Letters to the Editor 2, Issue 1.3
What’s in a Name?
Todd D. Morgan, DMD, Diplomate, ABDSM
Scripps Memorial Hospital–Encinitas, Oral Medicine Section, Encinitas, CA
I am often struck by how the right word can make a difference. Two words may mean essentially the same thing, but carry a different connotation depending on the context for each listener. For example, the word “titration,” according to Wikipedia, means: “quantitative chemical analysis that is used to determine the unknown concentration of an identified analyte.” In the context of Sleep Medicine, titration means: “to determine the required pressure to be set on a CPAP flow generator to abolish both apnea & hypopnea events.” So this leads to the question: Does the term titration accurately apply to what we do in oral appliance therapy when we adjust the mandible’s horizontal and vertical positions to improve airway caliber?
When I began practicing dental sleep medicine in 1988, I was introduced to the word titration as it related to the graduated addition of air pressure to the patient upper airway at the CPAP mask interface. Back then, I would marvel at this technique and watch as the squiggly lines produced on paper by the PSG recorders were smoothed out with CPAP titration. This was “a good thing,” according to Dr. Phillip Westbrook, a pioneer in sleep medicine.
Early in my practice I was using a single piece device now termed a “monoblock design.” Before the George Gauge was available I made an educated guess about the protrusive starting point with a wax bite. I saw many awesome results and also failures. In the failures I suspected that I had missed determining the best protrusive position. The technique of cutting the arch trays apart and resetting forward allowed me to improve my results, and I had no compunction about doing this many times over for a patient. I performed my primitive alterations by cutting things apart and then re- uniting the pieces with acrylic in progressive jaw positions, all while using an oximeter to track progress. I’m not sure now when the term titration began to be applied to oral appliance adjustments.
I had been bitten too many times by patients who said they were doing fine only to find the follow up PSG results were lousy. Now there was no turning back—recalibrating the monoblocks while using home sleep testing put my destiny in my own hands. But was that titration?
The first adjustable appliance I fitted was the Klearway. After 10 years, no more tedium and smelling acrylic! The term titration appeared in the literature in the early 2000’s and it didn’t take long for practitioners to realize the advantages of adjustable devices. It was also evident that the humbling truth was that we couldn’t help all of our patients, even with new technology, and our best efforts. Turn the page. Now the dentists are invading the sleep lab and finding ways to adjust appliances during the PSG—something that could not have been imagined at the beginning of this journey.
Now back to the word. I believe it is time for a more accurate description of what we do. In searching for the best terminology to replace “titration” I keep arriving at the term “calibration.” Indeed, this is a much better description of what we do.
So here’s to continued growth and change within our field, including the nomenclature! My humble suggestion for change is to endorse a term that more accurately describes what we do with oral appliances. The term calibration fits and it is one that we can own.
Morgan TD. What’s in a name? Journal of Dental Sleep Medicine 2014;1(3):137.
SUBMISSION & CORRESPONDENCE INFORMATION
Submitted for publication August, 2014
Accepted for publication September, 2014
Address correspondence to: Todd Morgan, DMD 320 Santa Fe Drive Suite105 Encinitas, CA 92024; Tel: (760) 436-9292; Fax: (760) 436-9332; E-mail: firstname.lastname@example.org
This was not an industry supported study. Dr. Morgan has indicated no financial conflicts of interest.