In this issue - The American Academy of Dental Sleep Medicine

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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
ISSUE 4 | 2013 21 mm. Her mandible deviates to the right approximately 2 mm at full opening. Her midlines are not coincident: her mandibular midline sits 2.5 mm to the right of her maxillary midline in habitual closure. The patient’s oral examination revealed generalized abfractions, some of which had been restored. The longer clinical crown length of the teeth secondary to attachment loss creates more potential for cervical flexing stress and loss of cervical tooth structure. Gingival recession has developed on teeth #2, 3, 4, 5, 7, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 28, 29 and 31. Her anterior teeth reflect an incisal wear pattern. The patient is missing teeth #1, 16, 17 and 30. Her full mouth series of x-rays showed generalized periodontal attachment loss (osseous and gingival). A Miller’s Class 1 mobility was recorded for teeth # 23, 24, 25 and 26. She opens with a 2 mm deflection to the right at full opening. Her overbite measures 3 mm, and her overjet measures 5 mm. Her oral cancer screening was negative. The patient presented with a Class II (retruded lower jaw) dental relationship on the right side and a Class I (normal) dental relationship on the left side. She had significant open contacts between teeth #10 and 11, 12 and 13 and 24 and 25. We examined her in the late afternoon, at that time of day she had no tenderness or pain of the masticatory or TMJ regions. Stethoscopic evaluation of her joints revealed slight crepitus upon opening on both sides. Her neck muscles are stiff every day and she has pain with cervical rotation on her left side. She refused further TMJ or cephalometric x-rays. Diagnosis Per OCST, the sleep physician diagnosed the patient as follows: 1. Snoring 2. Severe Obstructive Sleep Apnea Syndrome AHI - 37.5 Supine AHI – 53.9 Lowest Desat - 70.0 RDI – 52.4 Non – Supine AHI – Percent Below 90% - 5.6% Decision Tree I selected an Elastic Mandibular Appliance (EMA) for this patient. The EMA has upper and lower vacuform polycarbonate trays connected with forgiving stretchable straps that button onto the trays. The straps come in nine different lengths for changing or titrating protrusion, each strap numbered according to its length in millimeters. In addition, each numbered strap is available in four different color-coded elastic strengths or tensions or 36 total straps in all. Patients usually start with a softer strap and move to a firmer strap as their joints permit. This variable strap design of the EMA allowed for customized lateral movement and joint care that this patient needed and allowed her jaw to move to its excursive posture. We delivered the EMA and she wore it for two weeks with the size 17mm length straps on both sides in yellow (moderate stretch). On her follow up appointment, the patient complained of pain in her left joint. Since she naturally protrudes her mandible to the right, I suggested that she wear a longer 19mm yellow strap on her left side. The 19 mm strap allowed her excursive jaw posture and provided gentle tension on her joints. I reduced her vertical slightly also from the 5mm vertical established with the original 5mm fork George Gauge bite registration. She continues to wear longer straps on the left to enable her right protrusive movement: #19 yellow on her left and #17 yellow on her right. Her joints are quite comfortable; we did not need to change the length or stretch of the straps. She prefers the previous, more vertical opening so I added acrylic to slightly open her vertical back to 5 mm. She feels negligible discomfort in the morning in her joint and teeth for about 15 minutes. The patient is very comfortable with the appliance and feels much less daytime sleepiness and fatigue. We referred her for follow up sleep testing. The evaluation showed an AHI of 9.2, an RDI of 17.2 and a nadir SpO2 of 88%. Since the patient’s AHI was still above normal, we suggested shorter straps for more protrusion. She currently wears shorter straps, 16 mm and 18 mm yellow straps, but has not returned for follow-up OCST. “Since the patient naturally protrudes her mandible to the right, I suggested that she wear a longer 19mm yellow strap on her left side.” continued . . .
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