Why patients with issues need clinicians familliar with sleep disorders, TMJ and chronic pain.

Four literature reviews and studies that document the association of OSA/SBD and bruxism. The 3rd study that found significant association between AHI (apnea-hypopnea index) severity and tooth wear severity is interesting. There are more studies I can post. Unfortunately little is published in the US on this topic, these studies were all conducted at universities outside of North America.

Sleep Med Clin. 2015 Sep;10(3):375-84
Overview on Sleep Bruxism for Sleep Medicine Clinicians.
Carra MC1, Huynh N2, Fleury B3, Lavigne G2.
Sleep bruxism (SB) is a common sleep-related jaw motor disorder observed in 8% of the adult population. SB diagnosis is based on history of tooth grinding and clenching and is confirmed by the polysomnographic recording of the electromyographic activity of jaw muscles during sleep. SB may be associated with orofacial pain, headaches, and sleep-disordered breathing. Managing SB cannot be done without a comprehensive clinical and, when indicated, polysomnographic differential diagnosis of other comorbidities, which need to be taken into account to select the best treatment approach.

Dent Clin North Am. 2012 Apr;56(2):387-413
Sleep bruxism: a comprehensive overview for the dental clinician interested in sleep medicine.
Carra MC1, Huynh N, Lavigne G.
Sleep bruxism (SB) is a common sleep-related motor disorder characterized by tooth grinding and clenching. SB diagnosis is made on history of tooth grinding and confirmed by polysomnographic recording of electromyographic (EMG) episodes in the masseter and temporalis muscles. The typical EMG activity pattern in patients with SB is known as rhythmic masticatory muscle activity (RMMA). The authors observed that most RMMA episodes occur in association with sleep arousal and are preceded by physiologic activation of the central nervous and sympathetic cardiac systems. This article provides a comprehensive review of the cause, pathophysiology, assessment, and management of SB.

J Clin Sleep Med. 2015 Apr 15;11(4):445-50. doi: 10.5664/jcsm.4602.
Frequency of obstructive sleep apnea syndrome in dental patients with tooth wear.
Durán-Cantolla J1,2,3,4,5, Alkhraisat MH6, Martínez-Null C1,2,3,4, Aguirre JJ6, Guinea ER6, Anitua E1,6.
STUDY OBJECTIVES: To estimate the frequency of obstructive sleep apnea syndrome (OSAS) in dental patients with tooth wear, and to assess the role of dentists in the identification of patients at risk of OSAS.

METHODS: Dental patients with tooth wear and treated with occlusal splint were prospectively recruited to perform sleep study. The severity of tooth wear was established by the treating dentist before patient referral to sleep disorders unit. Sleep questionnaires, anthropometric measurements, and validated respiratory polygraphy were performed.

RESULTS: All patients with dental wear were offered a sleepiness analysis. Of 31 recruited patients, 30 (77% males) participated in this study. Patients’ mean age was 58.5 ± 10.7 years (range: 35-90 years) and the body mass index was 27.9 ± 3.4 kg/m(2). Tooth wear was mild in 13 patients, moderate in 8 and severe in 9. The mean apnea-hypopnea index (AHI) was 32.4 ± 24.9. AHI < 5 was reported in 2 patients, AHI of 5-29 in 17, and AHI ≥ 30 in 11. A statistically significant association was found between AHI severity and tooth wear severity (Spearman R = 0.505; p = 0.004).

CONCLUSIONS: Tooth wear could be a tool to identify those patients at risk of having OSAS. This highlights the importance of dental professionals to identify and refer patients with OSAS.

Laryngoscope. 2003 Jun;113(6):973-80.
Association of systematic head and neck physical examination with severity of obstructive sleep apnea-hypopnea syndrome.
Zonato AI1, Bittencourt LR, Martinho FL, Júnior JF, Gregório LC, Tufik S.
OBJECTIVES/HYPOTHESIS: To identify upper airway and craniofacial abnormalities is the principal goal of clinical examination in patients with obstructive sleep apnea-hypopnea syndrome. The aim was to identify anatomical abnormalities that could be seen during a simple physical examination and determine their correlation with apnea-hypopnea index (AHI).

STUDY DESIGN: Consecutive patients with obstructive sleep apnea-hypopnea syndrome who were evaluated in a public otorhinolaryngology center were studied.

METHODS: Adult patients evaluated previously with polysomnography met the inclusion criteria. All subjects underwent clinical history and otolaryngological examination and filled out a sleepiness scale. Physical examination included evaluation of pharyngeal soft tissue, facial skeletal development, and anterior rhinoscopy.

RESULTS: Two hundred twenty-three patients (142 men and 81 women) were included (mean age, 48 +/- 12 y; body mass index, 29 +/- 5 kg/m2; AHI, 23.8 +/- 24.8 events per hour). Patients were distributed into two groups according to the AHI: snorers (18.4%) and patients with sleep apnea (81.7%). Sleepiness and nasal obstruction were reported by approximately half of patients, but the most common complaint was snoring. There was a statistically significant correlation between AHI and body mass index (P <.000), modified Mallampati classification (P =.002), and ogivale-palate (P <.001). The retrognathia was not correlated to AHI, but the presence of this anatomical alteration was much more frequent in patients with severe apnea when compared with the snorers (P =.05). Other correlations with AHI were performed considering multiple factors divided into two groups of anatomical abnormalities: pharyngeal (three or more) and craniofacial (two or more) abnormalities. There was a statistically significant correlation between pharyngeal landmarks and AHI (correlation coefficient [r] = 0.147, P =.027), but not between craniofacial landmarks and AHI. The combination of pharyngeal anatomical abnormalities, modified Mallampati classification, and body mass index were also predictive of apnea severity.

CONCLUSIONS: Systematic physical examination that was used in the present study indicated that, in combination, body mass index, modified Mallampati classification, and pharyngeal anatomical abnormalities are related to both presence and severity of obstructive sleep apnea-hypopnea syndrome. Hypertrophied tonsils were observed in only a small portion of the patients. The frequency of symptoms of nasal obstruction was high in sleep apnea patients. Further studies are needed to find the best combination of anatomical and other clinical landmarks that are related to obstructive sleep apnea.

Chair, Alliance of TMD Organizations
Diplomat, American Academy of Pain Management
Diplomat, American Board of Dental Sleep Medicine
Regent & Fellow, International College of CranioMandibular Orthopedics
Board Eligible, American Academy of CranioFacial Pain
Dental Section Editor, Sleep & Health Journal
Member, American Equilibration Society
Member, Academy of Applied Myofunctional Sciences

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