Authors: Dr Tony Soileau DDS, Candid Mouton LMT
Treatment Facility: Louisiana Sleep Solutions
420 Settlers Trace Blvd
Lafayette LA, 70508
Treating sleep apnea with a dental oral appliance can be effective for mild, moderate, and sometimes even severe sleep apnea (although not recommend for severe levels, unless the patient is PAP-intolerant). Dental Oral Appliance Therapy works by repositioning the mandible into a forward or protrusive position. They are sometimes referred to as MADs (mandibular advancement devices). The mandible is brought forward, causing the tongue to posture forward with the mandible. As the tongue comes forward, it stops obstructing the airway and also puts less pressure on the soft palate. As the soft palate is no longer positioned into the throat, the airway is opened further still. All MADs work in this manner.
Fabricating an oral appliance involves taking impressions of the dentition of both the maxilla and the mandible and taking a bite registration. The bite registration is the starting point from which the mandible will be titrated forward. The further the mandible is brought forward, the greater the airway is opened. What limits the distance the mandible can travel is the muscle tension exerted on the mandibular jaw joint, or TMJ. These muscles include the muscles involved in mastication, upper back, and chest. Pathology associated with these muscles such as trigger points, spasms, and dehydration can cause the muscles to overly contract and in time stay shortened. This can cause pain in the head and neck region along with clenching and grinding of the teeth. We also know that patients tend to grind their teeth during sleep stage N2 and before and after micro arousals. Another problem that is associated with pathological muscles is how the patient breathes, particularly patients who suffer from sleep apnea. As a baby, we breathe with our bellies (“belly breathing”). As a baby breathes in, their belly expands, and as they breathe out, their belly contracts. By breathing with their belly, they are fully inflating their lungs, particularly the bottom lobes. As they breathe in and out, the movement of their belly stimulates blood flow to their organs as they are compressed. Think of the typical body builder pose where the body builder sucks in their stomach to show off their abs. Patients suffering from sleep apnea and TMJ-D, temporal mandibular joint disorder, tend to breathe with their chest. If you squeeze your teeth together you will find your shoulders will begin to lift. If you lift your shoulders while exercising or carrying a heavy purse, you will find your teeth begin to contact. Your teeth should only contact when you swallow. When patients have TMJ-D and sleep apnea, their upper body muscles tend to stay tight and partially contracted. Their chest does not easily expand for them to “belly breathe”. So, they inhale by lifting their shoulders (“chest breathing” or “shoulder breathing”). Some of our patients not only breathe by lifting their shoulders but reverse the movement of their belly. As they breathe in, their belly contracts, when it should be expanding with increased air volume. This inactivity of chest expansion and diaphragm movement causes them to have less efficiency with the intake of air. Also, as they now lift their shoulders to breathe, causing their teeth to contact, they are causing their TMJ-D symptoms to worsen and the muscles that allow the jaw to move forward to stay even tighter. As their teeth begin to wear and break, their bite becomes unbalanced. This further exacerbates the TMJ-D problem.
So for a dentist treating sleep apnea with an oral appliance (MAD), the problem of the patient’s muscles being tight due to trigger points, clenching/grinding (bruxism) during daytime hours, clenching/grinding during micro arousals, chest breathing, and worn dentition must be overcome. If the controlling and supporting muscles of the mandible do not allow enough forward positioning, the tongue will still be obstructing the airway. Conversely, the mandible may be brought forward enough to reduce the AHI, but the appliance causes facial myopathy and is not worn.
Case Report Techniques
To overcome these muscles issues in our practice, we utilize two therapies, ULF tens and massage. The first is an ultra-low frequency tens (ULF tens) and a combination of massage, stretching, and acupressure before we record the patient’s bite. This therapy continues during treatment. The patient is first “tensed” for 30 minutes. The tens unit provide a low frequency, periodic, bilateral stimulation to cranial nerves 5 and 11. The purpose of the tens is not to fatigue the muscle. It is set in amplitude and time to contract the muscles of the head and neck 20 percent every second. This stimulates blood flow in and out of the affected muscles. As blood flow increases, the buildup of lactic acid and other waste products in the muscles are reduced, and the muscle begins to relax and lengthen.
Following the tens session, the patients has massage/acupressure therapy for 30 minutes in the dental chair. The protocol for this therapy was developed by our in-office massage therapist. The purpose and flow of this protocol is to give the patient as much relief from pain and tension of the head and neck areas as possible in 30 minutes of chair time. It is not intended to be a onetime procedure. It begins with acupressure techniques to relax the patient and clear the sinus and lymphatic congestion which may be giving a false indication of muscle tension or tooth pain. It continues with opening lymphatic channels to allow stagnant chemical mediators such as lactic acid and prostaglandins to be transported out of targeted muscles. Targeted muscle groups of the head, neck, and shoulders are then stretched and massaged to locate, reduce or eliminate trigger points while stimulating increase blood flow to aid in healing and prolonged pain relief. Additional stabilizing muscles are also stretched and treated as necessary. Sharing breathing techniques along with mobilization of the sternum and ribs helps the patient to begin to breathe with their belly and further relaxes the shoulders. Intra oral trigger point therapy is also done to relax the masseter and pterygoid muscles to allow the jaw to rotate to a natural yaw position. As intraoral trigger point therapy can be the most uncomfortable, it is performed toward the end of the therapy when the patient is the most relaxed and contributing muscles have been treated. The use of the ULF tens and massage/acupressure session allows the temporal mandibular joint to be decompressed to a natural state. The relaxation and mobilization of the ribs, sternum, pectoral, and abdominal muscles, along with coaching, allows the patient to begin to breathe with their belly again and not their chest. The therapy ends with getting the patient as relaxed as possible in their head, neck, and shoulders.
Once the muscles have been relaxed we take a bite registration to use for the MAD fabrication. We place bite shims (small wafers of plastic) between the front teeth. The wafers are 1mm in thickness. Wafers are added until the lips seem to part when the patients relaxes. One wafer is then removed to give us the amount of opening for the patients. If the MAD opens the patient’s mouth to a point where the lips separate during sleep, drooling may occur. The jaw is then allowed to translate forward until tension is felt in any of the facial or neck muscles. The jaw is then brought back slowly until no tension is felt. The patients is asked to hold this position for 60 seconds to ensure comfort. The bite is then recorded at this starting position. Once the MAD is fabricated, we will see the patient once a week for a month, then once a month for 3-4 months. Each visit, the patient is evaluated for muscle tension or discomfort and additional massage therapy is provided before we advance the appliance. Because we started at a relaxed bite position dictated by the patient’s muscle comfort, our patients have very little bite accommodations each morning. Most report no changes in bite position. As we bring the patient’s mandible forward to find the position that lowers their AHI to below 5, we continue to relax the muscles, remove trigger points, remove pain inducing muscular waste, restore proper breathing for the most efficient intake of air and ensure appliance comfort. We feel this plays a large role in the success we have in helping our patients have a restful and restorative sleep.
Treating patients with MADs who have sleep apnea can be very rewarding. Especially for those patients who cannot tolerate a CPAP. But it can also be frustrating for both the patient and the dental team when the appliance is not comfortable. By taking the time to get the patient’s muscles ready for their appliance ahead of time and during treatment both the patient and the dental team will have a much greater chance for a successful outcome.