(Stuart Rich, Les Priemer, Barry Glassman, John Viviano, Shouresh Charkhandeh, Dennis Marangos, Todd Morgan, Sharnell Muir, David Rawson, Harry Ball, Steve Carstensen, Erin Elliott, Kent Smith, Keith Thornton, Tony Soileau, John Carollo, Steve Lamberg, Promila Mehan, Gina Pepitone-Mattiello, Christopher Kelly, Mark Collins, Ken Luco)
The LinkedIn Discussion Group, “SleepDisordersDentistry” has just completed an open discussion on “Patients adjusting their OSA Oral Appliances at home…Risk vs. Benefit!”. Here is a consensus for all to ponder.
What was asked,
“Some clinicians routinely have their patients adjust their appliance “at home” during the calibration process; others prefer to adjust the appliance “in office”. Yet others vary their protocol based on certain criteria. Let’s share our protocols, why and when we do what…”
What was said,
As expressed in the question above, there seems to be two camps, routine “in-office” calibration, and routine “at-home” calibration. However, with few exceptions most clinicians are open to the alternative approach based on exceptions or special circumstances. Here is a summary of the rational for each camp and their exceptions…
At-home Appliance Calibration:
A number of clinicians discussed their “at-home” calibration protocols. In all cases, the patients were provided specific verbal instructions and were advised to return upon reaching various end-points, specific time periods or resolution of specific symptoms. The symptom they were most often requested to monitor was elimination of snoring, however, other symptoms included witnessed apnea, number of trips to the bathroom, increased dreaming, increased daytime energy etc. Interestingly, although some clinicians may do so, no one mentioned providing the patient written instructions, which is recommended by the American Academy of Dental Sleep Medicine.
Some have the patient advance in very small increments and others, in larger increments, the rational for larger increments being that reaching the optimum position sooner may reduce potential for TMD symptoms due to the reduction in sleep bruxism that often accompanies normalization of AHI.
A number of clinicians discussed using the “at-home” calibration protocol after they have seen the patient once on follow-up, allowing an opportunity to ensure that the appliance is fitting properly and that the patient is not experiencing any meaningful side effects that would be problematic for continued advancement.
Most of the “at-home” protocol clinicians routinely offer making “in-office” adjustments if the patient does not feel comfortable with the “at-home” calibration protocol, however, they report that most patients opt for the convenience of “at-home” calibration and a subset opt for the clinician making the adjustments “in-office” due to their concern of doing it “wrong”. Other reasons a patient may prefer ‘in-office” calibration is lack of manual dexterity or poor eyesight, which is common with elderly patients.
Some clinicians discussed providing the Sleep Techs with written instructions should further calibration be required at the in-lab sleep study. Others provide the sleep techs with a chart so they document various positions and apnea levels, used to help finalize the most optimum position.
Les Priemer described his protocol, which involves both “at-home” calibration and “in-lab” fine tuning,
“I show every patient how to advance their appliance but advise them not to adjust it until I reassess them after one week. At that time if there are any significant symptoms of SDB I advance the appliance with the patient watching so that they can titrate further until I see them one month later. I instruct them to stop further adjustments if there are any TMD issues. At the one month reassessment, if indicated, I’ll make further adjustments and set the patient up with an in-lab PSG with instructions for the sleep tech so that the final titration can be done.”
Todd Morgan explained how we resolve sleep disordered breathing (SDB), “Since we undo SDB by fixing apnea first, then hypopnea, and then UAR with snoring finally in that order, we allow the patient to do that themselves unless they are incapable. The passive airway yields comfort.” He instructs his patients to advance ½ mm every other night until snoring resolves.
Some clinicians have their patients advance their appliances in very small increments, making “in-office” calibration impractical. The fear of having them come to the office too many times is that they may stop coming, resulting in a sub-optimal position. It was also mentioned that having the patient participate in the appliance calibration can help the patient feel that they have a stake in the process, perhaps aiding in compliance and overall efficacy. For instance, Lynne Hayes told us about her TAP 3 appliance, which she calibrates “at-home”, herself, with the help of her husbands feedback.
Steve Carstensen shared that the AASM has a new program called SleepTM (Sleep Telemedicine), an organized, billable way to take care of patients over an Internet Portal. Imagine, taking care of a patient issue with a face-to-face communication over the computer, eliminating both travel time and “in-office” chair time. Those 5-minute appointments that the patient travelled an hour to get to could be a thing of the past!
Apologetically, the notion of minimizing chair-time was also mentioned. No need to apologize Kent, you were just brave enough to say it. Of course, providing this therapy in an efficient manner not only benefits us but also the patients. As a matter of fact, I believe that we are obligated to provide quality care in the most efficient manner possible, keeping costs in line for all involved and thus lowering barriers to treatment. Thanks for mentioning this Kent.
Keith Thornton shared some literature findings with us,
“the evidence clearly shows that patient involvement has better outcomes in reducing RDI/AHI. Hoekema’s conclusion was that the two reasons for superior success were patient adjusted protrusion and greater protrusion. All of the patients in the Holly study self titrated. Final titration was in a sleep lab. Both of these studies showed ability to treat severe patients.”
Keith explained that protrusion beyond maximum protrusion into a passive protrusive position can be achieved only by the patient while the appliance is in the mouth. Maximum passive protrusion is around 2mm beyond maximum active protrusion.
Virtually all of Keith’s patients calibrate “at-home”. Of course, the TAP appliance facilitates “at-home”, “in-mouth” calibration, allowing the patient to take advantage of the passive ROM he describes. Since apnea varies nightly depending on fatigue, alcohol, and other factors, he tells them to move the jaw out a couple of turns as necessary, even teaching bed-partners to calibrate the appliance while the patient is asleep.
David Rawson pointed out, “we as the Drs. are always in charge and make the final decisions, so it is up to the comfort level of the patient and Dr. to decide who gets to adjust at home”.
Barry Glassman discussed the concept that “the patient should be on the treatment team”, and pointed out that when patients are physically and mentally capable of intelligent decision-making, given the right information, they have every right to participate in their own care.
Using the CPAP example of patients not having access to lowering their pressure and how often CPAP ends up in the closet, Barry makes the point that patients having the ability to adjust their appliance results in a higher compliance which may start off as sub-optimal therapy for some, but with time, many of these same patients will tolerate further adjustment taking them to a higher therapeutic level. Of course, this scenario is much more desirable than terminating therapy all together because they are being forced to tolerate a position that is not within their comfort level. Providing the patient the ability to calibrate their appliance “at-home” facilitates this process.
When an oral appliance outcome is less than optimum, often, physicians are quick to dismiss the merit of continuing with it, even when the patient is pleased with the symptom relief they are experiencing. However, it makes sense to prioritize compliance, and work towards optimum calibration, especially if the alternative is no treatment at all. Unfortunately, too many clinicians do not value a partial success as being worthwhile and part of a journey, which could also include lifestyle changes like weight loss, fitness level etc. that could take the outcome the rest of the way.
Barry also pointed out that a subset of patients would rather not adjust their appliance “at-home” or are simply not capable of doing so. He adjusts those appliances “in-office”.
Shouresh Charkhandeh wrote,
“patients getting involved in their treatment/titration, helps with compliance and taking ownership of their condition”
When using the MATRx, which establishes a “Target” position that is likely to be therapeutic, Shouresh follows the following protocol:
“If that “Target” is within 80% of their range of motion, he starts the patient at that position. If the “Target” is between 80% and 100% of their range of motion, he starts them at 80% and has them “at-home” titrate 0.5mm per week, to a max of 2mm before seeing them on follow-up.”
For Non-MATRx cases, Shouresh follows the following protocol:
“First Appointment: Insertion. We don’t even teach our patients how to titrate. The goal is for them to wear it as much as possible, keeping “comfort” in mind. It’s basically their “acclimatization” period. They’re advised although they may notice a difference in their snoring/sleep, that is not the objective of the first three weeks and all they’re trying to achieve is to get used to the appliance. This is to keep their expectations in control and avoid any “disappointment”.
First Follow-up: Review titration protocol. They’re advised to titrate 0.5 mm per week, up to 2 mm maximum between the visit (5-6 weeks). They stop if; 1) Snoring Stops 2) They have too much discomfort that does not go away with the “usual” exercises and some rest (They’re advised to contact us) 3) They reach the 2 mm. This way, although they are “titrating”, they cannot “over-titrate” by much between appointments.
2nd and 3rd follow-up is the same, followed by a level-3 follow-up to review the objective data.”
(Barry Glassman, John Viviano, Shouresh Charkhandeh, Stuart Rich, Dennis Marangos, Les Priemer, Todd Morgan Sharnell Muir, David Rawson, Harry Ball, Steve Carstensen, Erin Elliott, Kent Smith, Keith Thornton)
In-office Appliance Calibration:
Tony Soileau once again discussed his Physiotherapy protocol, so of course, these adjustments must be “in-office”. For patients that come from afar, or are mechanically inclined with the desire to adjust their appliance “at-home”, he accommodates this. However, in his words, “We get our best (fastest) results if we do the adjusting”.
John Carollo, also prefers “in-office” calibration as he has experienced many patient errors with “at-home” calibration. He does however feel comfortable sending the patient home with the next adjustment strap for the Panthera D-SAD appliance, so the patient can place it on the appliance a few days before their next appointment. He feels there is limited chance of error when just one adjustment strap is provided. Promila Mehan shared similar concerns about patient error and limits the “at-home” calibration practice to those patients that absolutely cannot make it in to follow her usual “in-office” protocol.
Steve Lamberg also believes in the “in-office” approach, for the same reasons stated above, “A good percentage of them will make adjustments incorrectly. Even with the LSW, which is a single labeled central insert, I have seen them put it in backwards.” Of, course, like most clinicians, he does make exceptions (if he deems them capable), if the patient is not able to re-appoint for an extended period of time.
Gina Pepitone-Mattiello very strongly emphasized her practice of “in-office” calibration, citing the fact that it helps cultivate and maintain a good relationship with the patient and helps facilitate a better outcome. Having said that, she did concede that there are exceptions to the rule.
Christopher Kelly adjusts appliances “in-office”, and only lets the patient adjust when they are doing multiple night at-home sleep studies in various appliance positions.
Mark Collins shared his concern with “at-home” calibration, and previous experiences regarding incorrect “at-home” adjustments that led to issues. He also pointed out that office appointments provide the opportunity to reinforce appliance use and proper care.
(Tony Soileau, John Carollo, Steve Lamberg, Promila Mehan, Gina Pepitone-Mattiello, Christopher Kelly, Mark Collins, Ken Luco, John Viviano)
Steve Lamberg summed things up nicely for us,
“There’s no correct approach for ALL patients. One benefit of having the office do the adjustments is that we get to check in with them and find out the positive and negative aspects of their personal OA experience, but a risk of insisting they return to the office for adjustments may be a turn off to those patients who live far away or who have difficult schedules. On the other hand, a benefit of having them adjust their own appliance is having less traffic in your office, however a risk of having the patients do their own adjustment is that they may do it incorrectly. Why not treat patients like the unique “snowflakes” they are? At the end of the day (or 90 days) our focus should be on our results....which do not depend so much on which path you take here. Maybe we should be asking the patient what their preference is regarding adjustments.”
So, once again, we have heard some of the top clinicians in North America explain their protocols: this time, about appliance calibration, “in-office” vs. “at-home”; there are two very distinct camps, each with very valid rational for their position, and each acknowledging the flexibility to work with the alternative protocol when necessary. Whichever camp “feels” right for you to work in, as Steve points out, the uniqueness of our patients requires us to be flexible in order to accommodate their needs.
Thanks to all that participated in our first discussion of 2016. As usual, this sharing is very helpful for those clinicians new to this field and very insightful to those of us, that have been at it a while. I look forward to many more discussions on our SleepDisordersDentistry LinkedIn Group.
John Viviano DDS D ABDSM
Facility Accredited by American Academy of Dental Sleep Medicine