In this issue - The American Academy of Dental Sleep Medicine

20
ISSUE 4 | 2013
Case Presentation: Patient requiring quick and
effective treatment for severe obstructive sleep apnea
By Sue Ellen Richardson, DDS, MAGD, FICD, FAACP
Introduction
This is an interesting case because the patient urgently needed
treatment: Her untreated severe obstructive sleep apnea (OSA)
and disrupted sleep precipitated enough cognitive impairment
to cause her to have four car accidents in the previous five
months. It is well known that untreated sleep apnea is a significant
contributor to motor vehicle crashes. 1-3 The treatment of choice
for severe obstructive sleep apnea is continuous positive airway
pressure (CPAP) because this affords an immediate benefit to the
patient. This patient could not tolerate CPAP. She felt terrified of
the mask, secondary to acute claustrophobic reactions and feelings
of suffocation. She chose to attempt conservative oral appliance
therapy (OAT) first before considering any of the surgical sleep
apnea treatments.
Because the patient required immediate treatment, this put a
significant demand on the oral appliance to succeed quickly.
Rapidly advancing a patient to a therapeutic position with OAT
could irritate the temporomandibular joint (TMJ) and this patient
presented to my office with pre-existing minor TMJ disorder signs
and symptoms; she also had an unusual excursive movement habit.
It has been reported that a high prevalence, 52 percent, of OSA
patients referred for OAT arrive at the dental office with joint
pain, or symptoms of TMJ disorder. 4 Indeed, wearing an oral
appliance (OA) to treat OSA can even aggravate the TMJ. 5,6 Up
to 77 percent of patients wearing an OA for the treatment of
OSA report temporomandibular discomfort as a side effect. 4,7
However, despite this prevalence, significant and persistent TMJ
problems with OA use are uncommon 4,7 and OAT use has proven
harmless to the TMJ. 8 It has also been found that TMJ discomfort
isn’t connected to discontinuation of OA use. 9 In fact, sometimes
long-term use can often improve TMJ disorder symptoms. 10
The patient usually awakens with general pain in her joint, neck
and teeth that lasts until late morning. She protrudes on a 2mm
diagonal to the right on full protrusion. She habitually bruxes
SUE ELLEN RICHARDSON
DDS, MAGD, FICD, FAACP
Dr. Sue Ellen Richardson has been in the private
practice of General Dentistry for 32 years. She has
taught at the University Of Texas School Of Dentistry
and the Greater Houston Dental Society. She became
involved in the sleep field four years ago when her
mother needed help for her sleep apnea. She is a
Diplomate of The American Board of Dental Sleep
Medicine and a Fellow in The American Academy of
Craniofacial Pain.
diurnally and nocturnally, at which time she postures to her right
para-functional excursive position. However, when examined
midafternoon, she had no tenderness or pain of the masticatory
or TMJ regions. We chose to treat the patient who had joint
symptoms in light of these ambiguities.
Case Description
This 51-year-old married female struggles with fatigue and fights
significant drowsiness during the day. It scares her that she feels
sleepy while she is driving; in the past five months, she has been
involved in four car accidents. She is distressed that she doesn’t
feel alert and competent. She complains of nighttime choking
and gasping spells that awaken her. Additionally, her husband
complains that her loud snoring is disruptive to his sleep.
History of Present Illness
Continuous positive airway pressure (CPAP) was prescribed. The
patient’s medical history includes Type 2 Diabetes, metabolic
syndrome and menopausal symptoms. She currently takes
Adderall (stimulant), Bi-est (estrogen replacement hormone),
injectable Victoza (Type 2 diabetes), progesterone and injectable
growth hormone. The patient is a smoker. She has uncontrolled
OSA that is severe, according to both the sleep physician’s report
and the out of center sleep testing (OCST). She scored 15 on the
Epworth Sleepiness Scale (ESS), which mirrors her feelings of
excessive daytime sleepiness (EDS).
Relevant Past Medical History
The patient had a tonsillectomy as a child. She’s been monitored
for generalized, moderate to severe chronic periodontitis for years.
In the past, she said she’s had periodontal surgery with a gum graft,
and by her description, it was most likely flap surgery with scaling
and root planing and a gingival graft. She had three wisdom teeth
extracted and her right lower first molar. She feels cold and hot
sensitivity in most of her teeth. She has noticed a change in bite,
probably shifting due to her bone loss. Food now becomes caught
between teeth.
Clinical Findings
The patient presented with a blood pressure of 127/69, with a
pulse of 96, and a body mass index (BMI) of 31.5. Her tongue
examination showed it was scalloped and a level III (high) tongue.
A Mallampati airway inspection showed a Class III airway.
Her uvula appeared elongated. She developed a small maxillary
torus in her palate, and medium mandibular tori on the lingual
aspect of her mandible. Her mandibular range of motion
measurement recorded as low normal at 43 mm maximum interincisal
opening. Her lateral movements registered as normal with
a left lateral excursion of 12 mm and a right lateral excursion of 12