TMJ and OSA are sisters

Abstract

Dr. Riley H. Lunn, Editor in Chief of CRANIO, has been the catalyst for the interest in and growth of TMJ and, ultimately, dental sleep medicine. For years, Dr. Lunn and his staff have produced the CRANIO Journal. It began as CRANIO: The Journal of Craniomandibular Practice and, subsequently, became CRANIO: The Journal of Craniomandibular and Sleep Practice. Many brilliant colleagues and authors from all over the world have contributed to this wealth of information related to the two intertwined subjects: TMJ and OSA (temporomandibular joint disorders and obstructive sleep apnea). Now, in the middle of 2019, we continue making strides, moving forward in this most interesting area of dentistry. Dental clinicians are presented with patients of various needs. The general dental supervision of the patient, requiring hygiene and dentition management, is the most fundamental element. Beyond that are the multiple disciplines within dentistry and dental sleep medicine that have rapidly accelerated through the needs of patients and through dentist recognition. Like most of you, I am a clinician, but I am also an educator. After 13 years of occlusal and restorative dentistry, I limited my practice to the diagnosis of head, neck, and craniofacial pain and temporomandibular disorders and, ultimately, dental sleep medicine. I’ve also been afforded hundreds of opportunities to present educational programs relative to these subjects. Development of the temporomandibular joint plays an important role in the development of the airway. The converse is also true [1]. Particularly if present before and during puberty, nasal airway breathing obstruction may result in craniofacial (skull or jaw) deformities [2]. This explains, in part, why we find a strong correlation between patients who suffer from TMJ pain and dysfunction and patients who have sleep-disordered breathing problems including, but not limited to, snoring, sleep bruxism and obstructive sleep apnea. Additionally, like temporomandibular disorders, all too often sleep-disordered breathing goes undiagnosed and, therefore, untreated [3]. The fields of sleep medicine and dental sleep medicine need to solidify a model for the relationship between the medical field and the dental field [4]. There has been great progress since 2013, but there continues to be a need. The prevalence of OSA in America is comparable to the diseases of asthma and diabetes, affecting 25 to 30 million people. We know that it is slightly more common in males than females and progressively worsens with age. The nine identified Sleep Disorders are: Primary Snoring, Upper Airway Resistance Syndrome (UARS), Central Sleep Apnea, Sleep Bruxism, Parasomnias, Restless Leg Syndrome, Narcolepsy, Insomnia and Obstructive Sleep Apnea (OSA). These nine are not mutually exclusive and can interrelate with one another to create a more difficult case [5]. Obstructive Sleep Apnea is defined as “cessation of airflow for greater than 10 seconds with continued chest and abnormal effort” [6]. Its subset, Hypopnea, defined as “a decrease in the amount of air breathed (some say by 50%) with a desaturation of at least 4% arousal response,” is often a precursor to OSA [7]. Through my studies and lectures, in 1998, I derived my own definition of obstructive sleep apnea as “fundamentally an orthopedic problem from the inability of the mandible to maintain a patent airway”. Certain positions of the mandible and the tongue can lead to OSA. Patients who do not sleep well cannot heal well. Given the importance of sleep to health, I believe dentists must have a better awareness of patients’ overall health and wellness and screen every patient for sleep disorders and TMJ disorders. For sleep disorder diagnoses, the use of the Epworth Sleepiness Scale, the STOP-Bang questionnaire, or an equivalent simple test can be very helpful. For temporomandibular joint disorders, I developed the One Minute TMJ Screening. Through its use, practitioners can make more informed referrals to a dentist with the required training to properly evaluate and treat TMJ disorders and OSA. A thorough evaluation of the patient’s history and clinical signs and symptoms is recommended, along with polysomnography (PSG) or a home sleep test (HST) for airway and breathing problems. Doppler auscultation and CBCT (cone beam computerized tomography) is beneficial for assessing temporomandibular and occlusal concerns. This thorough evaluation ensures the best possible course of treatment for the patient [8]. More and more studies are showing a connection between TMD and sleep disturbances [9]. When the temporomandibular joint is not functioning properly, it can CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 2019, VOL. 37, NO. 5, 273–274 https://doi.org/10.1080/08869634.2019.1641910