The science is in the results.

http://www.usatoday.com/sports/2009-11-16-neuromuscular-mouthguard-cover_N.htm

The American Academy of Sleep Medicine has recognized the importance of oral appliances for the treatment of OSA as a “first line of defense”. Please read my article below to gain a better understanding of this common condition and the unknown treatment options. I have tried to make sense of it all to make my patients more aware and better informed. Enjoy!

The Importance of  Sleep and Airway

The incident of airway obstructions causing disordered breathing during sleep affects some fifteen million people in this country. Ninety percent of those affected have not been diagnosed.

Harvard trained physician John Remmers MD believes that Sleep Apnea will be the most chronic disease in all industrialized countries.

Consider the following facts concerning Obstructive Sleep Apnea:

-          65-85% of ALL stroke victims suffer from OSA

-          Systemic inflammation is increased with OSA

-          OSA is responsible in a 10 point drop in IQ

-          Untreated OSA results in a 20% drop in life expectancy

-          OSA person is 23x more likely to have heart attack than healthy person

These are some extremely startling facts considering that so many people are unaware that they have this condition. The most common type of Sleep Apnea occurs when the airway is actually obstructed during sleep, usually at base of the tongue as the lower jaw falls back during sleep. As air intake is interrupted, the body struggles to function from lack of oxygen in the blood.

Medicine’s gold standard for unraveling the mysteries that occur when we sleep is a sleep study or Polysomnogram (PSG). The PSG provides detailed information to understand the quality of sleep through the various stages of sleep. Once this information is gathered, a sleep physician will diagnose OSA into either mild, moderate or severe. Treatments for any type of OSA include another gold standard in sleep medicine the CPAP. Continuous Positive Airway Pressure provides a constant flow of oxygen passed the obstruction by providing a mask connected to an oxygen pump. Unfortunately, while effective the CPAP is obtrusive and loud, causing loss of intimacy, irritations of the face and throat.

These specific complications lead to 4-5 hrs of sleep per night (7-8 needed) and 20% compliance at 36 months of use. With such poor compliance, the American Academy of Sleep Medicine now considers oral appliances to be the “first line of defense” for mild to moderate sufferers, and an alternative to the CPAP in severe cases.

The principle of oral appliances is simple; maintain an open airway during sleep by preventing the lower jaw from falling back and blocking the pharyngeal airway. Oral appliances have minor problems (that may not affect all users) but should be considered before use. Excessive salivation appears to be the main implication, but is often transient as the user becomes more accustom to a foreign object in their mouth. Tooth movement can also arise with short and long term wear (with short term changes often caused by improper fitting, which can be easily corrected.) Long term use will likely cause tooth movement, but effects are often minor. Changes in the bite are common, and are also easily reversible early on.

As a user wears the appliance, it holds the jaw in an improved position causing healing of joints and muscle adaptation. Most describe the changes to be favorable (50%.) Because of the high satisfation, continued use is likely among more users.

TMD – The Grand Impostor

Let’s begin with the area that is affected by this condition: the Tempromandibular Joint. The TMJ is located just in front of the ear openings on both sides of the head. This joint is the connection point of the lower jaw to the skull, and with contraction and relaxation of muscles, the lower jaw can move in many different dimensions. The TM Joint is unique in that it is the ONLY joint that can rotate and slide. This is vital for the movements necessary for talking, swallowing, chewing and supporting the head on the spine.

Tempromandibular Dysfunction (TMD) or Craniomandibular Dysfunction are terms used to describe the affects that occur when the lower jaw opens/closes abnormally, attempting to bring teeth together for function. With the condition, the bite is influenced by abnormal postural influences from below the neck. As a result, the muscles attached to the jaw, as well as the TMJ, are forced to accommodate to that “position” good or bad. The bad side includes a great variety of local and systemic symptoms that mimic unrelated conditions, giving us the hidden veil of the Grand Impostor.

All muscles throughout the body have a resting level of activity known as muscle tone. Tones hold the body (or a body part) in a particular position, when performing particular movements or functions. The awareness of the body and its movement in space is relayed to the brain through nerves and special sensors located within muscles, joints and tendons. This information of awareness, known as proprioception,  is constantly being relayed to the brain so we always have a “feel” of how the body (or parts) is positioned in space. Noxious information generated by body parts that may not align correctly is also being relayed. For example one leg may be shorter than the other or the upper and lower teeth may not mesh correctly, causing sliding or grinding.

All of this useless extra sensory and motor information is directed through a tiny network of nerves located in the brain stem known as the Reticular Activation System (RAS). The RAS has profound influences on our awareness and how we think, learn and act. Symptoms of this abnormality include: anxiety, depression, inability to concentrate and insomnia. Basically, a collapse of the dentition and associated hypertension of the head occurs, and neck and jaw musculature causes upper airway problems.

Here are some other examples of how an unbalanced bite can influence the body:

High Blood Pressure -  Because of the instability created in the cervical spine complex with a unbalanced bite as well as the unique vulnerability of the atlas (c1) the likelihood of c1,c2 being out of proper alignment is very high. These anatomical abnormalities of the cervical spine at the level of the Atlas Vertebra are associated with relative ischemia of the brain stem circulation and increased blood pressure.

Headaches – Headaches/Migraines are very common with unbalanced bites. Due to the accommodation often necessary for muscles to brace for swallowing, chewing, talking and support the cervical neck complex as well as the head on the spine, muscles are often the culprit.

Ear symptoms – These side effects are well researched but not often considered in the treatment of tinnitus, hearing impairment, ear pain, plugged/inability to relieve pressure,  ear popping/grating/crunching and roaring/rushing sounds.

Menier’s Disease – Is a condition of abnormality of the inner ear. Diagnosed medically by SYMPTOMS of vertigo, tinnitus, ear pressure/pain, fluctuating hearing impairment and/or hearing loss. Is it not a coincidence that these are the same symptoms affecting the TMJ/TMD sufferer? One could expect that proper treatment will lead to partial or complete recovery.

This is a abbreviated list. The systemic and biochemical changes can be global, affecting anxiety, depression, moods  and quality of sleep. Physical changes in posture occur from head to toe.

Dr. Dan & Staff

Dr. Dan