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Michigan Head & Neck Institute

TMJ Blog

11. 21. 2019

Physicians Only

Oral Appliance Therapy/Titration

As we know, TMJ/TMD patients frequently present with overlapping signs and symptoms of OSA/sleep disorder patients.  TMD affects approximately 5% to 15% of the population, predominantly women.

Many patients exhibit sleep dysfunction associated with persistent pain and inability to sleep on their side, but sleeping supine in most people increases the risk for sleep disordered breathing, since gravity pulls the tongue down when we sleep on our back.

Myofacial pain and arthralgia are the most common symptoms of TMD.  Retrognathia, a condition that can result from TMJ arthritis, also constitutes a risk factor for SDB (sleep disordered breathing).  In addition, several different craniofacial configurations such as a more caudally positioned hyoid and smaller anteroposterior dimensions of the lower face have been associated with a greater prevalence of OSA/SDB.

Patients with SDB have frequent arousals from sleep and suffer from sleep deprivation.  They have frequent and repetitive episodes of oxygen desaturation.  The most common clinical symptoms are loud snoring, apneas witnessed by bed partners and excessive daytime sleepiness.  In addition, the condition has been linked to delayed reaction times, difficulty concentrating, and is linked to cardiovascular disease.

Treatment with a mandibular repositioning device is now frequently used in the treatment of mild-to-moderate OSA, and severe OSA may be treated with a combination oral appliance to reduce the AHI and thus reduce CPAP pressure.  An intraoral appliance is easier to travel with, that’s for sure, and more socially acceptable.

Patient compliance is much better with the oral appliances as well. Most patients, as multiple peer reviewed articles document, who use their CPAP only do so for 4-6 months and then it ends up in the closet.

A few names you may have heard before include the following:

  • The Silencer
  • HAP
  • Herbst
  • PM Positioner
  • SUAD
  • TAP
  • Silent Night
  • NAPA
  • Moses

At Michigan Head & Neck Institute, we exclusively offer treatment for 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. Each patient that chooses an oral appliance (OA) as their treatment, will receive follow up sleep studies (either at-home or a in a sleep lab) which will ensure the OA is positioned accordingly.

We must always remember to reference Centric Relation.  Centric Relation is a concept where dentists manipulate the jaw to find a hinge axis position and then use that position to establish the bite.  The proper relations of the jaws are determined when the muscles are at their healthiest.  The most important function of the jaw, jaw muscles, tongue and entire trigeminal neuromuscular complex is to maintain the airway.

Oral Appliances can cause bite changes (and can exacerbate jaw problems). If the jaw problems pre-exist the oral appliance therapy, then we must be sure to address both.  Bite changes that take place with the use of oral appliance therapy is actually a healing mechanism that occurs when the temporomandibular joint is unloaded and the retrodiscal lamina in the posterior portion of the joint compartment rehydrates and acts to mechanically change the bite.

So, how are these appliances adjusted correctly?  At what interval is appropriate to make adjustments?  There are several titration protocols designed to eliminate problems. Over a period of several weeks/months, the mandible can be advanced in 1mm increments.  These appliances are then adjusted in the same way a CPAP is titrated.  The mandible is advanced until respiratory events are eliminated (confirmed by follow-up sleep test with PSG).

Teeth 2

 

 

 

 

 

 

For more information on oral appliance therapy, or to schedule a consultation with Dr. Klein, please contact our office at (586) 573-0438.

References

Cunali PA, Almeida FR, Santos CD, Valdrighi NY, Nascimento LS, Dal’fabbro C, Tufik S, Bittencourt LR. Aims: To evaluate the prevalence of pain associated with temporomandibular disorders (TMD) in obstructive sleep apnea syndrome (OSAS) patients referred for oral appliance therapy. J OROFAC PAIN 2009; 23:339-344.

Sutherland K, Vanderveken OM, Tsuda H, et al. Oral Appliance Treatment for Obstructive Sleep Apnea: An Update. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine. 2014;10(2):215-227. doi:10.5664/jcsm.3460

Doff MHHoekema AWijkstra PJvan der Hoeven JHHuddleston Slater JJde Bont LGStegenga B. Oral appliance versus continuous positive airway pressure in obstructive sleep apnea syndrome: a 2-year follow-up. Sleep. 2013 Sep 1;36(9):1289-96. doi: 10.5665/sleep.2948

Wade PS. Oral appliance therapy for snoring and sleep apnea: preliminary report on 86 patients fitted with an anterior mandibular positioning device, the Silencer. J Otolaryngol.2003 Apr;32(2):110-3.

De Almeida FRLowe AATsuiki SOtsuka RWong MFastlicht SRyan F. Long-term compliance and side effects of oral appliances used for the treatment of snoring and obstructive sleep apnea syndrome. J Clin Sleep Med.2005 Apr 15;1(2):143-52.

Bartolucci MLBortolotti FRaffaelli ED’Antò VMichelotti AAlessandri Bonetti G. The effectiveness of different mandibular advancement amounts in OSA patients: a systematic review and meta-regression analysis. Sleep Breath.2016 Sep;20(3):911-9. doi: 10.1007/s11325-015-1307-7. Epub 2016 Jan 15.

Critical Reviews in Oral Biology & Medicine. Vol 9, Issue 3, pp. 345 – 361 First Published July 1, 1998 https://doi.org/10.1177/10454411980090030701

White DPShafazand S. Mandibular advancement device vs. CPAP in the treatment of obstructive sleep apnea: are they equally effective in Short term health outcomes? Clin Sleep Med. 2013 Sep 15;9(9):971-2. doi: 10.5664/jcsm.3008

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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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