Follow-Up Care & Device Titration

The Importance of Ongoing Care in Oral Appliance Therapy

Oral appliance therapy isn’t a “set it and forget it” treatment. To achieve and maintain optimal results—keeping your sleep apnea effectively treated year after year—proper follow-up care is essential. This includes careful initial device optimization (titration), objective verification that the treatment is working, and long-term monitoring to ensure continued success.

At Aloha Sleep Apnea & Airway Center, comprehensive follow-up care is built into our treatment approach from day one. We’re invested in your long-term success, not just getting a device in your mouth.

Why Follow-Up Matters

Treatment Optimization: Unlike CPAP, which auto-adjusts pressure, oral appliances require manual calibration to find your optimal position. Without proper titration, you may not achieve maximum benefit.

Objective Verification: Subjective improvement (feeling better) doesn’t guarantee adequate treatment. Follow-up testing confirms your AHI is actually controlled, protecting your health and satisfying medical requirements.

Side Effect Management: Early identification and management of any side effects prevents problems from developing or worsening.

Dental Health Protection: Long-term oral appliance use requires monitoring to identify any tooth movement or bite changes early.

Appliance Maintenance: Regular evaluation ensures your appliance remains in good condition and continues functioning properly.

Adaptation to Change: Your body, weight, and dental status can change over time. Follow-up allows treatment adjustment as needed.

Phase 1: Titration (Device Optimization)

The first weeks of oral appliance therapy focus on finding your optimal treatment position through systematic titration.

Understanding Titration

Titration is the process of gradually adjusting your oral appliance to find the ideal jaw position—advanced enough to effectively open your airway, but not so far forward as to cause discomfort or jaw strain.

Think of it like adjusting a prescription: too little won’t help, too much causes side effects, and finding the right level requires careful calibration.

The Science of Titration

Why Gradual Adjustment?

Sudden, maximum advancement would:

• Cause significant jaw muscle strain and pain
• Potentially stress the TMJ
• Be uncomfortable enough to prevent use
• Not allow muscles and ligaments to adapt

Instead, we start conservatively and advance gradually, allowing your musculoskeletal system to adapt at each level before progressing.

The Therapeutic Range:

Most patients achieve optimal treatment within these parameters:

• Advancement range: Typically 5-10mm from neutral position
• Percentage of maximum protrusion: Usually 50-75% of your maximum capability
• Sweet spot: The minimum effective advancement that controls your apnea comfortably

The Titration Process in Detail

Week 1-2: Initial Adaptation

Starting Position:

• Conservative advancement (typically 50-60% of maximum)
• Focus on comfort and adaptation
• Establishing nightly wearing habit

What You May Experience:

• Getting used to the appliance in your mouth
• Possible excess salivation (temporary)
• Morning jaw stiffness (usually mild)
• Learning morning exercise routine

Our Monitoring:

• How well you’re tolerating the device
• Any comfort issues to address
• Symptom changes from baseline

Weeks 3-8: Active Titration

Progressive Advancement:

• Every 2-4 weeks, we advance the appliance by small increments
• Typical increment: 0.5-1.0mm per adjustment
• Each advancement followed by adaptation period

What We’re Looking For:

• Reduction in snoring (often reported by bed partner)
• Improvement in daytime energy
• Better sleep quality
• Reduction in morning headaches
• Any symptoms that indicate we’re approaching optimal position

What We’re Monitoring:

• TMJ tolerance and comfort
• Jaw muscle adaptation
• Any side effects
• Balance between effectiveness and comfort

Reaching Optimal Position:

We know we’re approaching optimal when:

• Snoring is eliminated or nearly eliminated
• Daytime symptoms improve
• Sleep quality is better
• Morning refreshment improves
• Further advancement provides diminishing returns

Titration Appointments: What to Expect

Before Your Appointment:

• Note any changes in symptoms since last visit
• Track snoring (bed partner feedback is valuable)
• Rate your energy and sleep quality
• Note any concerns or questions

During the Appointment (20-30 minutes):

Symptom Review:

• How are you sleeping?
• Has snoring improved?
• How’s your daytime energy?
• Any morning symptoms?

Comfort Assessment:

• How does the appliance feel?
• Any sore spots or discomfort?
• Is the fit secure?
• Any difficulty with insertion/removal?

TMJ and Dental Check:

• Jaw comfort and function
• Range of motion
• Any muscle soreness
• Teeth and gum check

Appliance Adjustment:

• Advancement to next level (if appropriate)
• Minor fit adjustments if needed
• Verification of proper function

Education and Planning:

• What to expect at the new setting
• When to contact us
• Next appointment scheduling

Typical Titration Timeline:

• 4-8 weeks to reach optimal position
• 3-5 titration appointments typically
• Individual variation based on response

Phase 2: Efficacy Verification

Once titration achieves what appears to be optimal positioning based on symptoms, we verify treatment effectiveness objectively.

Why Objective Testing Matters

Subjective Improvement Isn’t Enough: Feeling better doesn’t guarantee your AHI is adequately controlled. Some patients feel improved even with partial treatment, while others may not perceive improvement despite excellent AHI reduction.

Health Protection: Inadequately treated sleep apnea continues to damage your cardiovascular system, affect your metabolism, and increase accident risk—even if you feel somewhat better.

Insurance and Documentation: Most insurance companies require efficacy verification. Additionally, proper documentation protects you medically and legally.

Treatment Optimization: If testing shows room for improvement, we can continue optimizing your treatment.

The Verification Process

Coordinating with Your Physician:

After clinical titration is complete, we communicate with your sleep physician:

• Report of titration progress and symptom improvement
• Request for efficacy testing order
• Current appliance position documentation
• Recommendation for home sleep test with appliance

Follow-Up Sleep Testing:

You’ll complete a home sleep apnea test (HSAT) while wearing your oral appliance:

• Same type of test used for diagnosis
• Performed at your optimized appliance setting
• Measures your “treated” AHI

Interpreting Results:

Your physician reviews the test and determines:

Treatment Success (AHI < 5-10 or >50% reduction):

• Continue at current appliance setting
• Proceed to maintenance phase
• Documentation of successful treatment

Partial Response (Some improvement but not optimal):

• Consider further advancement if room exists
• Repeat testing after additional titration
• Evaluate if different appliance design might help

Insufficient Response (Minimal improvement):

• Evaluate for causes (anatomy, compliance, device issues)
• Consider alternative appliance designs
• Discuss combination therapy or alternatives
• Determine if oral appliance therapy is appropriate for you

What Success Looks Like

Clinical Goals:

• AHI reduction to < 10 (ideally < 5)
• Oxygen desaturation improvement
• Significant symptom improvement
• Good tolerance and compliance

Real-World Success:

• Snoring eliminated or markedly reduced
• Feeling refreshed upon waking
• Improved daytime energy and alertness
• Better concentration and cognitive function
• Bed partner sleeping peacefully
• Consistent nightly use

Phase 3: Long-Term Maintenance

After successful titration and verification, ongoing maintenance ensures continued treatment success.

Regular Check-Up Schedule

Recommended Frequency: Every 6 months

Standard Maintenance Visit Includes:

Treatment Assessment:

• Current symptom review
• Sleep quality discussion
• Energy and daytime function
• Any new concerns

Dental Monitoring:

• Examination of teeth for any movement
• Bite check for changes
• Gum health assessment
• Assessment for wear patterns

TMJ Evaluation:

• Jaw function and comfort
• Range of motion
• Joint sounds or symptoms
• Muscle assessment

Appliance Inspection:

• Wear patterns
• Adjustment mechanism function
• Material integrity
• Fit and retention

Adjustments if Needed:

• Minor setting modifications
• Fit adjustments
• Repair or replacement planning

Appliance Care and Maintenance

Daily Care:

After Each Use:

• Remove appliance upon waking
• Rinse with cool or lukewarm water
• Brush gently with soft toothbrush and mild soap
• Rinse thoroughly
• Allow to air dry before storing

Important Don’ts:

• Never use hot water (can warp the appliance)
• Avoid abrasive toothpaste (scratches surface)
• Don’t use alcohol-based mouthwash (can degrade materials)
• Never leave in direct sunlight or hot car

Weekly Deep Cleaning:

• Soak in denture cleaning solution or specialized appliance cleaner
• Follow product instructions for timing
• Rinse thoroughly after soaking
• Inspect for any damage or wear

Storage:

• Keep in provided case when not in use
• Store in cool, dry place
• Keep away from pets (dogs love to chew appliances!)
• Bring case when traveling

Longevity:

With proper care, oral appliances typically last 3-5 years. Factors affecting lifespan:

• Bruxism (grinding) accelerates wear
• Material type influences durability
• Frequency of adjustments
• Quality of daily care

When to Contact Us Between Appointments

Don’t wait for your scheduled visit if you experience:

Treatment Concerns:

• Return of snoring or witnessed apneas
• Increased daytime sleepiness
• Waking unrefreshed again
• Morning headaches returning

Comfort Issues:

• Significant jaw pain or TMJ symptoms
• Sore spots in mouth
• Difficulty wearing appliance
• Loose or poor fit

Appliance Problems:

• Visible damage or cracks
• Broken adjustment mechanism
• Difficulty adjusting advancement
• Unusual wear patterns

Life Changes:

• Significant weight gain or loss
• Major dental work planned
• Starting new medications affecting sleep
• New health conditions

Compliance: The Key to Treatment Success

Why Compliance Matters

Oral appliance therapy only works when you wear the device. Unlike medications that remain in your bloodstream, an oral appliance provides zero benefit on nights you don’t use it.

The Health Equation:

• Nights wearing appliance = treated sleep apnea
• Nights not wearing appliance = untreated sleep apnea
• Inconsistent use = inconsistent protection

Untreated Sleep Apnea Risks Persist: Every night without treatment, you experience:

• Repeated oxygen desaturation
• Cardiovascular stress
• Hormonal disruption
• Fragmented sleep
• Increased accident risk next day

The Oral Appliance Compliance Advantage

Studies consistently show oral appliances have higher long-term compliance than CPAP:

Why Better Compliance?

• More comfortable
• No mask or hose
• No machine noise
• Easy travel
• Simple to use
• Feels less intrusive

Supporting Your Compliance

We Help You Succeed By:

Setting Realistic Expectations:

• What to expect during adaptation
• Normal adjustment timeline
• When to expect improvement

Addressing Issues Promptly:

• Comfort concerns handled quickly
• Adjustments made as needed
• Problems solved, not ignored

Providing Education:

• Understanding why treatment matters
• Recognizing improvement
• Knowing when to seek help

Celebrating Success:

• Acknowledging your improvement
• Reinforcing benefits
• Encouraging continued use

Common Barriers and Solutions

Coordination with Your Healthcare Team

Throughout your treatment, we maintain communication with your medical providers.

Ongoing Physician Coordination

We Communicate With Your Sleep Physician About:

• Titration progress and symptom improvement
• Efficacy testing results
• Any concerns or complications
• Treatment modifications
• Long-term monitoring status

We Provide Documentation Including:

• Treatment summary reports
• Efficacy testing coordination
• Side effect management
• Compliance assessment

Integrated Care Approach

We Work With:

• Sleep medicine physicians for diagnosis and monitoring
• Primary care providers for overall health coordination
• Dentists for dental health concerns
• Specialists as needed (ENT, TMJ, etc.)

This collaborative approach ensures comprehensive, coordinated care.

Our Commitment to Your Success

At Aloha Sleep Apnea & Airway Center, follow-up care isn’t an afterthought—it’s central to our approach. We’re committed to:

Structured Titration: Systematic optimization to find your best treatment position.

Objective Verification: Confirming treatment effectiveness through testing, not just symptoms.

Regular Monitoring: Ongoing assessment to ensure continued success.

Accessible Support: Available when questions or issues arise between visits.

Long-Term Partnership: Supporting your sleep health for years to come.

Questions About Follow-Up Care?

If you have questions about what follow-up care involves, want to schedule a routine check-up, or have concerns about your current treatment, contact us. We’re here to support your journey to better sleep—now and in the future.

Note: Home sleep apnea testing (HSAT) is ordered and interpreted by a physician. We coordinate testing and provide oral appliance therapy as a CPAP alternative in collaboration with the patient’s sleep physician. We serve patients throughout Aloha, Hillsboro, Beaverton, Portland, and the greater Oregon metro area.