Steve Lamberg, Tim Mickiewicz, Christopher Kelly, Dennis Marangos, Steve Carstensen, David Rawson, Daniel Klauer, Tony Soileau, Steve Marinkovich, John Viviano, Shouresh Charkhandeh, Erin Elliott, Ken Luco, Stuart Rich, Dan Tache, Kent Smith, Barry Glassman)
The LinkedIn Discussion Group, “SleepDisordersDentistry” has just completed an open discussion on TMD as a disqualifier for oral appliance therapy. Here is a consensus for all to ponder.
What was asked,
“We all hear it from our patients, “I have TMJ” and then they move their mandible around in various ways trying to show us their “TMJ”. Of course, in most cases, they are just fine, and are simply dealing with noises and deviations that are well within their adaptive capacity. However, untreated OSA impacts on both “Quality of Life” and “Longevity”. So, when it comes to TMD, how do we decide who qualifies for an OSA Appliance and who doesn’t…”
What was said,
Barry Glassman posted a link to a recent article he published in DS3 magazine, page 27.
Barry’s article helped set the stage for our discussion, explaining the origins of the unfounded association between oro-facial pain and the dental / orthopedic misalignment of the cranium and jaw structures. He stated that understanding the potential untoward effects of oral appliance therapy is critically important.
“Understanding how to evaluate a patient’s adaptive capacity and likelihood of developing those side effects is essential when considering oral appliance therapy. Being able to diagnose ligament insertion injuries, as opposed to joint sprains and/or strains or musculoskeletal pain and treat accordingly, not abandon therapy out of fear, allows us to make more advised treatment decisions…Simply diagnosing TMD and turning away is not in the best interest of our patients.”
Steve Lamberg shared that he documents the following when assessing a patient presenting for oral appliance therapy for OSA with claims of TMD;
· Severity and frequency of discomfort
· Source of discomfort i.e. capsulitis or muscle pain
· How long have they been suffering
· History of the condition, documenting if it was the result of an accident, a habit, parafunction, or constricted envelope of function
David Rawson shared with us how he uses a Tomographic image of the TMJ to determine the exact location of the jaw joint, helping him determine how much and in which direction he can move the mandible for every OSA patient he treats.
The two circumstances reported by a number of clinician’s that would at least temporarily disqualify a patient were a recent jaw fracture and a “closed lock’. However, in both of these circumstances, it was stated that once appropriate therapy and healing took place, these patients would once again be candidates for an OSA appliance.
It was a common consensus that joint sounds were common and of no real consequence.
A number of clinicians discussed the association between pain and unresolved OSA; with complaints of pain resolving once OSA is resolved. Other clinicians discussed pain as a creator of sleep fragmentation. It was also mentioned that compromised sleep lowers a patient’s pain threshold, which can be misinterpreted as TMD by the patient. By managing their OSA, their perceived TMD often resolves. Some clinicians evaluate for bruxism pre and post appliance therapy. Of course, the notion that in many cases, management of both TMD and OSA with an oral appliance is very similar was discussed.
The ability to evaluate a patient’s adaptive Capacity, which is the ability of a patient to comfortably adapt to a particular or required jaw posture was described as being more an art than science. Basically using intuition to not push the patient beyond their limit and backing off when necessary.
Dennis Marangos shared with us a number of statistics regarding the prevalence of TMD in OSA patients and the fact that the literature suggests that OSA symptoms precede the first onset to TMD. He said,
“TMD is not a contraindication to OAT but in fact with proper records and diagnostic protocols (JVA, CBCT scans of the joints etc), these patients can be greatly improved in sleep and pain issues.”
Regardless of what your personal opinion on what constitutes “proper records” for these patients, the take home message here is that TMD is not a disqualifier for oral appliance therapy in Dennis’s office.
Steve Marinkovich made the very important point, that patients presenting with TMD should be advised that the process may go slower for them and that although it is extremely rare, if they have too much difficulty, they may need to consider an alternative therapy. Transparency! Advise the patients, ensure that they understand, document and of course always obtain a signed consent.
Tony Soileau discussed his physio-therapy approach, providing a Link to a recent article he has posted on this subject. He feels that every sleep apnea patient he sees presents with some TMD symptoms. So, he considers them all “combo” patients. Tony discusses taking it beyond the 4” circle around the TMJ to the musculature of the rest of the body and a number of clinicians jumped in endorsing this approach with discussion of different physio-therapy approaches such as Postural Restoration Institute (PRI) and the Alexander Technique.
Further supporting the importance of musculature, Steve Carstensen shared a preview of a paper he reviewed where simple mouth opening stretches three times a day prior to and after getting an oral appliance resulted in significantly less muscle side effects than a control group. Dan Tache provided a Link to a very good article discussing the use of exercises in oral appliance therapy.
While Tony Soileau encouraged us to look beyond the 4” circle around the TMJ, Steve Carstensen encouraged us not to focus exclusively in the 4” circle surrounding the uvula. Both very valid statements!
It was a universal sentiment that perceived TMD is often a muscular issue and very rarely disqualifies a patient for OSA therapy with an oral appliance.
Another universal sentiment was the importance of educating our medical counterparts on this topic. Unfortunately, all too often, patients are misled by derogatory remarks such as “oral appliances cause TMJ”, and “a history of TMJ problems disqualifies you from using an oral appliance”, shared with them by physicians and sleep lab personnel. Of course, these comments steer patients away from oral appliance therapy without even considering a consultation. This is particularly problematic when we are talking about a patient that has already failed CPAP, often leaving them with no other alternative.
The simplest approach goes to Kent Smith,
“I say to Mrs. Jones:
"Do you have pain or discomfort when you do this?" (Pretend you see me protruding my mandible). Depending on their answer, I make a decision both on whether I can treat and what type of appliance I would use.
I don't put any more thought into it than that. The airway is too important for me to be looking for reasons not to treat.”
So, to sum up,
· It is rare to disqualify a patient for oral appliance therapy due to TMD
· It is common for a patient to feel that they are not a candidate when in fact they are
· It is rare for a patient to stop wearing an appliance due to TMD issues
· What patients perceive as a joint issue is often a muscular / ligament issue which is reversible and can be managed with proper guidance
· It is important to be respectful of the patient’s unique adaptive capacity
· As clinicians providing this service, we need to look beyond the joint and to the musculature, providing the patient guidance and support through exercise routines and physiotherapy
· There is much mis-information amongst physicians and sleep lab personnel. It is important to actively educate them regarding this issue
Once again, I would like to express a heartfelt thanks to all that participated in this discussion. As always, these consensus articles should be considered working documents, meant to guide those clinicians new to this field and also present some valuable insights to those of us that have been at it a while. I look forward to future discussions on our SleepDisordersDentistry LinkedIn group!
John Viviano DDS D ABDSM
Facility Accredited by American Academy of Dental Sleep Medicine