Disclosures. The Troublesome Connection Between TMJ Health and Airway Health. Chief Complaint. TMD - Discovery

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1 The Troublesome Connection Between TMJ Health and Airway Health Disclosures I have no financial connection with anything mentioned in this talk Steve Carstensen DDS Diplomate, American Board of Dental Sleep Medicine I am Editor-in-Chief of Dental Sleep Practice Magazine TMD - Discovery Chief Complaint?

2 What Else? What About Parafunction Bruxism?

3 Jaw Movements During Sleep Parafunction Link to OSA Masticatory Muscle Activity With Contact = Sleep Bruxism Arousals Cause SB Tooth Contact, or Sleep Bruxism RMMA Two big breaths Suprahyoid muscle tone increases Tachycardia Brain EEG activity levels increase to -0.8 sec -4.0 sec decrease in parasympathetic dominance rise in autonomic cardiac sympathetic dominance -4.0 min

4 You Do Ask about heart disease.about diabetes about chronic pain.about TMD about Airway Airway Health Do You Snore? Have you been diagnosed with OSA? I don t snore

5 My Doctor Doesn t Have an Answer They tested me: No OSA What do Dentists Do? We Own TMD We re Comprehensive

6 We Got This

7 Help? Fix? I hate this splint We Got What do you need more of? more of This

8 But Not Old or Fat Your Patient is Sleepy Sleep Hygiene noun habits and practices that are conducive to sleeping well on a regular basis What does Dr. G say? Flow Limitation RERA Negative Pressure

9 The Data Say Esophageal Pressure -33cm H2O 3 second alpha intrusion arousals on EEG Body responds before Oxygen drops No Apnea PSG Diagnosis No Hypopnea No Desats Your Patient isn t Healthy

10 What Else Do We Know? UARS ODI Unremarkable OSAS ODI Significant Insomnia patients with primary insomnia have increased high-frequency EEG activation, abnormal hormone secretion, increased whole body and brain metabolic activation, and elevated heart rate and sympathetic nervous system activation during sleep. Sleep Med Rev Feb;14(1):9-15. doi: /j.smrv Hyperarousal and insomnia: state of the science. Bonnet MH1, Arand DL. Functional Somatic Syndrome Medically Unexplained migraine headache/tension headache syndrome irritable bowel syndrome (IBS) Somatic Syndrome Anxiety temporomandibular joint (TMJ) syndrome fibromyalgia Insomnia UARS OSAS Somatic Syndrome - Anxiety - Insomnia Gold AR, Functional somatic syndromes, anxiety disorders and the upper airway: A matter of paradigms Sleep Med (2010), doi: /j.smrv

11 Homeostasis Maintaining Stability through achieving constancy of the internal environment Allostatic Challenge Emotional, Psychological or Physical Stressors Allostasis Maintaining Stability through changes. Enables the organism to deal with increased demands Testing Allostasis Capacity Allostatic Challenge Challenge Response Reset Acute Allostatic Challenge Exercise Overheating Return to Normal Response Sweating

12 Chronic Allostatic Challenge Perpetuating Allostatic Challenge Challenge Adaptation UARS HPA Axis Activation Conditioning Functional Somatic Syndrome Functional Somatic Syndrome Medically Unexplained migraine headache/tension headache syndrome irritable bowel syndrome (IBS) temporomandibular joint (TMJ) syndrome fibromyalgia Somatic Syndrome - Anxiety - Insomnia What s the Mechanism? Odorants attach to Main Olfactory Epithelium Electrical Signals are Generated to the Cortex

13 Olfactory Nerve - CN I Limbic System Mechanoreceptors in the Olfactory Bulb Send Pulses to the Limbic System with Airflow Pressure Changes J Neurosci Nov 7;32(45): doi: /JNEUROSCI Stimulation of electro-olfactogram responses in the main olfactory epithelia by airflow depends on the type 3 adenylyl cyclase. Chen X1, Xia Z, Storm DR. Emotion ANS Regulation Endocrine Systems Neural Sensitization Paradigm Perpetuating Allostatic Challenge Acute Allostatic Challenge creates a response Perpetuating Allostatic Challenge UARS HPA Axis Activation sensitizes the Limbic System Functional Somatic Syndrome

14 SDB Increased Airflow UARS vs. OSAS Lower Pressure Triggers Signals to Limbic System Pressure High Upper Airway Resistance: Sustained pharyngeal narrowing during inspiration causing obstructive alveolar hypoventilation Obstructive Sleep Apnea: Recurrent pharyngeal occlusion causing transient respiratory events

15 UARS Perpetuating Allostatic Challenge Sustained low pressure / high airflow sends repeated signals to Limbic System UARS HPA Axis Activation Perpetuates the Allostatic Challenge Functional Somatic Syndrome Functional Somatic Syndrome Hypothalamus Chronically Irritated Hypothalamic Regulation Blood Pressure Memory Function Thermoregulation Thyroid Function Circadian Disturbances Appetite Growth Hormone Wakefulness Cortisol Dopamine GI Stimulation Sleep Regulation Illustration from Anatomy & Physiology, Connexions Web site. Jun 19, By Images are generated by Life Science Databases(LSDB). - from Anatomography, website maintained by Life Science Databases(LSDB).

16 UARS: 88 Living the Life OSAS: 365 Athens Insomnia Scale Pittsburgh Sleep Quality Index Epworth Sleepiness Scale Symptom Checklist-90-Revision Eysenck Personality Questionnaire

17 UARS patients tend to have more neurotic and sensitive personalities than patients with OSAS, which may be a cause of the clinical features of UARS. UARS TMJ patients tend to have more neurotic and sensitive personalities than patients with OSAS, TMJ which may be a cause of the clinical features of UARS. A Comparison of Personality Characteristics and Psychiatric Symptomatology between Upper Airway Resistance Syndrome and Obstructive Sleep Apnea Syndro Soo-Jung So1, Heon-Jeong Lee1 *, Seung-Gul Kang2, Chul-Hyun Cho1, Ho-Kyoung Yoon1, and Leen Kim1 Psychiatry Investig 2015;12(2): What Can You Do? Expand Your History Look for Somatic Pain Syndromes

18 Airway Diagnosis Medical + Risk OSA Likely Outcome CPAP Likely Outcome No Apnea No Hypopnea PSG Diagnosis No Desats

19 Airway Diagnosis No + Medical Treat the Symptoms Do What You Can to Verify Risk Cardiopulmonary Coupling SNS Oral Appliance Choice Activation

20 Simple Airway Testing Nasal Breathing Nutrition American Dental Association Policy Statement on the Role of Dentistry in the Treatment of Sleep-Related Breathing Disorders 1.Dentists are encouraged to screen for SRBD and refer for diagnosis 2.Screening includes children, although referral and treatments differ from adults 3.Oral appliance therapy is appropriate 4.Physicians prescribe OAT but dentists are responsible for evaluation, choosing, and providing the service 5.Informed consent is required PCP Collaboration 6.Dentists treating SRBD with OAT should be capable of recognizing and managing side effects 7. Dentists should test patients using OAT for effectiveness, including use of home sleep apnea monitors to obtain interim results for the purpose of OA titration 8. Surgery may be necessary 9. Dentists should continually update their knowledge and training 10. Dentists should maintain regular communication with patient s other medical providers 11. Follow-up testing by physicians should be done to confirm treatment efficacy TMD? Lower Sleep Efficiency More Frequent Awakenings Responds to Melatonin Dentists are the only health care provider with the knowledge and expertise to provide OAT. J Pain Symptom Manage Sep;46(3): doi: /j.jpainsymman Epub 2012 Nov 27. Analgesic and sedative effects of melatonin in temporomandibular disorders: a double-blind, randomized, parallel-group, placebo-controlled study. J Clin Sleep Med Feb 15;10(2): doi: /jcsm Polysomnographic investigation of sleep and respiratory parameters in women with temporomandibular pain disorders.

21 TMD? Airway? Airway? TMD? It s the question Both

22 Curiosity + Action = Clinical Wisdom People's beliefs about health problems, perceived benefits of action and barriers to action, and self-efficacy explain engagement (or lack of engagement) in health-promoting behavior Janz, Nancy K.; Marshall H. Becker (1984). "The Health Belief Model: A Decade Later". Health Education & Behavior. 11 (1): 1 47 Learn What They Believe Treat What They Value

23 You Can Expand Their Possibilities You Can Change Their Life Know Your Work Sound Familiar? Know Your Patient Apply Your Knowledge Know Yourself The Troublesome Connection Between TMJ Health and Airway Health Steve Carstensen DDS Diplomate, American Board of Dental Sleep Medicine SeattleSleepEducation.com