,
I
believe that if you are
going to invest in a sleep screener it makes sense to obtain one that provides objective evaluation
of Sleep Bruxism. For those of you that restore and reconstruct the dentition, evaluating for
Sleep Bruxism will not only allow you to make better restorative treatment planning decisions
but will also help you uncover underlying sleep apnea so that you can make appropriate
physician referrals.
In my dedicated Sleep Apnea Dental Practice I use theNOX-T3 ambulatory sleep screener
distributed by Carefusion to help determine titration end points, monitor for supine related apnea
and Sleep Bruxism. My oldest unit is now almost three years old, has been used regularly, and is
still going strong. The very low cost of NOX T3 disposables allows repeated use of this HST
without economic burden to my office or the patient. In addition, the easy evaluation of Sleep
Bruxism makes it useful not only in my Sleep Office but in my General practice as well.
Think of the ambulatory sleep screener as a tool that provides you objective measurements of
criteria of interest. For those of you that perform endodontic treatment, could you imagine doing
so without an apex locator? Although at one time endodontics was performed without the help of
an apex locator, no one would think of doing that today. Similarly, if you titrate oral appliances
without the objective aide of a HST, I would argue you are not working to the current standard
of care. What Standard of Care are you striving for?
John Viviano B.Sc. DDS Diplomate ABDSM; from Mississauga ON Canada,obtained his
credentials from U of T in 1983, he provides conservative therapy for snoring and sleep apnea
in his clinic, Limited to the Management of Breathing Related Sleep Disorders. A member of
various sleep organizations, he is a Credentialed Diplomate of the American Board of Dental
SleepMedicine, and has lectured internationally regarding management of Sleep-Disordered
Breathing and the use of Acoustic Reflection. Dr Viviano has also conducted original research,
authored articles and established protocols on the use of Acoustic Reflection for assessing the
Upper Airway and its Normalization. For more info or to contact Dr Viviano click: Sleep Disorders
Dentistry