Follow-up

A follow-up appointment 1-3 weeks status post MAD insertion should be undertaken to assess progress. The following check list can aid the practitioner:

• Is the MAD appliance tolerated?

• Quantify patient adherence to the MAD. Is it worn nightly? If not, how often is it worn? How many hours per night is the MAD being used?

• Is the titration plan on track?

• Any side effects or problems of fit or retention with the appliance?

• Check the dental and oral tissues for any signs of irritation

• Check to make sure the patient can insert and remove the MAD on their own

• Have the patient demonstrate that they know how to protrude/retrude the MAD

• Does the bed partner still report snoring?

• Any QOL improvements in daytime sleepiness? In addition to the patient’s subjective QOL reporting, a repeat ESS or STOP-BANG can provide additional data in this regard. The STOP-BANG includes blood pressure which should also be re-checked.

In regard to titrating the MAD, i.e. progressively protruding the mandible, track progress since time of delivery. If there was jaw discomfort at a particular protrusive setting, consider retruding the device by 0.25 mm or the next smallest increment particular to the MAD system you are using. These first few weeks are critical to finding a balance between tolerability and improvement in sleep. Sleep quality and device tolerability determine the titration pattern of the adjustable MAD. Do not exceed 100% of patient’s maximum protrusive ability as the TMJ retrodiscal laminae may elongate.

The ESS should be repeated at each patient visit and can even be done over the phone or via email at periodic desired time points. If the ESS is less than 10, the appliance is tolerable and the patient is compliant with its use then no further titration is necessary for the time being.

Once the desired protrusive setting achieved, the patient should continue wearing the MAD for another month or longer to acclimate to the appliance to ensure complete adherence. If this is demonstrated, then it is crucial to conduct a follow up PSG with the MAD inserted into place. A good sleep technician would be familiar with advancing the MAD during the sleep study if they want to further optimize AHI. The patient will now have a pre-treatment AHI value and a post-treatment AHI value. Success can be defined by reducing the AHI to less than 5, or in more severe cases a reduction of AHI by 50% or greater is also considered a good outcome.