Dr. Gilles Lavigne, Faculté de médecine dentaire ... · Dr. Gilles Lavigne, Faculté de médecine dentaire, Université de Montréal, copies réservées 1 Sleep Bruxism and Orofacial

Dr Gilles Lavigne Faculteacute de meacutedecine dentaire Universiteacute de Montreacuteal copies reacuteserveacutees

1

Sleep Bruxism and

Orofacial PainTMD - Headache Sleep Apnea

Gilles Lavigne DMD PhD FRCDFac meacutedecine dentaire Universiteacute de Montreacuteal

Centre Eacutetude sur le Sommeil Hocircp du Sacreacute Coeur de Montreacuteal

Grants CIHR FRQS CFI Canada Research Chair

Gilles Lavigne DMD PhD FRCDFac meacutedecine dentaire Universiteacute de Montreacuteal

Centre Eacutetude sur le Sommeil Hocircp du Sacreacute Coeur de Montreacuteal

Disclosure

Neither I nor my immediate family have any

financial interests that would create a conflict of

interest or restrict my independent judgment with

regard to the content of this course

Other Relations ndash GrantsResearch Support CRC CIHR FRQS

ndash Speakers BureauHonoraria Lectures to Dental Study Group or Societies

ndash Other Past president of Canadian Pain Society

ndash Book Quintessence ndash DSM 2009 ndash re edition for 2019

ndash Free use of oral appliances and recording systems (eg NarvalResmed amp

Somnomed Braebon Bruxoff Night Shift)

Role(s) of dentistry in sleep medicine

Green light sleep bruxism= Our Expertise

recognition diagnosis and management

Yellow light sleep bruxism in presence of other

sleep disorders and pain =

COLLABORATION + referrals recognition

management

Red light sleep apnea insomnia REM Behaviour

Disorder (RBD) Gastric reflux (GERD)=

- MD responsibility

-- DMD= recognition ++ not diagnosis

--- We collaborate to management

What is Bruxism

An open and ongoing debate for years

An oral activity (clenching and grinding)

that can occur in some person(s)

during WAKE and SLEEPhellip

Spectrum ndash not a continuum

- A usual oral motor activity in reaction to lifehellip

- Or an oral behavior- Or a disorder

(signs amp symptoms presence of risk factors

co morbidities etc) (small of population)


2

Sleep Bruxism definitionndash MEDICAL amp DENTAL

From parasomnia in medicine and parafunction in

dentistry

(Int Class Sleep Disorders 1 Am Acad Sleep Med)

- MEDICAL ICSD 2 and 3 (2014)

SLEEP Movement Disorder

- DENTAL Revisited (Lobbezoo et al J of O R 2013 and ICSD 3)

Repetitive jaw-muscle activity characterized by

clenching or grinding of the teeth andor by bracing

or thrusting of the mandible

Two distinct circadian manifestations sleep (indicated as sleep bruxism)

or wakefulness (indicated as awake bruxism)

POLYGRAPHY A sleep bruxism episode

with a cessation of breathing

OCCASIONAL ndash NOT IN all patients - AGINGhellip

LOC

ROC

EMG

C3A2

SpO2

Airflow

Mic

O1A2

ECG

LegL

MasR

MasL

TempR

TempL

O2Flow

RMMA of SBPeriodic Limb Mvt

HR interval

Autonomic amp EEG arousal

SB and snoring in Japan(Kato T et al Sleep and Breathing 2012

Tachibana M et al Oral Dis 2016))

In general population

bull Prevalence= 8

bull + tooth grinding as child = OR of 8 as adult

bull OR of snoring= 26

In children

bull Prevalence = 21

bull OR for snoring= 18 5-7 yo=17

move ++ and mouth open breathing =15

Children 14-20

Teenagers and Adults 12 to 8

Over 50 years of

age

5-3

Mayer Heinzer and Lavigne CHEST 2016

Self reports Prevalence drop with AGEParents or Sleep Partner Awareness (not always precise)


3

Self reports Not very solid

Am Acad Sleep MedicineCriteria suggested to screen patients with SB

(Int Class Sleep Disor 3 - 2014)

not absolute answer

Your clinical interview

You ask about awareness of tooth grinding (sleep)

andor clenching (wake and sleep)

SELF REPORTS

PREVALANCE and False + and False ndashMaluly M et al J Dent Red 2013 Sao Paolo Brazil - sleep lab population

34 47 +

16

33

12

5

One night

19

Criteria suggested to screen patients with SB (Int Class Sleep Disor 3 - 2014)

1 A recent history of tooth grinding sounds occurring at least 3-5 nights per week over 6 months (if sleep alone)

+ in less than 50 of AWARE cases with sleep lab PSG

2 Presence of tooth wear

it is a YES or NO

- NOT for current or severity assessments

AND no difference in EMG measures

(Abe S et al Int J Prostho 2009 Jonsgar C et al J Dent 2015)

NB not reliable since can be past SB episodes

Masseter muscle hypertrophy due to

CLENCHING alone andor chewing gum tic etc


4


3- Muscle FATIGUE amp temporal HEADACHE =

Morning masticatory muscle pain

- Rompreacute et al J Dent Res 2007 Montreal

- Schmitter et al Sleep Med 2015 Germany

- Palinkas M et al J Clin Sleep Med 2015 Brazil

High sensitivity (78 amp 67 OR 96 amp 92)

Debated see Raphael K note JCSM 2016

- Stuginski-Barbosa J et al J Prostho Dent 2016 Brazil

The report of regular or frequent SB (4Xweek) and the presence of (1) incident of abnormal tooth wear or (2) incidents of transient morning jaw muscle pain or fatigue best discriminatory items of ICSD-3 for SB diagnosis

Diagnostic (Dx) tools

lsquoSleep bruxismapnearsquo

RMMA EMG index (hr sleep)Rhythmic Masticatory Muscle Activity

2- 4 low frequency

4 and more modest to high frequency

Need to be validated in general population

of all ages

The 2-4 RMMAhr and 4hr EMG criteria are

- Lower in children 1-2hr sleep (Huynh et al Sleep Med 2016)

- In absence of audio-video scoring index is 238

higher (Carra MC et al Sleep amp Breathing 2014)

- Time to time variability in RMMA over 25

Needs to estimate criteria with Type 4 (1 channel)

and Type 3 (3 channels +) recorders

adjusted for age co-morbidities etc

Sleep ProfilerGrind Care 2 Nox T3


5

Etiology-Mechanism of RMMA-SB onset (Mayer Heinzer and Lavigne CHEST 2016)

Sleep arousal

the coucou survival system

A sleeping brain is filtering the outside world for

irrelevantrelevant or threahtening events

every 20 to 40 sec

- Protection of sleep continuity

- Fight or flight physiological readiness

CYCLIC ALTERNATING PATTERN

Or Coucou system ndash VIGILANCE amp SURVIVAL

Strong association

between RMMASB and

CAP A3 Arousal dominant

phase

AROUSAL during sleep = Transient activation

(3-15 sec 7 to 14 times per hr) of brain

muscle and heart + respiratory system

Cerveau amp Psychologie

2007


6

Cyclic alternating pattern (CAP)

The marker of sleep instabilityParrino L Ferri R Bruni O Terzano MG Sleep Med Rev 2012

Carra

Dent Cli Noth Am

2012

Central Nervous System and SB

Brainstem to Cortex if AROUSAL

LOC

ROC

EMG

C3A2

SpO2

Airflow

Mic

O1A2

ECG

LegL

MasR

MasL

TempR

TempL

O2Flow


HR interval

RMMA with Autonomic amp EEG arousal

NOT EXPLANING ALL RMMA ONSET

- Concomitant in young subjects

60- 90 of SB episodes Lavigne et al ndash many papers Nukazawa C et al Cranio 2017

Tsujisaka A et al J Prostho Res 2018

- About frac14 with respiratory arousal Tsujisaka A J Prostho Res 2018

- Less in general population 50 Maluly M JDR 2013

Management

Pharmacologic

Approaches

Cardioactive (proposed by Sjoholm)

1- Propranolol NO EFFECT in

Experimental RCT

BUT

2- Clonidine 03 mg

60 reduction but hypotension in

20 of subjects (Huynh et al SLEEP

2006)

Re-produced (Baba et al J Sleep Res 2016

Japan) with 015 mg amp no problemhellipRx by MD

0

1

2

3

4

5

6

7

Study 1 - propranolol Study 2 - clonidine

05

1015202530354045


0

1

2

3

4

5

6

7


05

10152

0

2530354045

Study 1 ndashpropranolol

Study 2

clonidine


7

Saper Trends in Neurosci 2001

Sleep System

GABAVLPO

HIST

5-HT NE

ACh

ThalamusThalamus

WAKESLEEP

Saper CB et al Trends Neurosci 2001

Wake System

GABAGAL

HIST

5-HT NE

ACh

WAKESLEEP


Sleep partial isolation

Wake full interaction Cortex and brainstem

Fig3b

Fig4b

Fig1

Fig2

Fig3a

Fig4a

SB over

time

epihr

A1Sleep

continuity

hr

A2Sleep

transition

hr

A3Arousal

pressure

hr

Time distribution

(temporal pattern) of

Sleep Bruxism and

Arousal over nonREM

to REM cycles

AROUSALS (A2 ampA3)

as a permissive like

window for RMMA

onset(Carra SLEEP 2010)

Parma amp Montreal collaboration

Crescendo

Crescendo

REM

Peak before

REM

may be

mechanism

related

Medical and Behavioralpsychological

conditions = secondary SB

Medical and dental collaboration

mandatory

Identify single or combination of risks causes- Stress-psychology

- Tooth grinding-tooth wear

- Sleep arousal brain and autonomic

- Exacerbated by brain activation

- Insomnia related

- Headache If in morning OSA or SBhellip

- Temporomandibular pain

- Periodic limb movementRLS awakehellip

- Obstructive sleep apnea (OSA)

- Gastro esophageal reflux (GERD)

- REM Behavior Disorder (RBD) Epilepsy etchellip

Caution

If

+


8

Psychophysiological

aspects debatedRole of life pressure

Psychological if following

debatedhellip

bull Obsessive-compulsive behavior interpersonal

sensitivity depression anxiety paranoid ideation

and psychoticism ASSOCIATED to SB-RMMA

(R2 T score 0359hellipso it EXPLAIN about 36 of variability

more than 25 of variability)

FROM Potential association between psychopathological status

and rhythmic masticatory muscle activity of young patients with

sleep bruxism in Tianjin China Z Shen et al SLEEP Medicine 2018

40 (1025 small sample size) scored + on psychopathology

scale ndash Mean age 28 yo (SCL-90 T score 178 plusmn 049SB vs 119 plusmn 008 Ctl p 0000)

INSOMNIA 20 to 30 min (if NAP) to fall asleep or

cannot resume sleep if awakening

Prevalence 10 general population up to 30 in

chronic pain patients

Initial insomnia induce significant rise in pain over

time (explain 16 of the variance Temporomandibular

pain n=53 Quartana et al PAIN 2010)

NB Insomnia is present in 56 of Substance Abuser

Subjects (Mafoud Y et al 2009 Pilot study)

INSOMNIA in PAIN amp SLEEP interaction General Sleep Lab population (n=1042)

No association with DEPRESSION OSAS SNORING

but YES with INSOMNIA (Maluly J Dent Res 2013)

2 X +


9

Difficulties maintaining sleep

REPORTED by 478 of tooth grindingSB

person in general population (self report awareness) ndash

Khoury et al SLEEP 2016

NB over 25 in Maluly sample one night PSG

Poor Sleep Quality and Sleep Bruxism

Differential Dx critical - SECONDARY SB

Concomitant Neurological sleep disorders Oromandibular myoclonustooth tapping in 10 of Sleep

bruxism subjects (Kato T 1999)

-REM behaviour disorder (Sleep bruxism and

mainly Oromandibular Myoclonus found in RBD

subjects Abe Sleep Med 2013) hellip

UNKNOWN IF LINKED TO

RISK of developing Parkinson Disease Multiple

System Atrophy Dementia = 30 at 3 y amp 66

at 75 y (Postuma RB Neurology 2015)

Sleep bruxism

with

orofacial pain (TMD) amp headache


10

Wake and Sleep Bruxism OVERLAP

Threshold from normal to DxPhenotype ndash sub-group of SB (Rompre J Dent Res 2007)

bull OVERLAPWAKE clenching in over 90 of occasionnal

sleep bruxism cases

bull LOW FREQUENCY of RMMA Episodes hr of sleep 70 had

MORNING PAIN

0

20

40

60

80

100

clenching painful jaw

upon

awakening

fatigue of

masticatory

muscles

SB-in SB-out controls

bull Low FREQUENCY of RMMA Episodes hr in SB patients

bull BELOW 4 RMMAhr











- If morning muscle fatigue longer tonic EMG (Yoshida 2016)

More RMMASB do not = more pain

No more RMMA contraction in Morning

Transient Pain (Abe S JOFP 2013)

No reduction in RMMA if transient morning pain


11

Comparison of the EMG data ( of EMG events per hour of sleep)

between different groups ndash ONE CHANNEL EMG temporalis

Yachida W et al J DENT RES 201291562-567

Copyright copy by International amp American Associations for Dental Research

SB and Temporomandibular Disorder

httpsyummylookscomteeth-clenching

Smith M et al SLEEP 2009

Sleep Lab TMD population

bull 358 INSOMNIA

bull 284 OSAbull 173 SLEEP BRUXISM

SMITH SLEEP 2009

bull 45 of TMD patients 1 sleep disorder bull 26 of TMD patients 2 sleep disorderbull 17 of TMD patients 3 sleep disorder

TMDCtl = Same RMMA-SB index K Raphael-JADA 2012


12

Again no more EMG SB related difference

but poorer sleep if TMD

(pain 4910 76 morning pain or soreness)

Schmitter M et al Sleep Med 2015

71 fits ICSD 3 -2014

screening criteria

No JAW muscle relaxation during sleep of

female TMD cases

TO be reproduced

Wake time carry over influencesIn TMD cases= pain due tohellip

Elevated - Sustained Activity in all sleep

period for 72 of TMD cases (n124 42 Ctl) (K Raphael JOR 2013)

Background EMG during non-SB event periods is significantly

higher for women with myofascial TMD (median = 331 uV and

mean = 498 uV) than for control women (median = 283 uV and

mean = 388 uV)

Background EMG was positively associated with pain Intensity

AWAKE ndash CARRY OVER

WHILE RMMA-SB event related EMG was negativelyhellip

Hyperarousal Insomnia model

(Riemann et al Sleep Med Rev 2010)

Sleep quality worsens prior (last 6-12 months) to onset of temporomandibular

disorder (TMD) in incident cases while remaining unchanged for matched

controls

GD Slade et al J DENT RES 2016951084-1092


Small delta

caution in

extrapolation


13

Morning headache complaints

Think OSA bruxism Hx Traumatic

brain injury etchellip

wwwboldskycomhealthdisorders-cure

httppocketdentistrycom15-

introduction-to-dental-trauma-

managing-traumatic-injuries-in-the-primary-dentitions0105

TBI (Traumatic Brain Injury)

Dentist see tooth damage

but is it the only damage

i2wpcomneurosciencenewscom

httpminnesotahockeymagcomwp-

contentuploads201212Concus1jpg

NEW DATA mTBI amp Bruxism and HEADACHECorrelation between frequency of RMMA and MIDAS

score HIGHER RMMA with HIGHER MIDAS SCORE (Suzuki Y et al J Oral Facial Pain Headache 2017)

1

2

3

4

00 20 40 60 80

Number of RMMA

MIDAS score

Spearmanrsquos correlation

r=0559 P=0006

MIDAS 3 amp 4 moderate

to severe disability

ASSOCIATED to

higher frequency of

RMMA (but independent can

contribute to predict HA)

Periodic Limb Movement Arousal

and RMMA-SB

bull RMMA with PLM in 85 events

bull 70 just before onset of RMMA-SB

bull MOST with micro-arousal (Zhang Y et al Sleep Med 2017 (Dr D Yao China))

bull Positive correlation SB and PLM and

sleep arousal(van der Zaag J et al Clin Oral Investigation 2014)


14

RLS complaints rise with age

SB grinding drop

Concomitant in 9 to 17 Lavigne and Montplaisir Sleep 1994

Sleep bruxism

with

OSA

sleep disordered breathing

Arousal precede RMMA SB

APNEA precede ArousalhellipIntersecting prevalence with age

may explain why you see in your practice

Sleep Bruxism decreases

Sleep Apnea increases

SB 12 to 3Lavigne amp Montplaisir

Sleep 1994

AHI 15 and over

95 to 174Peppard 2013

SB

Apnea

Overlap period35-50 yo

Age transitionMaluly et al Sao Paolo Br

unpublished


15

Respiratory events in young SB subjectsTsujisaka A et al J Prostho Res 2018

- Young SB subjects (24 yo) moderate + RMMA

- 624 (25)= + respiratory events (OSA +)

- 68 Hypopnea 15 Obstructive 13 Central

- RMMA dominant N1 and N2 20 in REM

-Non specific activity 60 N1 N2 30 in REM

35 1 1 3 4 5 6 7 84 22 9 10 15 2011 12 13 14 16 17 18 19

Before SB onset AfterO2

satu

rati

on

(

)

955

965

970

975

980

960

950

(sec)

A sub group of SB patients (27) present

mild hypoxia (SaO2 1-18) in relation to RMMAI Dumais et al J Oral Rehab 2015

oxygen saturation change 8 seconds after SB onset

-25 -15 -10 -05 0 05-20SUB GROUP

phenotype

SEQUENCE of Respiratory events in

young SB subjectsTsujisaka A et al J Prostho Res 2018

OSA to RMMA 2 RMMA to OSA 4

T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

OLDER PATIENTS (mid 50ties) OVERLAP SB and

OSA

What is first SB-RMMA or Apnea Saito M et al Hokkaido University Sapporo Japan

(J Sleep Res 2014)

55 to Sleep Bruxism


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25

20 of SBE not associated to Apnea events

OSA and Temporomandibular Disorder




bull 358 INSOMNIA


SMITH SLEEP 2009


Differential Dx critical -

Concomitant sleep disorders

breathing

QUESTIONNAIRE only

IF TMD= 4 SampS of OSA with OR= 36 for

chronicity of TMD pain (Sanders JDR 2013 ndash OPPERA study)


17

TMD population RERA are higher in TMD female than

in Control Subjects (B Dubrosky J Clin Sleep Med 2014)

ManagementLow on evidence medication off label based on expert

opinion or experience amp logic from available data

Age group may guide us if comorbidity

Behavior to DISORDER

Hypothetical Distribution of RMMA ndash Lavigne et al JOR 2008

FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18

Choice of treatment link to risks causes- Stress-psychology Txhellippsycho amp Talk explain

- Tooth grinding-tooth wear Txhellip splinthellip

- Sleep arousal brain amp autonomic Txhellip medication

- Over brain activation Tx Md medic psy

- Insomnia related Txhellip CBTpsycho medication


- Temporomandibular pain Txhellip splint medic etc

- Obstructive sleep apnea appliance exercise Md

- Gastro esophageal reflux (GERD) position medic

- REM Behavior Disorder(RBD) Epilepsy physician

Intersecting prevalence with age





Sleep 1994

AHI 15 and over


SB

Apnea



unpublished

Child to younghellip

4-5 yo

Adolescenthellip

The challenge is to build guidance

taking into consideration

- patient-family beliefs

- Expertise of clinicians

- Evidence based literature

- Personalized medicine

Children have airway changes with aging

from 1-2 yo till 20 yo of ageStacey Quo et al PPSM 2016

1 1-2 yo =

Tongue hyoid larynx

Go down

2 4-5 yo = Adenoids and

tonsil minimal space

3 7 yo=Forward growth

maxilla downward

4 14 yo = Palatal suture get solid

5 14-20 yo =Vertical face growth

Involution of adenoids


19

OTHER management for SB Effect amp Level of evidence

Winocur in Sleep Med for Dentist Quintessence2009

Behavioral management approaches

bull Explanation of causes and exacerbation factors for SB

bull Elimination of clenching teeth and bracing jaw during daytime in

reaction to life pressures

bull Lifestyle changes introduction of sleep hygiene relaxation

autohypnosis and winding down before sleep

bull Physical therapy and training in relaxation and breathing

bull Psychologic therapy to manage stress and life pressure

Questionable effect ndash Weak evidence so far but patients report

subjective well-being

Listen and guide

according to beliefs

Palatal ExpansionDagmar Quo S Pliska B and Huynh N in Principles and practice of

sleep medicine 2016 Elsevier

SLEEP APNEA IN CHILD

The effect of rapid palatal expansion (56-66 mm) on

sleep bruxism in children (11 yo)

Bellerive A et al Sleep Breathing 2015

In 65 of subjects= reduction over 25 in RMMA-SB index

Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)

Tonsil removal- Tonsillectomy may improve

child behavioural problems

such as attention hyperactivity

and sleepiness (Wei JL et al Arch Otolaryngol Head Neck Surg

2007 + Chervin RD et al Pediatrics 2006)

- AFTER tonsil removal 10-15 child still present sleep apnea-hypopnea (Mitchell RB Larygoscope 2007)

- debate on surgery total reduction in only 25 (Tauman R et al J Pediatric 2006) and

44 cure (NG et al Sleep Med 2010)

- For bruxism only questionnaire study suggesting + results (cases + reduction)

(DiFrancesco RC et al Int J Pediatr Otorhinolaryngol2004 Eftekharian A Int J Pediatr Otorhinolaryngol2008 )


20

Young adulthellip













Listen and guide


Do sleep hygiene measures and progressive

muscle relaxation influence sleep bruxism

Report of a randomised controlled trial

No effect of sleep hygiene measures

together with progressive relaxation

techniques on sleep bruxism or sleep

over a 4-week observation period

BUT n of 8 per group power probably too low for such outcome ndash

If comorbidity (insomnia )

Valiente Loacutepez M et al (Lobbezoo F lab)

J Oral Rehab 2015

ORAL APPLIANCES

- Occlusal Splint to prevent tooth damage

Ideal on lower jaw if risk of Sleep Breathing Disordersnoring-apnea

- Mandibular Advancement DeviceAppliance

If you suspect breathing issues

Then follow-up in sleep medicine to monitor BREATHING (home recording)

- NTITM or home made deprogrammer

For short term use + evidence but riskhr use

Svensson J Oral Rehab 2007

Somnomed

Narval ResMed


21

Splint studies = SHORT TERM changes in EMG level

Over time Muscle fibers length = adaptation

Motoneurons activity ldquostabilisationrdquo

0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks

laquo Cyclic variation raquo

Orofacial EMG estimation

ambulatory no video

van der Zaag JOP 2005

1st night= 62-74

4 week later= 111- 106

Orofacial EMG indexhr

No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline

Lower RMMA episodeshr with occlusal (bite)

splint (lower) and a MAA (Silencer BC) (A Landry-Schonbeck Int J Prostho 2009)

trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al

J Prosthet Dent 2017

+ at night 15 and 30

nights

Example of tooth contact recorder and

stimulator (BruXane EU)

See also P McAuliffe J Oral Rehab 2015

Since very big

and upper jaw

tongue spacehellip

Adult with overlaphellip

- Insomnia

- TMD-orofacial pain headache

- Sleep disordered breathing

- GERD ndash reflux


22

bull Sedative and muscle relaxants (see Sakai et al J Sleep Res 2016)

ndash Clonazepam= Positive effect to negative Risk of dependence DEBATED

ndash Diazepam buspirone= Positive effect Case reports - Risk of dependence

bull Serotonin-related (Uca et al Clin Neuropharmacol 2015)

PARADOX WITH GENETIC FINDINGS ndash secondary SB by some SSRI

ndash Tryptophan= No effect

ndash Amitriptyline= No effect in RCT or RISK to increase

bull Dopaminergic (us and Cahlin et al J Sleep Res 2016)

ndash Levodopa= Modest effect in RCET (30) ndash Moderate evidence

ndash Pergolide= Positive effect - Case report ndash implant related

ndash Bromocriptine Pramipexole= No effect in RCT

bull Cardioactive (Huynh et al SLEEP 2006 Sakai et al J Sleep Res 2016)

ndash Clonidine= Positive effect in RCET ndash Moderate evidence - risk of

hypotension in morning ndash MEDICAL supervision and lowest dose

ndash Propanolol= No effect in RCET

OVERVIEW on PHARMACOLOGICAL management for SB

Effect amp Level of evidences ndash Winocur Sleep Med for Dentist Quintessence2009

OFF LABEL

Possible medication

low on EB for OFPTMD andor SBMild Condition- short term

1 Muscle Relaxant (NSAI amp relaxing agent etc)

2 Or NSAI and antihistaminic (Advil NightPM)

Moderate Condition OFF LABEL

SEDATION Flexeril (cyclobenzaprine)

frac12-1 co 10mg HS

Rivotril (clonazepam)

05 mg HS ndash addiction

Risk of sleepiness

IF Insomnia

- Cognitive amp behavioural advices and

Therapy refer to psychologist neuropsychologist for

more effective managementhellip

Melatonin 1 to 3 mg

If more severe or persistent INSOMNIA

(Rx by MD Off label for sleep and pain)

Rx to facilitate sleep continuity or stability in

order to realize a level of good restorative

sleep quality

bull zolpidem (expensive)

bull trazodone (1-3 nights a week most Rx in USA lower $

++ is Apnea etchellip)

bull amitriptyline (low dose) or duloxetine

bull Or gabapentin or pregabablin (at bed-time

lowest dose possible- WAKE time sleepiness reduce it use)


23

Trial

10

20

30

40

50

60

70

80

90

Reduction of Morning

headache in young

adults (100 mmVAS SELF REPORTS)

Can Morning headache be relieved by appliance preventing

backward mandibular displacementSequence Off ndash On ndash Off- On - Off

Open study ndash Narval appliance L Franco ndash J Orofacial Pain 2011

On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration

MC CARRA ndash SLEEP MEDICINE 2013 ------ OFF LABEL NOT FDA

Narval applianceReduction of Headache in the morning

57

BSL= baseline nightA= free splints

B= MAA in central occlusionC= MAA advanced (50)

VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux

Yamakawa PE Brazilian Otorhyno

J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24

Breathing AHI aggravation in adults

with Occlusal Splint

(Gagnon et al Int J Prostho 2004)

0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings

reproducedNikolopoulou M et al

JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights

Medical managementCPAP = Continuous Positive Airway Pressure (1980)

bull Gold Standard for SDB-OSA (not central one)

bull lt on compliance (50-70 to 29 in mild cases)

Did not work in our

young healthy SB

One + case report

in an OSA severe caseOksenberg A Arons E

Sleep Med 2002

httpsenwikipediaorgwikiPositive_airway_pressure

Other Tx


25

Botulinum Toxin reduces the intensity

rather than the generation

of the contraction in jaw-closing muscles

Amplitude is smaller not less SB-RMMA

So the generator remain active

SUGGESTING a Central Origin

Off Label

SB subjects tend to sleep on their backsupine position Okeson et al 1991 J Cranio Dis Phillips et al Chest 1989 Miyawaki et al Sleep 2003

Positional therapy for sleep bruxism Under trial

Sleep

Position

Trainer

Heinzer Lavigne et al

Sleep Med 2012

OSA ++

Low

compliance

IF snoring and bruxism + effect expected

EXPERIMENTAL

Motor evoked potentials (MEPs) amp

transcranial magnetic stimulation

(TMS) ndash Emerging ndash not yet for us

Abnormal excitability of the central masticatory

pathways in SB patients

and indicate that SB may be mainly

under the influence of brainstem networks

rather than that of cortical networks

Huang et al Neurosci Lett 2014

Short-term effects (5 days) of repetitive (20 min)

transcranial magnetic stimulation on sleep bruxism

- a pilot (open) study Zhou WN et al Int J Oral Sci 2016

Off Label


- Insomnia



- GERD ndash reflux


26

Figure 2 (A) Variability of the efficacy ratio and gastrointestinal (GI) findings (BndashD) Scatterplots of the efficacy ratios for electromyography (EMG) bursts rhythmic masticatory muscle activity (RMMA) episodes and RMMA episodes with grinding noise Filled circles indicate the patients who demonstrated

an efficacy ratio of lt1 (ie positive therapeutic effects from proton pump inhibitor [PPI]) for all parameters on both the first and second nights

Empty circles indicate the patients who demonstrated an efficacy ratio of lt1 for EMG bursts and RMMA episodes on both the first and second nights Triangular marks indicate the patients who demonstrated an efficacy ratio of gt1 (ie negative therapeutic effects from PPI) for EMG bursts or RMMA

episodes on either the first or second night

Published in H Ohmure K Kanematsu-Hashimoto K Nagayama H Taguchi A Ido K Tominaga T Arakawa S Miyawaki Journal of Dental Research 95

1479-1486

Copyright copy 2016 International amp American Associations for Dental Research

+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages

Some patients may present overlap

not a one size fits all approachhellip

Suspect co-morbidity if

- Headache in morning ndash transient one

- If snoring and or mouth breathing

- Retrognathia large tonsil and tongue

- Fatigue sleepiness and INSOMNIA

- Rule out presence of RBDtapping GERD etc

+ Pay attention to CHILD (5-7 yo) and early

forties cases with above complaints

SUMMARY SB (modified from Mayer Heinzer and Lavigne CHEST 2016)

Clinical INDICATORS- Tooth Grinding Sounds(current)

- Awareness of Clenching

- Tooth Wear (not reliable for current SB)

Sleep Recording

PSG (at least one Masseter muscle)

- Mild frequency of SB (2-4 RMMA episodehr)

Or

- Moderate to high frequency of RMMA (4 or + RMMA episodehr)

Presence of Sleep

Disordered Breathing

ENT andor Orthodontic

+ PSG (Md home)

Mandibular Advancement Appliance

(0 to 70 titration)

Or CPAP

With or without medication (see above)

Absence of

Sleep Disorder

Breathing

(SDB)

- Cognitive Behavioral Treatment (modest level of evidence)

- Occlusal Splint (no if SDB)

- Biofeedback sleep positional devices

- Medication clonazepam clonidine botulinum toxin (short term low dose amp medical supervision)

If headache

breathing

Medical

collaboration

If GERD proton pump inhibitor Ohmure H et al J Dent

Res 2016 or Positional belt hellip Allampati S et al 2016

Merci

Dr R Heinzer CH


2

Sleep Bruxism definitionndash MEDICAL amp DENTAL

From parasomnia in medicine and parafunction in

dentistry

(Int Class Sleep Disorders 1 Am Acad Sleep Med)

- MEDICAL ICSD 2 and 3 (2014)

SLEEP Movement Disorder

- DENTAL Revisited (Lobbezoo et al J of O R 2013 and ICSD 3)

Repetitive jaw-muscle activity characterized by

clenching or grinding of the teeth andor by bracing

or thrusting of the mandible

Two distinct circadian manifestations sleep (indicated as sleep bruxism)

or wakefulness (indicated as awake bruxism)

POLYGRAPHY A sleep bruxism episode

with a cessation of breathing

OCCASIONAL ndash NOT IN all patients - AGINGhellip

LOC

ROC

EMG

C3A2

SpO2

Airflow

Mic

O1A2

ECG

LegL

MasR

MasL

TempR

TempL

O2Flow


HR interval

Autonomic amp EEG arousal

SB and snoring in Japan(Kato T et al Sleep and Breathing 2012

Tachibana M et al Oral Dis 2016))

In general population

bull Prevalence= 8

bull + tooth grinding as child = OR of 8 as adult

bull OR of snoring= 26

In children

bull Prevalence = 21

bull OR for snoring= 18 5-7 yo=17

move ++ and mouth open breathing =15

Children 14-20

Teenagers and Adults 12 to 8

Over 50 years of

age

5-3

Mayer Heinzer and Lavigne CHEST 2016

Self reports Prevalence drop with AGEParents or Sleep Partner Awareness (not always precise)


3




not absolute answer




SELF REPORTS


34 47 +

16

33

12

5

One night

19





it is a YES or NO








4














2- 4 low frequency



of all ages











5


Sleep arousal




every 20 to 40 sec





Strong association

between RMMASB and


phase





2007


6



Carra

Dent Cli Noth Am

2012



LOC

ROC

EMG

C3A2

SpO2

Airflow

Mic

O1A2

ECG

LegL

MasR

MasL

TempR

TempL

O2Flow


HR interval








Management

Pharmacologic

Approaches



Experimental RCT

BUT

2- Clonidine 03 mg



2006)



0

1

2

3

4

5

6

7


05

1015202530354045


0

1

2

3

4

5

6

7


05

10152

0

2530354045


Study 2

clonidine


7


Sleep System

GABAVLPO

HIST

5-HT NE

ACh

ThalamusThalamus

WAKESLEEP


Wake System

GABAGAL

HIST

5-HT NE

ACh

WAKESLEEP




Fig3b

Fig4b

Fig1

Fig2

Fig3a

Fig4a

SB over

time

epihr

A1Sleep

continuity

hr

A2Sleep

transition

hr

A3Arousal

pressure

hr

Time distribution


Sleep Bruxism and

Arousal over nonREM

to REM cycles

AROUSALS (A2 ampA3)


window for RMMA



Crescendo

Crescendo

REM

Peak before

REM

may be

mechanism

related




mandatory





- Insomnia related







Caution

If

+


8

Psychophysiological



debatedhellip























2 X +


9

















Sleep bruxism

with



10




sleep bruxism cases


MORNING PAIN

0

20

40

60

80

100


upon

awakening

fatigue of

masticatory

muscles



bull BELOW 4 RMMAhr

















11









bull 358 INSOMNIA


SMITH SLEEP 2009




12






screening criteria


female TMD cases

TO be reproduced







mean = 388 uV)








controls



Small delta

caution in

extrapolation


13
















1

2

3

4

00 20 40 60 80

Number of RMMA

MIDAS score


r=0559 P=0006



ASSOCIATED to

higher frequency of




and RMMA-SB







14


SB grinding drop


Sleep bruxism

with

OSA








Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


15







35 1 1 3 4 5 6 7 84 22 9 10 15 2011 12 13 14 16 17 18 19


satu

rati

on

(

)

955

965

970

975

980

960

950

(sec)




-25 -15 -10 -05 0 05-20SUB GROUP

phenotype




T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25






bull 358 INSOMNIA


SMITH SLEEP 2009




breathing

QUESTIONNAIRE only




17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


3




not absolute answer




SELF REPORTS


34 47 +

16

33

12

5

One night

19





it is a YES or NO








4














2- 4 low frequency



of all ages











5


Sleep arousal




every 20 to 40 sec





Strong association

between RMMASB and


phase





2007


6



Carra

Dent Cli Noth Am

2012



LOC

ROC

EMG

C3A2

SpO2

Airflow

Mic

O1A2

ECG

LegL

MasR

MasL

TempR

TempL

O2Flow


HR interval








Management

Pharmacologic

Approaches



Experimental RCT

BUT

2- Clonidine 03 mg



2006)



0

1

2

3

4

5

6

7


05

1015202530354045


0

1

2

3

4

5

6

7


05

10152

0

2530354045


Study 2

clonidine


7


Sleep System

GABAVLPO

HIST

5-HT NE

ACh

ThalamusThalamus

WAKESLEEP


Wake System

GABAGAL

HIST

5-HT NE

ACh

WAKESLEEP




Fig3b

Fig4b

Fig1

Fig2

Fig3a

Fig4a

SB over

time

epihr

A1Sleep

continuity

hr

A2Sleep

transition

hr

A3Arousal

pressure

hr

Time distribution


Sleep Bruxism and

Arousal over nonREM

to REM cycles

AROUSALS (A2 ampA3)


window for RMMA



Crescendo

Crescendo

REM

Peak before

REM

may be

mechanism

related




mandatory





- Insomnia related







Caution

If

+


8

Psychophysiological



debatedhellip























2 X +


9

















Sleep bruxism

with



10




sleep bruxism cases


MORNING PAIN

0

20

40

60

80

100


upon

awakening

fatigue of

masticatory

muscles



bull BELOW 4 RMMAhr

















11









bull 358 INSOMNIA


SMITH SLEEP 2009




12






screening criteria


female TMD cases

TO be reproduced







mean = 388 uV)








controls



Small delta

caution in

extrapolation


13
















1

2

3

4

00 20 40 60 80

Number of RMMA

MIDAS score


r=0559 P=0006



ASSOCIATED to

higher frequency of




and RMMA-SB







14


SB grinding drop


Sleep bruxism

with

OSA








Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


15







35 1 1 3 4 5 6 7 84 22 9 10 15 2011 12 13 14 16 17 18 19


satu

rati

on

(

)

955

965

970

975

980

960

950

(sec)




-25 -15 -10 -05 0 05-20SUB GROUP

phenotype




T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25






bull 358 INSOMNIA


SMITH SLEEP 2009




breathing

QUESTIONNAIRE only




17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


4














2- 4 low frequency



of all ages











5


Sleep arousal




every 20 to 40 sec





Strong association

between RMMASB and


phase





2007


6



Carra

Dent Cli Noth Am

2012



LOC

ROC

EMG

C3A2

SpO2

Airflow

Mic

O1A2

ECG

LegL

MasR

MasL

TempR

TempL

O2Flow


HR interval








Management

Pharmacologic

Approaches



Experimental RCT

BUT

2- Clonidine 03 mg



2006)



0

1

2

3

4

5

6

7


05

1015202530354045


0

1

2

3

4

5

6

7


05

10152

0

2530354045


Study 2

clonidine


7


Sleep System

GABAVLPO

HIST

5-HT NE

ACh

ThalamusThalamus

WAKESLEEP


Wake System

GABAGAL

HIST

5-HT NE

ACh

WAKESLEEP




Fig3b

Fig4b

Fig1

Fig2

Fig3a

Fig4a

SB over

time

epihr

A1Sleep

continuity

hr

A2Sleep

transition

hr

A3Arousal

pressure

hr

Time distribution


Sleep Bruxism and

Arousal over nonREM

to REM cycles

AROUSALS (A2 ampA3)


window for RMMA



Crescendo

Crescendo

REM

Peak before

REM

may be

mechanism

related




mandatory





- Insomnia related







Caution

If

+


8

Psychophysiological



debatedhellip























2 X +


9

















Sleep bruxism

with



10




sleep bruxism cases


MORNING PAIN

0

20

40

60

80

100


upon

awakening

fatigue of

masticatory

muscles



bull BELOW 4 RMMAhr

















11









bull 358 INSOMNIA


SMITH SLEEP 2009




12






screening criteria


female TMD cases

TO be reproduced







mean = 388 uV)








controls



Small delta

caution in

extrapolation


13
















1

2

3

4

00 20 40 60 80

Number of RMMA

MIDAS score


r=0559 P=0006



ASSOCIATED to

higher frequency of




and RMMA-SB







14


SB grinding drop


Sleep bruxism

with

OSA








Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


15







35 1 1 3 4 5 6 7 84 22 9 10 15 2011 12 13 14 16 17 18 19


satu

rati

on

(

)

955

965

970

975

980

960

950

(sec)




-25 -15 -10 -05 0 05-20SUB GROUP

phenotype




T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25






bull 358 INSOMNIA


SMITH SLEEP 2009




breathing

QUESTIONNAIRE only




17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


5


Sleep arousal




every 20 to 40 sec





Strong association

between RMMASB and


phase





2007


6



Carra

Dent Cli Noth Am

2012



LOC

ROC

EMG

C3A2

SpO2

Airflow

Mic

O1A2

ECG

LegL

MasR

MasL

TempR

TempL

O2Flow


HR interval








Management

Pharmacologic

Approaches



Experimental RCT

BUT

2- Clonidine 03 mg



2006)



0

1

2

3

4

5

6

7


05

1015202530354045


0

1

2

3

4

5

6

7


05

10152

0

2530354045


Study 2

clonidine


7


Sleep System

GABAVLPO

HIST

5-HT NE

ACh

ThalamusThalamus

WAKESLEEP


Wake System

GABAGAL

HIST

5-HT NE

ACh

WAKESLEEP




Fig3b

Fig4b

Fig1

Fig2

Fig3a

Fig4a

SB over

time

epihr

A1Sleep

continuity

hr

A2Sleep

transition

hr

A3Arousal

pressure

hr

Time distribution


Sleep Bruxism and

Arousal over nonREM

to REM cycles

AROUSALS (A2 ampA3)


window for RMMA



Crescendo

Crescendo

REM

Peak before

REM

may be

mechanism

related




mandatory





- Insomnia related







Caution

If

+


8

Psychophysiological



debatedhellip























2 X +


9

















Sleep bruxism

with



10




sleep bruxism cases


MORNING PAIN

0

20

40

60

80

100


upon

awakening

fatigue of

masticatory

muscles



bull BELOW 4 RMMAhr

















11









bull 358 INSOMNIA


SMITH SLEEP 2009




12






screening criteria


female TMD cases

TO be reproduced







mean = 388 uV)








controls



Small delta

caution in

extrapolation


13
















1

2

3

4

00 20 40 60 80

Number of RMMA

MIDAS score


r=0559 P=0006



ASSOCIATED to

higher frequency of




and RMMA-SB







14


SB grinding drop


Sleep bruxism

with

OSA








Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


15







35 1 1 3 4 5 6 7 84 22 9 10 15 2011 12 13 14 16 17 18 19


satu

rati

on

(

)

955

965

970

975

980

960

950

(sec)




-25 -15 -10 -05 0 05-20SUB GROUP

phenotype




T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25






bull 358 INSOMNIA


SMITH SLEEP 2009




breathing

QUESTIONNAIRE only




17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


6



Carra

Dent Cli Noth Am

2012



LOC

ROC

EMG

C3A2

SpO2

Airflow

Mic

O1A2

ECG

LegL

MasR

MasL

TempR

TempL

O2Flow


HR interval








Management

Pharmacologic

Approaches



Experimental RCT

BUT

2- Clonidine 03 mg



2006)



0

1

2

3

4

5

6

7


05

1015202530354045


0

1

2

3

4

5

6

7


05

10152

0

2530354045


Study 2

clonidine


7


Sleep System

GABAVLPO

HIST

5-HT NE

ACh

ThalamusThalamus

WAKESLEEP


Wake System

GABAGAL

HIST

5-HT NE

ACh

WAKESLEEP




Fig3b

Fig4b

Fig1

Fig2

Fig3a

Fig4a

SB over

time

epihr

A1Sleep

continuity

hr

A2Sleep

transition

hr

A3Arousal

pressure

hr

Time distribution


Sleep Bruxism and

Arousal over nonREM

to REM cycles

AROUSALS (A2 ampA3)


window for RMMA



Crescendo

Crescendo

REM

Peak before

REM

may be

mechanism

related




mandatory





- Insomnia related







Caution

If

+


8

Psychophysiological



debatedhellip























2 X +


9

















Sleep bruxism

with



10




sleep bruxism cases


MORNING PAIN

0

20

40

60

80

100


upon

awakening

fatigue of

masticatory

muscles



bull BELOW 4 RMMAhr

















11









bull 358 INSOMNIA


SMITH SLEEP 2009




12






screening criteria


female TMD cases

TO be reproduced







mean = 388 uV)








controls



Small delta

caution in

extrapolation


13
















1

2

3

4

00 20 40 60 80

Number of RMMA

MIDAS score


r=0559 P=0006



ASSOCIATED to

higher frequency of




and RMMA-SB







14


SB grinding drop


Sleep bruxism

with

OSA








Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


15







35 1 1 3 4 5 6 7 84 22 9 10 15 2011 12 13 14 16 17 18 19


satu

rati

on

(

)

955

965

970

975

980

960

950

(sec)




-25 -15 -10 -05 0 05-20SUB GROUP

phenotype




T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25






bull 358 INSOMNIA


SMITH SLEEP 2009




breathing

QUESTIONNAIRE only




17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


7


Sleep System

GABAVLPO

HIST

5-HT NE

ACh

ThalamusThalamus

WAKESLEEP


Wake System

GABAGAL

HIST

5-HT NE

ACh

WAKESLEEP




Fig3b

Fig4b

Fig1

Fig2

Fig3a

Fig4a

SB over

time

epihr

A1Sleep

continuity

hr

A2Sleep

transition

hr

A3Arousal

pressure

hr

Time distribution


Sleep Bruxism and

Arousal over nonREM

to REM cycles

AROUSALS (A2 ampA3)


window for RMMA



Crescendo

Crescendo

REM

Peak before

REM

may be

mechanism

related




mandatory





- Insomnia related







Caution

If

+


8

Psychophysiological



debatedhellip























2 X +


9

















Sleep bruxism

with



10




sleep bruxism cases


MORNING PAIN

0

20

40

60

80

100


upon

awakening

fatigue of

masticatory

muscles



bull BELOW 4 RMMAhr

















11









bull 358 INSOMNIA


SMITH SLEEP 2009




12






screening criteria


female TMD cases

TO be reproduced







mean = 388 uV)








controls



Small delta

caution in

extrapolation


13
















1

2

3

4

00 20 40 60 80

Number of RMMA

MIDAS score


r=0559 P=0006



ASSOCIATED to

higher frequency of




and RMMA-SB







14


SB grinding drop


Sleep bruxism

with

OSA








Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


15







35 1 1 3 4 5 6 7 84 22 9 10 15 2011 12 13 14 16 17 18 19


satu

rati

on

(

)

955

965

970

975

980

960

950

(sec)




-25 -15 -10 -05 0 05-20SUB GROUP

phenotype




T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25






bull 358 INSOMNIA


SMITH SLEEP 2009




breathing

QUESTIONNAIRE only




17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


8

Psychophysiological



debatedhellip























2 X +


9

















Sleep bruxism

with



10




sleep bruxism cases


MORNING PAIN

0

20

40

60

80

100


upon

awakening

fatigue of

masticatory

muscles



bull BELOW 4 RMMAhr

















11









bull 358 INSOMNIA


SMITH SLEEP 2009




12






screening criteria


female TMD cases

TO be reproduced







mean = 388 uV)








controls



Small delta

caution in

extrapolation


13
















1

2

3

4

00 20 40 60 80

Number of RMMA

MIDAS score


r=0559 P=0006



ASSOCIATED to

higher frequency of




and RMMA-SB







14


SB grinding drop


Sleep bruxism

with

OSA








Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


15







35 1 1 3 4 5 6 7 84 22 9 10 15 2011 12 13 14 16 17 18 19


satu

rati

on

(

)

955

965

970

975

980

960

950

(sec)




-25 -15 -10 -05 0 05-20SUB GROUP

phenotype




T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25






bull 358 INSOMNIA


SMITH SLEEP 2009




breathing

QUESTIONNAIRE only




17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


9

















Sleep bruxism

with



10




sleep bruxism cases


MORNING PAIN

0

20

40

60

80

100


upon

awakening

fatigue of

masticatory

muscles



bull BELOW 4 RMMAhr

















11









bull 358 INSOMNIA


SMITH SLEEP 2009




12






screening criteria


female TMD cases

TO be reproduced







mean = 388 uV)








controls



Small delta

caution in

extrapolation


13
















1

2

3

4

00 20 40 60 80

Number of RMMA

MIDAS score


r=0559 P=0006



ASSOCIATED to

higher frequency of




and RMMA-SB







14


SB grinding drop


Sleep bruxism

with

OSA








Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


15







35 1 1 3 4 5 6 7 84 22 9 10 15 2011 12 13 14 16 17 18 19


satu

rati

on

(

)

955

965

970

975

980

960

950

(sec)




-25 -15 -10 -05 0 05-20SUB GROUP

phenotype




T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25






bull 358 INSOMNIA


SMITH SLEEP 2009




breathing

QUESTIONNAIRE only




17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


10




sleep bruxism cases


MORNING PAIN

0

20

40

60

80

100


upon

awakening

fatigue of

masticatory

muscles



bull BELOW 4 RMMAhr

















11









bull 358 INSOMNIA


SMITH SLEEP 2009




12






screening criteria


female TMD cases

TO be reproduced







mean = 388 uV)








controls



Small delta

caution in

extrapolation


13
















1

2

3

4

00 20 40 60 80

Number of RMMA

MIDAS score


r=0559 P=0006



ASSOCIATED to

higher frequency of




and RMMA-SB







14


SB grinding drop


Sleep bruxism

with

OSA








Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


15







35 1 1 3 4 5 6 7 84 22 9 10 15 2011 12 13 14 16 17 18 19


satu

rati

on

(

)

955

965

970

975

980

960

950

(sec)




-25 -15 -10 -05 0 05-20SUB GROUP

phenotype




T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25






bull 358 INSOMNIA


SMITH SLEEP 2009




breathing

QUESTIONNAIRE only




17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


11









bull 358 INSOMNIA


SMITH SLEEP 2009




12






screening criteria


female TMD cases

TO be reproduced







mean = 388 uV)








controls



Small delta

caution in

extrapolation


13
















1

2

3

4

00 20 40 60 80

Number of RMMA

MIDAS score


r=0559 P=0006



ASSOCIATED to

higher frequency of




and RMMA-SB







14


SB grinding drop


Sleep bruxism

with

OSA








Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


15







35 1 1 3 4 5 6 7 84 22 9 10 15 2011 12 13 14 16 17 18 19


satu

rati

on

(

)

955

965

970

975

980

960

950

(sec)




-25 -15 -10 -05 0 05-20SUB GROUP

phenotype




T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25






bull 358 INSOMNIA


SMITH SLEEP 2009




breathing

QUESTIONNAIRE only




17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


12






screening criteria


female TMD cases

TO be reproduced







mean = 388 uV)








controls



Small delta

caution in

extrapolation


13
















1

2

3

4

00 20 40 60 80

Number of RMMA

MIDAS score


r=0559 P=0006



ASSOCIATED to

higher frequency of




and RMMA-SB







14


SB grinding drop


Sleep bruxism

with

OSA








Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


15







35 1 1 3 4 5 6 7 84 22 9 10 15 2011 12 13 14 16 17 18 19


satu

rati

on

(

)

955

965

970

975

980

960

950

(sec)




-25 -15 -10 -05 0 05-20SUB GROUP

phenotype




T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25






bull 358 INSOMNIA


SMITH SLEEP 2009




breathing

QUESTIONNAIRE only




17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


13
















1

2

3

4

00 20 40 60 80

Number of RMMA

MIDAS score


r=0559 P=0006



ASSOCIATED to

higher frequency of




and RMMA-SB







14


SB grinding drop


Sleep bruxism

with

OSA








Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


15







35 1 1 3 4 5 6 7 84 22 9 10 15 2011 12 13 14 16 17 18 19


satu

rati

on

(

)

955

965

970

975

980

960

950

(sec)




-25 -15 -10 -05 0 05-20SUB GROUP

phenotype




T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25






bull 358 INSOMNIA


SMITH SLEEP 2009




breathing

QUESTIONNAIRE only




17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


14


SB grinding drop


Sleep bruxism

with

OSA








Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


15







35 1 1 3 4 5 6 7 84 22 9 10 15 2011 12 13 14 16 17 18 19


satu

rati

on

(

)

955

965

970

975

980

960

950

(sec)




-25 -15 -10 -05 0 05-20SUB GROUP

phenotype




T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25






bull 358 INSOMNIA


SMITH SLEEP 2009




breathing

QUESTIONNAIRE only




17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


15







35 1 1 3 4 5 6 7 84 22 9 10 15 2011 12 13 14 16 17 18 19


satu

rati

on

(

)

955

965

970

975

980

960

950

(sec)




-25 -15 -10 -05 0 05-20SUB GROUP

phenotype




T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25






bull 358 INSOMNIA


SMITH SLEEP 2009




breathing

QUESTIONNAIRE only




17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


16

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25






bull 358 INSOMNIA


SMITH SLEEP 2009




breathing

QUESTIONNAIRE only




17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


17








FOR

Majority of

population

NO TX needed hellip

1- Pep talk

2- Psychology

3- Pills

4- Plates


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


18
















Sleep 1994

AHI 15 and over


SB

Apnea



unpublished


4-5 yo

Adolescenthellip









1 1-2 yo =

Tongue hyoid larynx

Go down




maxilla downward





19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


19













Listen and guide









Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)












20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


20

Young adulthellip













Listen and guide












J Oral Rehab 2015

ORAL APPLIANCES









Somnomed

Narval ResMed


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


21




0

1

2

3

4

5

6

7

8

9

W 0 W 1 W 2 W 4

SB Index

1st night

Harada et al

J Oral Rehab 2006

6 weeks



ambulatory no video


1st night= 62-74



No video

EM

G

ep

iso

de

hr

Dubeacute JDR 2004

2 weeks ONLY

RMMA index

amp Laboratory

Baseline



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Since very big

and upper jaw

tongue spacehellip


- Insomnia



- GERD ndash reflux


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


22


















OFF LABEL

Possible medication






frac12-1 co 10mg HS



Risk of sleepiness

IF Insomnia




Melatonin 1 to 3 mg





sleep quality








23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


23

Trial

10

20

30

40

50

60

70

80

90


headache in young





On

10

On

50

Mandibular

advancement

10 and 50

Non SB amp

Non apneic

subjects

ORM Narval Fr

No need

for titration



57



VA

S

morning headache

p=005

p=004

Titration=

little benifit


- Insomnia



- GERD ndash reflux


J 2009

Nose

Sinus

Hyoid

Adenoids

Palate

Mallampati

singularsleepcom

Aspergillosis

Lingual tonsil

Hyoid ++


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


24




0

10

20

30

40

50

60

70

80

90

Baseline Splint

Night

Ap

nea

+ h

ypop

nea

h

r

gt 20 5

gt 20 2

gt 50 5

gt 50 0

mild

moderate

severe

Findings


JOFP 2013

Caution



trend

p 0002

0123456789

10 Mild benefit

No fracture

of MAA

SHORT

TERM 2 w

p 003

ADULT

Reproduced

Solanki N et al



nights




Did not work in our

young healthy SB

One + case report


Sleep Med 2002


Other Tx


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


25







Off Label



Sleep

Position

Trainer


Sleep Med 2012

OSA ++

Low

compliance


EXPERIMENTAL













Off Label


- Insomnia



- GERD ndash reflux


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH


26






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

Proton

Pump

Inhibitor

Take home messages















Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





If headache

breathing

Medical

collaboration



Merci

Dr R Heinzer CH

Documents

Dr. Gilles Lavigne, Faculté de médecine dentaire ... · Dr. Gilles Lavigne, Faculté de médecine dentaire, Université de Montréal, copies réservées 1 Sleep Bruxism and Orofacial