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Michigan Head & Neck Institute

TMJ Blog

01. 29. 2019

Sleep Aches, Sleep Apnea

Oral Appliance Therapy for Sleep Apnea

Oral appliance therapy is commonly used today in the treatment of mild to moderate Obstructive Sleep Apnea (OSA).  For patients who suffer from severe OSA and are utilizing a CPAP machine (gold standard for severe cases), an oral appliance can be used in conjunction with the CPAP for maximum benefit to the patient.  Some patients also use oral appliances when traveling or if they cannot tolerate the CPAP.  Although oral appliances are not always as effective as the CPAP, they are certainly better than nothing, and have still proven to reduce the effects of OSA and snoring while improving daytime performance.

Just like the CPAP opens up the airway by creating positive air pressure, an oral appliance opens up the airway by moving the lower jaw (mandible) forward.

You’re probably wondering how the oral appliance is controlled and/or measured to each patient.  This process, referred to as titration, is a method used which slowly advances the mandible forward until the patient reaches maximum medical improvement.  The standard titration protocol is to advance the mandible forward in 1mm increments over a period of several weeks while documenting the improvement/symptoms until the respiratory episodes are satisfactorily limited.  A licensed dental sleep medicine practitioner must of course do this titration. oral appliance therapy for sleep apnea

The upper airway has little support. Since there is inconsistency in the soft tissue and bony structures of the head and neck, there has to be mechanisms in place that adjust to these anatomical differences.

Upper airway obstruction increases during sleep, meaning increased collapsibility of the airway. Studies have shown that patients with sleep-disordered breathing (SDB) have anatomically smaller airways, which can trigger increased muscle activity and negative airway pressure.  SDB includes OSA, hypopnea, and UARS (upper airway resistance syndrome), and other non-airway problematic sleep pathologies such as restless leg syndrome, insomnia, narcolepsy, etc. that include diagnosis not in the scope of my practice.

People suffering from SDB experience frequent arousals from sleep and chronic sleep deprivation.  The most common symptom of this is loud snoring and/or apneas witnessed by bed partners.

What many people don’t realize is that sleep disturbances are often consistently reported in patients suffering from TMD (temporomandibular joint disorder) as well.

TMD is associated with primary sleep disorders, such as insomnia and OSA, and patients that commonly present with overlapping symptoms like morbidity and neuroendocrine disorders.  With long-term use of an oral appliance, a reduction in the signs and symptoms of TMD has been reported.

Sleep disorder symptoms

                                        Photo Courtesy of Hobart Orofacial Pain

 There are hundreds of oral appliances used to treat OSA.  Some names that may sound familiar include the following:

Herbst

TAP

Equilizer

NAPA

Klearway

Tessi

EMA

Moses

SUAD

Silencer

Esmark

HAP

Elastomeric

Z-training

Full Breath

TheraSnore

Silent Night

TPE

SnoreEx

TOPS

Snore-no-more

Narval

 

The pictures below show how the Airhead (a 3 dimensional piece movable demonstration model) visually documents mandibular advancement.

mandibular advancement

With oral appliance air flows normally   Without oral appliance air cannot                                                                                                                                 flow into lungs

One thing that the dentist/sleep medicine practitioner must look out for when treating a patient with OSA is any pre-existing jaw problems that are present upon delivery of the oral appliance. Oral appliance therapy can cause bite changes, which could lead to jaw problems down the road.

Quoting Dr. Clifton Simmons, My Friend, My Mentor:

Intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) may be considered medically necessary in adult patients with clinically significant OSA under the following conditions:  at least 5 events per hour in a patient with excessive daytime sleepiness or unexplained hypertension, AND .A trial with CPAP has filed or is contraindicated, AND …The device is prescribed by a treating physician, AND …The device is custom-fitted by qualified dental personnel, AND …There is absence of temporomandibular dysfunction or periodontal disease.

The American Association of Dental Research defines temporomandibular disorders (TMDS) as a group of musculoskeletal and neuromuscular conditions that involve the temporomandibular joint (TMJ), the masticatory muscles, and all associated tissue.

Resolved, that dentistry is defined as the evaluation, diagnosis, prevention and/or treatment (nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law.

The ADA House of Delegates approved Dental Practice Parameters for Temporomandibular (Craniomandibular) Disorders in 1997.  In these parameters of care, the ADA approved specific guidelines for assessing, diagnosing and managing temporomandibular disorders.

The orthopedic surgery community stopped treating TMDs in the 1980s.  Dentists are now the primary care providers for temporomandibular disorders.  Dentistry is the only professional that has the training and skills to differentiate dental pain from TMD musculoskeletal pain.

Dentists cannot divorce themselves from this duty.  A dentist does not have to treat the patient.  Any and all treatment can be referred to other dentists or health care practitioners.  This means that all dentists who examine living patients should evaluate them for TMDs.  Evaluation has been clearly described as a history, examination, and consultation.

So, there is a paradox. There is an area of care that the ADA has defined as within the scope of dentistry, has defined care through Dental Practice Parameters…and evidence-based care is available, and most state dental boards require competence in screening and diagnosis of this area of care.  Yet CODA does not require dental schools to prepare the dentist for this skill.

This has created an area of care in which many dentists do not have adequate training and skills to provide the necessary screening and diagnosis and therefore, there is an under diagnosis of TMDs…..

Dr Clifton Simons

 

 

 

 

 

 

 

 

 

 

 

 

 

Alternatively, treatment with an oral appliance can also act as a healing mechanism, as the physiologic balance of the muscles and their neurological connections are restored.  The patients wearing the appliances are returned to a healthy, balanced configuration as their muscles find the proper positions (jaw relationships).  The most important function of the jaw and surrounding muscles is to maintain an open airway.

Below are 2 examples of oral appliances that Dr. Klein uses in his office:

oral appliance 2

oral appliance

 

 

 

 

 

 

The designs have come a long way over the years.

 

old oral appliance

 

 

 

 

 

 

At Michigan Head & Neck Institute, we offer treatment for both TMD and Obstructive Sleep Apnea that consists of creating a custom-fit oral appliance (mouthpiece) which is comfortable and can be adjusted to meet the requirements of each patient.  Dr. Klein works with each patient to provide the best options for their specific treatment.  For more information please call (586) 573-0438 or visit www.michiganheadandneck.com.

 

 

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The contents of this website, such as text, graphics, images, and other materials are for informational purposes only. While there are many commonalities among multiple TMD and sleep apnea cases, each patient is unique. Information on this website should be used to educate the reader about what they should discuss with their doctor if they are suffering from the listed symptoms. The information is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Seek the advice of your physician or you may call our office with any questions you may have regarding TMD or sleep apnea. If you think you may have a medical emergency, call your doctor or 911 immediately.


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