Consensus on Dealing with Sleep Apnea Oral Appliance Side Effects
(Steve Carstensen, Tim Mickiewicz, Barry Glassman, Gina Pepitone-Mattiello, Les Priemer, Mark Collins, Shouresh Charkhandeh, Erin Elliott, Kent Smith, Ken Luco, John Viviano, Steve Lamberg, David Nueber, Tony Soileau)
The newly formed LinkedIn Discussion Group, “SleepDisordersDentistry” has just completed an open discussion on “Dealing with Oral Appliance Side Effects: Sharing our Clinical and Verbal Protocols…”. Here is a consensus for all to ponder.
A great deal of discussion revolved around proper disclosure and consent. An example of the consent form Ken Berley (Dentist and Lawyer) prepared for Steve Carstensen was posted on the site for all to review, revise and use if desired. Thanks Steve. The Link to this Consent form is:
Steve also pointed out the importance of having a well-trained team in this area. Of course, we all know that patients ask our team questions while they are waiting to see us, so this makes perfect sense. He suggests, “preparing yourself and your team for the conversations and questions that might happen for each of the listed side effects - the best way to do this is to role-play within your team”.
One of Steve’s favorite sayings is, “once a diagnosis has been made of OSA, 'Nothing's Free" - there are consequences for no treatment and for each of the therapy choices. What it boils down to is which set of side effects seems the most tolerable.” Putting things in this perspective from the initial consultation helps the patient accept the notion that there will be side effects from the get go. The importance of complete and thorough disclosure regarding the potential for bite changes which include shifting of teeth and jaw Anteriorization was discussed.
There was some very heated discussion about on-going disclosure and the notion that sensitizing the patient to these side effects posed the possibility of heightening their awareness and concern for these changes to the point that they drop out of therapy. The importance of stressing that these bite changes are insignificant when compared to the ramifications of remaining untreated was discussed at length and everyone was in agreement that up-front disclosure and on-going disclosure is necessary, however, it should be done in such a manner as to not alarm or overly concern the patient such that they could become motivated to abandon oral appliance therapy and remain untreated.
It was suggested that patients having difficulty re-establishing their bite in the morning may benefit from an anti-inflammatory taken at bedtime. However, the point that NSAIDs impact on body temperature regulation and melatonin synthesis through inhibition of prostaglandins was made, suggestive that this is probably not a good practice for long term use. Also, if the patient is wearing a two-piece appliance such as a Dorsal, they could take off the lower component prior to getting out of bed and continue wearing the maxillary component for about 20 minutes as a deprogrammer, or they could remove the entire appliance and go right to an actual deprogrammer for 20 minutes before starting their day. Finally, once a posterior open bite is established, the notion that lateral tongue thrusters have the potential to exacerbate their problem was discussed.
When a change in occlusion happens, we are obligated to inform the patient and discuss their options, which may range from doing nothing (which works most of the time) all the way up to restorative or orthodontic solutions. What is needed is education for all dentists and orthodontists so that patients can be properly advised and not misled when these bite changes occur. It is important to explain to the patient from the beginning that there can be bite changes that usually don't affect their ability to function or the way they look, that we will do all we can to minimize these changes and that we will continuously monitor them. When they do occur, the patient should be informed (who is often surprised and or unconcerned) and also advised that their dentist may become concerned. They are then advised that this issue is being monitored and after they listen to their dentists concerns, they can then give their dentist a hug and to quote Barry Glassman, tell them that, “it’ll be OK”.
How profoundly this therapy impacts on our patients lives was discussed along with how patients prioritize quality of life over how their teeth occlude. Accurate and thorough documentation of the patient’s initial Chief Complaints also helps keep things in perspective when bite changes become apparent. It is the resolution of these Chief Complaints that the patients will be balancing with the side effects we have been discussing. The general consensus was that most patients do not prioritize their occlusion over resolution of their Chief Complaints. Some of the verbal phrases used to discuss these issues with patients include,
"Your bite will feel different in the morning but we will give you exercises and some tools to help recapture that bite. Occasionally there is a more permanent bite change but when that happens half the time it is a good thing because the jaw was too far back anyways. Of those that it happens to most don't even notice and no one has ever missed a meal."
"Mr. Apnelot, all of the side effects we have discussed are just temporary. We can deal with them when and if they arise. The ONLY side effect that may be permanent is a change in the way your teeth fit together. We don't know why this happens sometimes and we don't know who it will happen to, but it could happen to you. Now, we will do everything we can to check this when we see you - this is one reason we took all of those photos - but YOU are the one who wakes up every day with your bite the way it is. We will give you exercises to use every morning to try and help, but you might still get this change. I can't check your bite every day, but YOU can.”
If your bite is changing, and you decide that change is not worth the benefit you are receiving - healthier sleep and a happier bed partner, for example - then you will need to let us know, or stop wearing it. If you wait too long, your bite might not ever go back to where it is right now. Do you understand this? Is there anything I have said that is unclear in any way?"
(Steve Carstensen, Tim Mickiewicz, Barry Glassman, Gina Pepitone-Mattiello, Les Priemer, Mark Collins, Shouresh Charkhandeh, Erin Elliott, Kent Smith, John Viviano)
Prevention and Management:
Gina shared with us a preventive technique she learnt from Dennis Bailey. While placing the tip of their tongue to the palate and rolling back, the patient clenches on the re-positioner, places their index fingers in their mouth towards the back and massages the masseter and medial pterygoids. Many patients say this actually relaxes their sore muscles and make this part of their daily routine. Kent tells patients to chew gum in the shower as the hot water massages their muscles and joints. If the bite is not back to normal after the shower, the patient is to wait until they are dressed to try other exercises. If one tries too hard, too quickly, there could be more discomfort. Tim shared with us the use of Rocabado 6X6 exercises, which are exercises created by Dr. Rocabado, to be performed by the patient at home. They consist of six different exercises and six repetitions of each exercise, performed six times per day until symptoms subside. These exercises emphasize correct postural position and help to combat the soft tissue memory of your old posture.
(Gina Pepitone-Matiello, Kent Smith, Tim Mickiewicz)
General Aches and Pains:
Sleep Apnea appliances are passive, unless the appliance does not fit properly, sore teeth are a result of para-function. Protrusion bruxers develop sensitive lower anterior teeth. lateral bruxers develop pain in the cuspids or first bicuspids and vertical bruxers develop pain in the molars.
Sore TMJ should never happen with anterior repositioning as we are decompressing the TMJ. However, the TMJ will get sore if the mandible is locked in place and the muscles are fighting the position, or, if the bite registration is shifted a bit to the left or right, and the resulting appliance is torqued to that side causing pain on the contralateral side. Another source of contralateral TMJ discomfort is occlusal balance. If the appliance is biting more heavily on one side, usually the contralateral TMJ will hurt. This balance issue becomes moot when an anterior discluding ramp is used since there is no posterior contact.
(Ken Luco, Barry Glassman, John Viviano)
A number of theories were discussed to explain morning bite changes.
· Steve Lamberg: “Jaw Anteriorization” is caused by a combination of overnight shortening of the Lateral Pterygoid muscles and a build up of retro-discal synovial fluid.
· David Nueber: Patients presenting at initial consultation with “Clicking, Popping, Deviation and Deflection” are susceptible to experiencing difficulties in re-establishing their normal bite in the morning. Kois refers to this “Deprogramed Bite” as Adaptive Centric Relation.
· David Nueber also shared that he works with Dentists that prevent AM bite issues by ensuring a healthy jaw joint position, "Gelb 4/7" as part of their appliance protocol.
· Kois: The role "functional occlusion" plays in the AM bite was discussed. When a patient has a constricted chewing pattern, an Oral Appliance will aide in deprogramming the bite through the night resulting in anterior edge-to-edge biting and posterior open bite in the AM. Kois states that this category of functional occlusion is more likely to experience changes in occlusion.
· Ken Luco: If the patient has a click before OSA treatment, the condyles may reposition onto the disk when wearing the appliance and stabilize in that position, leading to a posterior open bite. These are Class I's with a click (posterior displaced condyles in Centric Occlusion. As soon as the condyle reseats, they become a Class III. For patients presenting with a TMJ click, timing of the click is important. Late clicks are very unstable as the ligaments are very stretched. These patients rarely develop posterior open bites as they easily slip off the disks in the morning back into their habitual bite.
However, Barry Glassman pointed out that the literature indicates most deviation and deflections are the result of non-pathological asymmetries, or non-pathological adaptation. His routine clinical baseline Joint Vibration Analysis also does not support this “Disk Displacement” theory as they would pick up disk displacements when not obvious by report or by palpation. Barry also pointed out that there is limited evidence to suggest that "condylar position" in any specific moment in time (for example in MIP which is a nonfunctional dental state to begin with) is related to "health." The disk, which is fibro-cartilage and thus non-neural and non-vascular doesn't really need to "heal."
Steve Carstensen pointed out that “every human has adapted to the particular circumstances of the neuromuscular, skeletal, tooth configuration details that make up the stomatognathic system. Some have adapted with quiet joints, others, not so much. We are asking for more adaptation with our MAD therapy. So we don't need to focus on how we are causing deviations from some 'normal', which may or may not be present. Only from their 'normal', which is an unknowable variable. That's why we have such individual outcomes!” he goes on to suggest that we should help people understand how little we can predict what changes may take place, but assure them that we are “in it for them and we can follow along with their course of treatment and provide help as needed”. The notion of comparing OAT to medications they may have tried in the past that did not provide the desired benefit was discussed, helping the patient understand that outcomes cannot be assured.
The fact remains that the theories mentioned above are lacking in evidence and as such are simply theories. In fact, condyles are being advanced to eminence world wide without any untoward effects, which contradicts many of the theories espoused to date. Steve Lamberg discussed the notion that it is not really about occlusion, but rather it's about the pathway towards occlusion and tooth interference in that regard. However, he also goes on to say that the scientific literature is very conflicted and incomplete in this area. Finally, Barry posed a very interesting question, “is the tethering of the disk repeatable with all mandibular movements?” This question of course leads to a second question, “Why is everyone so obsessed with an activity that is so varied and unpredictable?”
(Steve Lamberg, David Nueber, Steve Carstensen, Barry Glassman, Ken Luco, John Viviano)
The loss of proper fit when no tooth or appliance changes have taken place was discussed; for no apparent reason, the appliance simply no longer fits properly (not associated with any particular appliance). The theory is that it is muscle changes that lead to this infrequent issue. This clinician has a physiotherapist on his team that works the muscles of mastication, which seems to always correct the appliance fit.
(Tony Soileau, Steve Carstensen)
Shouresh Charkhandeh shared some great insights that are represented in the following discussion. Side-effects should be considered a "normal" part of any treatment, and should not stop patients from receiving the treatment of their choice, as long as there is full disclosure, regular updating and the benefits outweigh the risks. The patient should decide whether or not to address the side-effects, and continue vs. discontinue treatment.
Full disclosure on any side-effects should take place, whether reported by the patient or observed during the exam. Both short-term and long-term consequences should also be discussed along with the possible solutions and alternative therapy options should they decide to discontinue oral appliance therapy.
There is very little science or understanding as to why these side effects occur, consequently, it makes more sense to manage them rather than treat them, since there is no guarantee that they will not simply occur again once they are treated. Management typically involves morning jaw exercises, AM bite aligners / re-positioners, chew tabs, and day-time orthotics.
We need to obtain a better understanding the effect of appliance design, retention mechanism, appliance material, level of protrusion and titration protocols on side-effects. Research is needed in these areas so that better clinical decisions can be made, potentially minimizing or eliminating these side effects.
Barry Glassman summarized the bite changes issue for us as follows:
· Occlusal changes can occur
· Occlusal changes can be put into two categories: odontogenic and non-odontogenic.
· Odontogenic changes include open contacts and tooth flaring, and are caused by force vectors on the teeth. Since the appliances themselves are passive, the force seems most likely to be related to para-function
· Non-odontogenic changes include jaw Anteriorization and theories regarding their cause include muscle memory alterations; altered muscle lengths; altered mandibular trajectories associated with or not associated with posterior cranial rotations.
· Most of these changes do not affect either function or aesthetics
· Therefore, the concern is overstated and often, the risk benefit quotient is not accurately assessed
· While several exercise protocols have been discussed, there is the difficulty of anecdotal reporting of success when we know that many patients do not do the exercises and have no changes.
· Aggressive attempts to return patients to their “habitual” bite may cause increased joint pain.
· Asking patients to "check their bite" in the morning has to be considered dangerous. Training the patient to be “conscious” of their "occlusion" may cause difficulties for some patients, contributing to a condition of occlusal dysesthesia. The patient may then make a decision to stop therapy based on their inability to "get their bite back" and thus make an inappropriate risk benefit decision.
· We need to be aware that there will be those in our profession that will give our patients bad information about the importance of their bite; and we need to prepare our patients for that situation.
”this presents a clinical dilemma when the patient is unconcerned about the occlusal change and refuses to abandon the appliance citing that the perceived benefits of treatment outweigh the dentist’s concern with the altered occlusion.”
Ferguson, K. A., R. Cartwright, et al. (2006). "Oral appliances for snoring and obstructive sleep apnea: a review." Sleep 29(2): 244-262.
Finally, the most thought provoking quote for this discussion goes to Barry Glassman,
“All of us have left the trunk of evidence-based medicine and stepped out on the branch. How far we step out on the branch is a personal decision that affects not only our stability, but also our patient’s welfare. Personally, I have made the choice to step out as far as I can, but keep a hand on the trunk. I see many sticking to the trunk and limiting their opportunity to help patients. I also have binoculars and see some so far on the limb they tend to fall (and often bring patients with them.)”
As clinicians, we all get to decide how far we want to venture from the Trunk full of evidence-based medicine as we manage our patients. That’s the cross we bear as clinicians. Once again, as with other topics we have discussed, it is very apparent how much we need to learn, and how little we can predict or ensure what is going to, or not going to happen. As Barry keeps pointing out, working in this field is a very different paradigm than what we were taught in dental school regarding the rules of engagement. I think clinicians reading this can take a sigh of relief regarding the issues they witness in their patients, knowing that it is the norm, not the exception. Document, advise, work to the highest scientifically based standards and align yourself with what other top clinicians that are of "like-mind" are doing. These are uncharted waters, and we are all learning on the go. I think this is a perfect example of the value of this type of open discussion; I thank all those that participated and look forward to future discussions on SleepDisordersDentistry LinkedIn Group.