Dr. Gilles Lavigne, Faculté de médecine dentaire, Université de … · 2020. 1. 7. · Dr. Gilles Lavigne, Faculté de médecine dentaire, Université de Montréal, copies réservées

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

1

Sleep bruxism causes and management when

associated to comorbidities such as orofacial

pain-headache andor insomnia apnea

Tampa FL 2020

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

Photo

Marlyse Heughebaert CH

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 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)

Sleep Bruxism definitionndash MEDICAL amp DENTAL

PAST Parasomnia (Medicine)

Parafunction (Dentistry)(Int Class Sleep Disorders 1 Am Acad Sleep Med)

PRESENT

- MEDICAL SLEEP Movement Disorder (ICSD 2 and 3 (2014)

- DENTAL Revisited - Repetitive jaw-muscle activity

characterized by clenching or grinding of the teeth

andor by bracing or thrusting of the mandible(Lobbezoo et al JOR 2013-18 and ICSD 3)

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

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


2

Children 14-20

Teenagers and Adults 12 to 8

Over 50 years of

age

5-3

See Mayer Heinzer and Lavigne CHEST 2016

50 of Dutch population for awake

bruxism and of 165 for sleep

bruxism drop age Wetselaar et al JOR 2019

Self reports Prevalence drop with AGE

Canada (Lavigne amp Montplaisir 1994)

Parents or Sleep Partner Awareness (not always precise)

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

From quest and sleep lab PREVALENCE Maluly M et al J Dent Red 2013 Sao Paolo Brazil GENERAL POPULATION

47 +

33

12

5

One night


3

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

- No association 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

Manfredini D et al JOFPH 2019)

Not reliable since can be past SB episodes

Masseter muscle hypertrophy due to

CLENCHING alone andor chewing gum tic etc


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

Etiology putative CAUSES ndash RISKS of SB Mayer Heinzer Lavigne CHEST 2016

Debated

Manfredini

JOFPH 2016

IJP 2017 etc

Polmann

JOR 2019

+ in young for arousal

and older insomnia apnea

Chronotype no student or Child JM Serra-Negra 2019 M Batista Ribeiro 2018

Carry over - rebound

Familialenvironment + Epigenetic


4

Sleep arousal

the coucou survival system

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

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

phaseCarra MC et al SLEEP 2010

Carra

Dent Cli Noth Am

2012


5

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

Medical and Behavioralpsychological

conditions = comorbid 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

+

Differential Dx critical

COMORBID SB amp Neurological sleep disorders

1- Oromandibular myoclonustooth tapping in 10 of SB

subjects (Kato T 1999) ndash mostly asymptomatic BUT can be

2- Sleep Epilepsy rare occurrence with SBhellip

3- REM behaviour disorder (Sleep bruxism and mainly

Oromandibular Myoclonus found in RBD subjects Abe Sleep Med 2013) hellip

TOOTH TAPPING mostly normal but amp refer to

neurology if unusual or violent movements in sleep hellip


6





UNKNOWN IF LINKED TO

RISK of Disease Conversion such as Parkinson

Disease Multiple System Atrophy Dementia =

- 30 at 3 y amp 66 at 75 y (Postuma RB Neurology 2015)

- 30 to 90 from 5 to 14 y (Galbiati A Sleep Med Rev 2018)

- Hazard ratio [HR] = age107 olfactory loss28

abnormal color vision31 subtle motor dysfunction39

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)

Destructive Bruxism secondary to whathellip

Concept from Ware and Rugh Sleep 1988

- Data extracted from 5 destructive cases (tooth

wear TMD pain ++) all with depression (3 under benzohellip)

- SB scored on EEG artifacthellip

- Dominance in REM not surprising with

depression


7

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)

Insomnia

2 X +

CLASSIC STATISTICS LOGISTIC REGRESSIONS

from QUESTIONNAIRES and PSG

PSG

Overweight (OR 298)

Insomnia DSM IV(OR 3)

No OR for age gender AHI

Questionnaires

Male (OR 15)

Overweight amp Obese (OR

33 amp 26)

INSOMNIA DSM IV (OR 27)

No OR for age or AHIOSA

Previous analysis regular statistics

What about if we use Machine Learning

a more powerfull mathematical method

Decision Tree Method was used to

identify best predictor of SB among

AGE GENDER BMI AHI INSOMNIA


8

Ice bridge from Paladinaz

OSA and Sleep Bruxism Association Yes and No

Literature Reviews

Systematic amp meta-

analysis

Progress

from 1 in 2014

to 7 papers in 2019

Is there an association between sleep bruxism and

obstructive sleep apnea syndrome A systematic reviewda Costa Lopes AJ Cunha TCA Monteiro MCM Serra-Negra JM Cabral LC

Juacutenior PCS Jour Oral Rehab 2019

From 270 papers= 7 in analysis PROGRESS

bull 4 studies support the association between SB and OSA (a) a

subtype of OSA patients may have SB as a protective response to

respiratory events (b) most episodes of bruxism occur shortly after the

end of apneahypopnea (AH) events (c) bruxism episodes occur

secondary to arousals arising from AH events and (d) there is a

correlation between the frequency of SB and AH events and

bull 3 studies did not support (e) AH episodes are related to non-specific

SB oromotor activities (f) SB episodes are not directly associated with the

end of AH events and (g) patients with OSA did not experience more SB

events than control group

bull There is no scientific evidence to support a conclusive

relationship between SB and OSA THEN we have work to do

PSG studies

Sleep bruxism CONCOMITANT to

OSA - sleep disordered breathing

(older cohort with + OSA)

SB and OSA Concomitant in 54 of mild

and 33 of moderate AHISjoholm T et al 2000

See also Maluly 2013 Hosaya H et al 2014

Tan M et al JOFPH 2019

Martynowicz H et al J Clin Med 2019


9

PSG studiesHosaya H et al Sleep Breathing 2014



Japan = 48 of mid age OSA subjects diagnose as SB

Poland = 50 of OSA that also had SB related muscle

activity ge 2 RMMA per hour

Singapore = 33 of OSA patients that presented

concomitant SB (10 years younger)

Sleep

Position

SUPINE is dominant for both

OSA and SB

In a PSG of OSA subjects AHI and

clenching index a surrogate of current

RMMAbruxism episode index correlated

significantly (r= 049) and supine sleep

position exacerbate both variablesPhillips B et al Chest 1986

See also

Miyawaki et al Sleep 2003

And ongoing work at the Instituto do Sono

(D Poyares S Tufik S Giamas Iafigliola et al)

Prevalence

Age dropnot

real

Intersecting


10

Intersecting prevalence with age

may explain why you see in your practiceSELF REPORTS of 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

Comorbidities

PSG study (n=110) Martynowicz H J Clin Med 2019

The bruxism episode index increased in mild and

moderate OSA (AHI lt30) BUT decrease in severe OSA (AHI

ge 30) (550 plusmn 458 vs 162 plusmn 128 p lt 005)

Independent predictors for the increased BEI in AHI lt 30 =

higher AHI (cut off 53 prediction 065)

male gender and diabetes(58 vs 26 bruxh p lt 005)

The relationship between OSA and SB depends on the degree of

severity of OSA

OSA is correlated with SB in mild and moderate cases of OSA

Association to

arousal


11

Arousal precede RMMA SB

APNEA precede Arousalhellip

Sequence

What precede

indicate

dominance

SB amp OSA- Noises in sleep

- Supine position

- Male BMI jaw morphology

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


12

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

Association to

hypoxia

Reduction in

oxygen

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

It is the mild drop

in O2

that precede

RMMA

not the one

in CO2

Y Suzuki J Prostho Res 2019

CONCOMITANT

mid age

OSA and SB

Sub group

of patients

Not pathomemonic


13



cases

with an OR of 39 to be a positive SB in comparison to

control subjects

It is noteworthy that frequency of phasic SB activity were

significantly associated to AHI micro-arousal and

oxygen desaturation

Another piece of evidence can be added a high

correlation was noted for OSA events preceding micro-

arousal and phasic RMMA activity (r= 061 ie explaining

about 36 of the variability)

SB as a protective

reaction to OSA

Revisit the concept of a

protective role of SB ie opening airway in

OSA

Phenotype subgroup

First studies

protective role of SB in OSA

Phenotype subgroup

First studies

Masseter contraction does not close the jaw but

may serve to stabilize itMandible position and activation of submental and masseter

muscles during sleep Hollowell DE Suratt PM J Appl Physiol

(1985) Dec 1991

MORE Genioglossus PHASIC activity in OSA before

APNEA

Upper airway muscle activation is augmented in patients with

obstructive sleep apnea compared with that in normal subjects

Suratt PM McTier RF Wilhoit SC Am Rev Respir Dis 1988


14

Protective role of SB ie opening airway

in OSA

Suggested from a 2003 review

Criti Rev Oral Biol 2003

The final section of this review

proposes that RMMA during sleep

has a role in lubricating the upper

alimentary tract and increasing

airway patency


YET unidentified OSA phenotype


See also

Abstract from Simmons and Prehn 2009 Airway protection the missing link between

nocturnal bruxism and obstructive sleep apnea

SLEEP 200932(Abstract Supplement)A218

EXPERT OPINION from Manfredini et al Sleep and Breathing 2015

Conclusion of case series Tan el al J Orofacial Pain and Headache 2019

Figure 1

CHEST DOI (101016jchest201706011)

Copyright copy 2017 American College of Chest Physicians Terms and Conditions

Carberry et al Chest 2017

As for OSA 4 phenotype traits

WE need to assess phenotypes of SB patients OSA and Temporomandibular Disorder

httpsyummylookscomteeth-clenching


15

Nose

Sinus

Hyoid

Adenoids

Palate

singularsleepcom

Hyoid ++

Female 33 yo

TMD and OSA

CPAP +

but struggle in sleep

TX CF in ENT

TMD AND UARS TAY DKL AND PANG KP J ORAL REHAB 2018

Functional somatic complaints

66middot3 headaches

41middot9 neck aches

53middot5 masticatory muscle myalgia

68middot6 temporomandibular joint (TMJ) arthralgia

90middot7 reported sleep bruxism (SB)

AND 91 Nasal congestion (mouth breathing)

Case series

Conclusion

lsquoPatients with persistent TMD

andor reporting SB should be

screened for UARS and chronic

nasal obstruction especially

when they also present with

FHP rsquo =

NB Forward head posture in

80

with narrow space C0 to C3 and

high hyoid bone

A South East Asian

PHENOTYPE

Case series

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


16

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)

TMD population RERA are higher in TMD female than

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

Sleep bruxism with PAIN

(orofacial and TMD)More RMMASB do not = more pain

for all conditions

and all individuals

effect of phenotype subgroup to

identify


17

MAY BE CONCLUDED THAT BRUXISM TO SOME EXTENT IS

ASSOCIATED WITH MUSCULOSKELETAL SYMPTOMS

HOWEVER THE EVIDENCE IS CONFLICTING AND SEEMS TO

BE DEPENDENT ON MANY FACTORS SUCH AS AGE WHETHER

THE BRUXISM OCCURS DURING SLEEP OR

WAKEFULNESS AS WELL AS DIAGNOSTIC

METHODOLOGY REGARDING BRUXISM AND

MUSCULOSKELETAL SIGNS AND SYMPTOMS

To what extent is bruxism associated with

musculoskeletal signs and symptoms A systematic

review Baad-Hansen L et al 2019

THE LITERATURE DOES NOT SUFFICIENTLY SUPPORT A

DIRECT LINEAR CAUSAL RELATIONSHIP BETWEEN

BRUXISM AND SUCH SIGNS AND SYMPTOMS

BUT POINTS MORE IN THE DIRECTION OF A MULTIFACETED

RELATIONSHIP DEPENDENT ON THE PRESENCE OF

OTHER RISK FACTORS




No TMD =

pain for short period of time or

headache

PSG studies

No more RMMA contraction in Morning

Transient Pain (Abe S JOFP 2013)

No reduction in RMMA if transient morning pain


18

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

Clinical jaw-muscle symptoms in a group

of probable sleep bruxersThymi M Shimada A Lobbezoo F Svensson P J Dent 2019

- Jaw symptoms tiredness (78) tension

soreness unpleasantness stiffness and Pain (30

overall in 57 of TMD +)- Ambulatory one channel EMG ++ nights

No association EMG and jaw symptoms

SB and Temporomandibular Disorder


With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009


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

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

EMG of SB (RMMA 2 +-) and TMD Pain

No associationSmardz J et al Frontier Neurol 2019

Sleep lab

N=77


20

Absence of joint pain identifies high levels of sleep masticatory muscle activity in myofascial temporomandibular disorder

Journal of Oral Rehabilitation First published 04 July 2019 DOI (101111joor12853)

frac14 of the 34 muscle pain cases had SB PSG Dx

Non significative - Santiago V and Raphael K 2019Women with TMD cannot fully relax their jaw

muscleshellip HYPERVIGILANCEarousal th

K Raphael JOR 2013 Elevated - Sustained Activity in all

sleep period for 72 of TMD cases (n124 42 Ctl)

- Background EMG during non-SB event periods is significantly

higher for women with myofascial TMD

- Background EMG was positively associated with pain Intensity

NON dipping= no drop in muscle tone as expected

during sleepManfredini et al JOR 2011 --- Healthy subjectshellip

The duration of MMA events and the muscle work during

the first hour of sleep was related to trait anxiety scores for

both masseter (P = 0007) and temporalis muscles (P = 0022)

Absence of joint pain identifies high levels of

sleep masticatory muscle activity in

myofascial temporomandibular disorderSantiago V and Raphael K 2019

2 groups of TMD female around 4 yo

Muscle pain alone (pain 4710 n 34)=

more SB (2X MMA but less pain)

and higher EMG backgroud level =

no muscle tone dipping

Joint amp muscle PAIN (pain 5510 n 90)=

During sleep EMG dipping as controls



Close to half of the 34 muscle pain cases

are non dipping


21

Think comorbidityhellip

Overlapping Chronic Pain ConditionsMaixner W et al J of Pain Sept 2016

Another PARAFUNCTION (long-lasting and

low-intensity muscle contraction) during

WAKE as a RISK factor for Chronic TMD

pain

Non functional tooth contact Not bruxism

Long-lasting

not forceful clenching

Wake time collection 20 min

beeper cell phone etc

TMD amp Non functional tooth contact

(Not bruxism long-lasting

not forceful clenching)

- FREQUENCY median TMD 35 Ctl 9

- link with STRESS

Chen Palla et al J of Orofacial Pain 2007

IN 52 of TMD cases Sato F et al 2006

Also reported by Glaros et al Cranio 2005

REPRODUCED

TMD amp Non functional tooth contact- Frequency of non-functional

tooth contact significantly higher

in patients with TMD than in the

healthy subjects (35middot0 vs

9middot6 P lt 0middot001)

- No significant group difference

for the frequency of functional

tooth contact the stress anxiety

depression and personality

Funato et al J Oral Rehab 2014

High periods


22

Emerging concept SB and cardiovascular risk - SB amp hypertension = higher frequency of RMMA index

body mass index etc Dominant in severe apnea (Martynowicz et al J Cli Med 2018)

- Tooth wear scores (weak biomarker) amp cardiopathies

OR = 3 for AW and SB (Marconcini et al J Cardio Ther 2018)

- EXPERTS say SB as an lsquoautomated self-regulated

responsersquo or lsquotrigemino-cardiacrsquo reflex needs evidence (Schames-Calif Dental J 2012 Manfredini-Sleep amp Breathing 2015

Chowdhury-Frontier Neurol 2017 Meira e Cruz-J Neu Brain Disor 2018)

- Association after controlling for apnea BME etc

Phenotype- subgroup

shutterstock_68886511 ManagementLow on evidence medication off label based on expert

opinion or experience amp logic from available data

Age group may guide us if comorbidity

Logical clinical algorithm in dental management of SLEEP BRUXISM ALONE(E Evidence value)

Health care providers

dentist psychologist respiratory exercisephysical therapist

Non invasivereversible

OA (Modest E) CBT (Low E) medication (Low-modest E) biofeedback (Modest E) TMS (Emerging) etc

Invasive

Occlusion-rehabilitation (Low E)

Self management

Life amp Sleep hygiene (Low Eintuitive)

alcohol control (Low E) sleep environment

Use of sleep position device

yogawind down emerging hellip

Identification of SB alone ndash no harm no medical Hx

Tooth grinding or tapping sounds tooth wear jaw muscle fatigue upon awakening etc

Dental examinationNO NEED for Sleep medicine diagnosis

amp sleep testing

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


23

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

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

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


24

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

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

IF BRUXISM PHARMACOLOGICAL management for SB

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

OFF LABEL

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

Osteopenic consequences of botulinum toxin injections in the masticatory muscles a pilot study

Raphael K et al J Oral Rehab 2014

Early molecular response and

microanatomical changes in

the masseter muscle and

mandibular head after

botulinum toxin intervention in

adult miceBalanta-Melo J et al Ann Anatomy 2018

Masseter muscle mass as well as

individual muscle fiber diameter were

significantly reduced in BoNTA-injected

side after 14 days post-intervention

At the same time in the mandibular heads

from the treated side the subchondral

bone loss was evinced by a significant

reduction in bone per tissue area (-40)

and trabecular thickness (-55)


25

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

If REFLUX

- Proton Pump Inhibitor

- Sleep Position corrections device

- Diet advices

Logical clinical algorithm in dental management ofSLEEP BRUXISM with OSA GERD RBD Epilepsy


physician dentist psychologist respiratory exercisephysical therapistNon invasivereversible

OA PAP orthodontic CBT acupuncture medication etc

Invasive

ENT orthognatic bariatric nerve stimulation surgeries etc

Self management

Life amp Sleep hygiene

Exercise weight loss alcohol control

regular amp high quality sleep environment

Use of sleep position device oro-pharyngeal exercise compression socks

compliance to treatment prescribed hellip

Identification of SB risks with OSA GERD RBD Epilepsy

fatigue sleepiness retrognathia macroglossia tonsiladenoids Mallampati mouth breathing reflux night sweating etc

Dental exam SB

Screening for OSA GERD RBD Epilepsy

Sleep medicine diagnosis amp

sleep testing for OSA GERD RBD

Epilepsy

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

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 )


26

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)

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


2

Children 14-20

Teenagers and Adults 12 to 8

Over 50 years of

age

5-3

See Mayer Heinzer and Lavigne CHEST 2016

50 of Dutch population for awake

bruxism and of 165 for sleep

bruxism drop age Wetselaar et al JOR 2019

Self reports Prevalence drop with AGE

Canada (Lavigne amp Montplaisir 1994)

Parents or Sleep Partner Awareness (not always precise)

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

From quest and sleep lab PREVALENCE Maluly M et al J Dent Red 2013 Sao Paolo Brazil GENERAL POPULATION

47 +

33

12

5

One night


3





- it is a YES or NO




















2- 4 low frequency



of all ages


Debated

Manfredini

JOFPH 2016

IJP 2017 etc

Polmann

JOR 2019







4

Sleep arousal






2007



every 20 to 40 sec





Strong association

between RMMASB and



Carra

Dent Cli Noth Am

2012


5



LOC

ROC

EMG

C3A2

SpO2

Airflow

Mic

O1A2

ECG

LegL

MasR

MasL

TempR

TempL

O2Flow


HR interval











mandatory





- Insomnia related







Caution

If

+











6












Psychophysiological



debatedhellip

















depression


7













Insomnia

2 X +



PSG

Overweight (OR 298)



Questionnaires

Male (OR 15)


33 amp 26)










8



Literature Reviews


analysis

Progress

from 1 in 2014

to 7 papers in 2019

















PSG studies










9









Sleep

Position


OSA and SB






See also




Prevalence

Age dropnot

real

Intersecting


10





Sleep 1994

AHI 15 and over


SB

Apnea



unpublished

Comorbidities









severity of OSA


Association to

arousal


11



Sequence

What precede

indicate

dominance


- Supine position


T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


12

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25


Association to

hypoxia

Reduction in

oxygen

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

It is the mild drop

in O2

that precede

RMMA

not the one

in CO2


CONCOMITANT

mid age

OSA and SB

Sub group

of patients

Not pathomemonic


13



cases


control subjects



oxygen desaturation





SB as a protective

reaction to OSA



OSA

Phenotype subgroup

First studies


Phenotype subgroup

First studies




(1985) Dec 1991


APNEA





14


in OSA







airway patency




See also






Figure 1








15

Nose

Sinus

Hyoid

Adenoids

Palate

singularsleepcom

Hyoid ++

Female 33 yo

TMD and OSA

CPAP +


TX CF in ENT



66middot3 headaches






Case series

Conclusion






FHP rsquo =


80


high hyoid bone

A South East Asian

PHENOTYPE

Case series



bull 358 INSOMNIA


SMITH SLEEP 2009



16



breathing

QUESTIONNAIRE only







for all conditions

and all individuals


identify


17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




3





- it is a YES or NO




















2- 4 low frequency



of all ages


Debated

Manfredini

JOFPH 2016

IJP 2017 etc

Polmann

JOR 2019







4

Sleep arousal






2007



every 20 to 40 sec





Strong association

between RMMASB and



Carra

Dent Cli Noth Am

2012


5



LOC

ROC

EMG

C3A2

SpO2

Airflow

Mic

O1A2

ECG

LegL

MasR

MasL

TempR

TempL

O2Flow


HR interval











mandatory





- Insomnia related







Caution

If

+











6












Psychophysiological



debatedhellip

















depression


7













Insomnia

2 X +



PSG

Overweight (OR 298)



Questionnaires

Male (OR 15)


33 amp 26)










8



Literature Reviews


analysis

Progress

from 1 in 2014

to 7 papers in 2019

















PSG studies










9









Sleep

Position


OSA and SB






See also




Prevalence

Age dropnot

real

Intersecting


10





Sleep 1994

AHI 15 and over


SB

Apnea



unpublished

Comorbidities









severity of OSA


Association to

arousal


11



Sequence

What precede

indicate

dominance


- Supine position


T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


12

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25


Association to

hypoxia

Reduction in

oxygen

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

It is the mild drop

in O2

that precede

RMMA

not the one

in CO2


CONCOMITANT

mid age

OSA and SB

Sub group

of patients

Not pathomemonic


13



cases


control subjects



oxygen desaturation





SB as a protective

reaction to OSA



OSA

Phenotype subgroup

First studies


Phenotype subgroup

First studies




(1985) Dec 1991


APNEA





14


in OSA







airway patency




See also






Figure 1








15

Nose

Sinus

Hyoid

Adenoids

Palate

singularsleepcom

Hyoid ++

Female 33 yo

TMD and OSA

CPAP +


TX CF in ENT



66middot3 headaches






Case series

Conclusion






FHP rsquo =


80


high hyoid bone

A South East Asian

PHENOTYPE

Case series



bull 358 INSOMNIA


SMITH SLEEP 2009



16



breathing

QUESTIONNAIRE only







for all conditions

and all individuals


identify


17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




4

Sleep arousal






2007



every 20 to 40 sec





Strong association

between RMMASB and



Carra

Dent Cli Noth Am

2012


5



LOC

ROC

EMG

C3A2

SpO2

Airflow

Mic

O1A2

ECG

LegL

MasR

MasL

TempR

TempL

O2Flow


HR interval











mandatory





- Insomnia related







Caution

If

+











6












Psychophysiological



debatedhellip

















depression


7













Insomnia

2 X +



PSG

Overweight (OR 298)



Questionnaires

Male (OR 15)


33 amp 26)










8



Literature Reviews


analysis

Progress

from 1 in 2014

to 7 papers in 2019

















PSG studies










9









Sleep

Position


OSA and SB






See also




Prevalence

Age dropnot

real

Intersecting


10





Sleep 1994

AHI 15 and over


SB

Apnea



unpublished

Comorbidities









severity of OSA


Association to

arousal


11



Sequence

What precede

indicate

dominance


- Supine position


T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


12

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25


Association to

hypoxia

Reduction in

oxygen

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

It is the mild drop

in O2

that precede

RMMA

not the one

in CO2


CONCOMITANT

mid age

OSA and SB

Sub group

of patients

Not pathomemonic


13



cases


control subjects



oxygen desaturation





SB as a protective

reaction to OSA



OSA

Phenotype subgroup

First studies


Phenotype subgroup

First studies




(1985) Dec 1991


APNEA





14


in OSA







airway patency




See also






Figure 1








15

Nose

Sinus

Hyoid

Adenoids

Palate

singularsleepcom

Hyoid ++

Female 33 yo

TMD and OSA

CPAP +


TX CF in ENT



66middot3 headaches






Case series

Conclusion






FHP rsquo =


80


high hyoid bone

A South East Asian

PHENOTYPE

Case series



bull 358 INSOMNIA


SMITH SLEEP 2009



16



breathing

QUESTIONNAIRE only







for all conditions

and all individuals


identify


17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




5



LOC

ROC

EMG

C3A2

SpO2

Airflow

Mic

O1A2

ECG

LegL

MasR

MasL

TempR

TempL

O2Flow


HR interval











mandatory





- Insomnia related







Caution

If

+











6












Psychophysiological



debatedhellip

















depression


7













Insomnia

2 X +



PSG

Overweight (OR 298)



Questionnaires

Male (OR 15)


33 amp 26)










8



Literature Reviews


analysis

Progress

from 1 in 2014

to 7 papers in 2019

















PSG studies










9









Sleep

Position


OSA and SB






See also




Prevalence

Age dropnot

real

Intersecting


10





Sleep 1994

AHI 15 and over


SB

Apnea



unpublished

Comorbidities









severity of OSA


Association to

arousal


11



Sequence

What precede

indicate

dominance


- Supine position


T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


12

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25


Association to

hypoxia

Reduction in

oxygen

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

It is the mild drop

in O2

that precede

RMMA

not the one

in CO2


CONCOMITANT

mid age

OSA and SB

Sub group

of patients

Not pathomemonic


13



cases


control subjects



oxygen desaturation





SB as a protective

reaction to OSA



OSA

Phenotype subgroup

First studies


Phenotype subgroup

First studies




(1985) Dec 1991


APNEA





14


in OSA







airway patency




See also






Figure 1








15

Nose

Sinus

Hyoid

Adenoids

Palate

singularsleepcom

Hyoid ++

Female 33 yo

TMD and OSA

CPAP +


TX CF in ENT



66middot3 headaches






Case series

Conclusion






FHP rsquo =


80


high hyoid bone

A South East Asian

PHENOTYPE

Case series



bull 358 INSOMNIA


SMITH SLEEP 2009



16



breathing

QUESTIONNAIRE only







for all conditions

and all individuals


identify


17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




6












Psychophysiological



debatedhellip

















depression


7













Insomnia

2 X +



PSG

Overweight (OR 298)



Questionnaires

Male (OR 15)


33 amp 26)










8



Literature Reviews


analysis

Progress

from 1 in 2014

to 7 papers in 2019

















PSG studies










9









Sleep

Position


OSA and SB






See also




Prevalence

Age dropnot

real

Intersecting


10





Sleep 1994

AHI 15 and over


SB

Apnea



unpublished

Comorbidities









severity of OSA


Association to

arousal


11



Sequence

What precede

indicate

dominance


- Supine position


T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


12

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25


Association to

hypoxia

Reduction in

oxygen

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

It is the mild drop

in O2

that precede

RMMA

not the one

in CO2


CONCOMITANT

mid age

OSA and SB

Sub group

of patients

Not pathomemonic


13



cases


control subjects



oxygen desaturation





SB as a protective

reaction to OSA



OSA

Phenotype subgroup

First studies


Phenotype subgroup

First studies




(1985) Dec 1991


APNEA





14


in OSA







airway patency




See also






Figure 1








15

Nose

Sinus

Hyoid

Adenoids

Palate

singularsleepcom

Hyoid ++

Female 33 yo

TMD and OSA

CPAP +


TX CF in ENT



66middot3 headaches






Case series

Conclusion






FHP rsquo =


80


high hyoid bone

A South East Asian

PHENOTYPE

Case series



bull 358 INSOMNIA


SMITH SLEEP 2009



16



breathing

QUESTIONNAIRE only







for all conditions

and all individuals


identify


17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




7













Insomnia

2 X +



PSG

Overweight (OR 298)



Questionnaires

Male (OR 15)


33 amp 26)










8



Literature Reviews


analysis

Progress

from 1 in 2014

to 7 papers in 2019

















PSG studies










9









Sleep

Position


OSA and SB






See also




Prevalence

Age dropnot

real

Intersecting


10





Sleep 1994

AHI 15 and over


SB

Apnea



unpublished

Comorbidities









severity of OSA


Association to

arousal


11



Sequence

What precede

indicate

dominance


- Supine position


T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


12

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25


Association to

hypoxia

Reduction in

oxygen

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

It is the mild drop

in O2

that precede

RMMA

not the one

in CO2


CONCOMITANT

mid age

OSA and SB

Sub group

of patients

Not pathomemonic


13



cases


control subjects



oxygen desaturation





SB as a protective

reaction to OSA



OSA

Phenotype subgroup

First studies


Phenotype subgroup

First studies




(1985) Dec 1991


APNEA





14


in OSA







airway patency




See also






Figure 1








15

Nose

Sinus

Hyoid

Adenoids

Palate

singularsleepcom

Hyoid ++

Female 33 yo

TMD and OSA

CPAP +


TX CF in ENT



66middot3 headaches






Case series

Conclusion






FHP rsquo =


80


high hyoid bone

A South East Asian

PHENOTYPE

Case series



bull 358 INSOMNIA


SMITH SLEEP 2009



16



breathing

QUESTIONNAIRE only







for all conditions

and all individuals


identify


17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




8



Literature Reviews


analysis

Progress

from 1 in 2014

to 7 papers in 2019

















PSG studies










9









Sleep

Position


OSA and SB






See also




Prevalence

Age dropnot

real

Intersecting


10





Sleep 1994

AHI 15 and over


SB

Apnea



unpublished

Comorbidities









severity of OSA


Association to

arousal


11



Sequence

What precede

indicate

dominance


- Supine position


T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


12

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25


Association to

hypoxia

Reduction in

oxygen

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

It is the mild drop

in O2

that precede

RMMA

not the one

in CO2


CONCOMITANT

mid age

OSA and SB

Sub group

of patients

Not pathomemonic


13



cases


control subjects



oxygen desaturation





SB as a protective

reaction to OSA



OSA

Phenotype subgroup

First studies


Phenotype subgroup

First studies




(1985) Dec 1991


APNEA





14


in OSA







airway patency




See also






Figure 1








15

Nose

Sinus

Hyoid

Adenoids

Palate

singularsleepcom

Hyoid ++

Female 33 yo

TMD and OSA

CPAP +


TX CF in ENT



66middot3 headaches






Case series

Conclusion






FHP rsquo =


80


high hyoid bone

A South East Asian

PHENOTYPE

Case series



bull 358 INSOMNIA


SMITH SLEEP 2009



16



breathing

QUESTIONNAIRE only







for all conditions

and all individuals


identify


17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




9









Sleep

Position


OSA and SB






See also




Prevalence

Age dropnot

real

Intersecting


10





Sleep 1994

AHI 15 and over


SB

Apnea



unpublished

Comorbidities









severity of OSA


Association to

arousal


11



Sequence

What precede

indicate

dominance


- Supine position


T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


12

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25


Association to

hypoxia

Reduction in

oxygen

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

It is the mild drop

in O2

that precede

RMMA

not the one

in CO2


CONCOMITANT

mid age

OSA and SB

Sub group

of patients

Not pathomemonic


13



cases


control subjects



oxygen desaturation





SB as a protective

reaction to OSA



OSA

Phenotype subgroup

First studies


Phenotype subgroup

First studies




(1985) Dec 1991


APNEA





14


in OSA







airway patency




See also






Figure 1








15

Nose

Sinus

Hyoid

Adenoids

Palate

singularsleepcom

Hyoid ++

Female 33 yo

TMD and OSA

CPAP +


TX CF in ENT



66middot3 headaches






Case series

Conclusion






FHP rsquo =


80


high hyoid bone

A South East Asian

PHENOTYPE

Case series



bull 358 INSOMNIA


SMITH SLEEP 2009



16



breathing

QUESTIONNAIRE only







for all conditions

and all individuals


identify


17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




10





Sleep 1994

AHI 15 and over


SB

Apnea



unpublished

Comorbidities









severity of OSA


Association to

arousal


11



Sequence

What precede

indicate

dominance


- Supine position


T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


12

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25


Association to

hypoxia

Reduction in

oxygen

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

It is the mild drop

in O2

that precede

RMMA

not the one

in CO2


CONCOMITANT

mid age

OSA and SB

Sub group

of patients

Not pathomemonic


13



cases


control subjects



oxygen desaturation





SB as a protective

reaction to OSA



OSA

Phenotype subgroup

First studies


Phenotype subgroup

First studies




(1985) Dec 1991


APNEA





14


in OSA







airway patency




See also






Figure 1








15

Nose

Sinus

Hyoid

Adenoids

Palate

singularsleepcom

Hyoid ++

Female 33 yo

TMD and OSA

CPAP +


TX CF in ENT



66middot3 headaches






Case series

Conclusion






FHP rsquo =


80


high hyoid bone

A South East Asian

PHENOTYPE

Case series



bull 358 INSOMNIA


SMITH SLEEP 2009



16



breathing

QUESTIONNAIRE only







for all conditions

and all individuals


identify


17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




11



Sequence

What precede

indicate

dominance


- Supine position


T1 (AHE to SBE) 10s

Apnea

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass


OSA


(J Sleep Res 2014)

55 to Sleep Bruxism


12

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25


Association to

hypoxia

Reduction in

oxygen

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

It is the mild drop

in O2

that precede

RMMA

not the one

in CO2


CONCOMITANT

mid age

OSA and SB

Sub group

of patients

Not pathomemonic


13



cases


control subjects



oxygen desaturation





SB as a protective

reaction to OSA



OSA

Phenotype subgroup

First studies


Phenotype subgroup

First studies




(1985) Dec 1991


APNEA





14


in OSA







airway patency




See also






Figure 1








15

Nose

Sinus

Hyoid

Adenoids

Palate

singularsleepcom

Hyoid ++

Female 33 yo

TMD and OSA

CPAP +


TX CF in ENT



66middot3 headaches






Case series

Conclusion






FHP rsquo =


80


high hyoid bone

A South East Asian

PHENOTYPE

Case series



bull 358 INSOMNIA


SMITH SLEEP 2009



16



breathing

QUESTIONNAIRE only







for all conditions

and all individuals


identify


17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




12

T2 (SBE to AHE)

Apnea

10s

Flow

Effort(Tho)

Effort(Abd)

SpO2

Mass

SB-RMMA to Apnea 25


Association to

hypoxia

Reduction in

oxygen

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

It is the mild drop

in O2

that precede

RMMA

not the one

in CO2


CONCOMITANT

mid age

OSA and SB

Sub group

of patients

Not pathomemonic


13



cases


control subjects



oxygen desaturation





SB as a protective

reaction to OSA



OSA

Phenotype subgroup

First studies


Phenotype subgroup

First studies




(1985) Dec 1991


APNEA





14


in OSA







airway patency




See also






Figure 1








15

Nose

Sinus

Hyoid

Adenoids

Palate

singularsleepcom

Hyoid ++

Female 33 yo

TMD and OSA

CPAP +


TX CF in ENT



66middot3 headaches






Case series

Conclusion






FHP rsquo =


80


high hyoid bone

A South East Asian

PHENOTYPE

Case series



bull 358 INSOMNIA


SMITH SLEEP 2009



16



breathing

QUESTIONNAIRE only







for all conditions

and all individuals


identify


17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




13



cases


control subjects



oxygen desaturation





SB as a protective

reaction to OSA



OSA

Phenotype subgroup

First studies


Phenotype subgroup

First studies




(1985) Dec 1991


APNEA





14


in OSA







airway patency




See also






Figure 1








15

Nose

Sinus

Hyoid

Adenoids

Palate

singularsleepcom

Hyoid ++

Female 33 yo

TMD and OSA

CPAP +


TX CF in ENT



66middot3 headaches






Case series

Conclusion






FHP rsquo =


80


high hyoid bone

A South East Asian

PHENOTYPE

Case series



bull 358 INSOMNIA


SMITH SLEEP 2009



16



breathing

QUESTIONNAIRE only







for all conditions

and all individuals


identify


17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




14


in OSA







airway patency




See also






Figure 1








15

Nose

Sinus

Hyoid

Adenoids

Palate

singularsleepcom

Hyoid ++

Female 33 yo

TMD and OSA

CPAP +


TX CF in ENT



66middot3 headaches






Case series

Conclusion






FHP rsquo =


80


high hyoid bone

A South East Asian

PHENOTYPE

Case series



bull 358 INSOMNIA


SMITH SLEEP 2009



16



breathing

QUESTIONNAIRE only







for all conditions

and all individuals


identify


17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




15

Nose

Sinus

Hyoid

Adenoids

Palate

singularsleepcom

Hyoid ++

Female 33 yo

TMD and OSA

CPAP +


TX CF in ENT



66middot3 headaches






Case series

Conclusion






FHP rsquo =


80


high hyoid bone

A South East Asian

PHENOTYPE

Case series



bull 358 INSOMNIA


SMITH SLEEP 2009



16



breathing

QUESTIONNAIRE only







for all conditions

and all individuals


identify


17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




16



breathing

QUESTIONNAIRE only







for all conditions

and all individuals


identify


17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




17

















OTHER RISK FACTORS




No TMD =


headache

PSG studies





18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




18













With TMD

PSG studies


19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




19



bull 358 INSOMNIA


SMITH SLEEP 2009








screening criteria



Sleep lab

N=77


20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




20





























are non dipping


21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




21






pain


Long-lasting








- link with STRESS




REPRODUCED











High periods


22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




22









Phenotype- subgroup









Invasive


Self management








amp sleep testing













Listen and guide



23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




23

ORAL APPLIANCES









Somnomed

Narval ResMed




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

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


24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




24




Since very big

and upper jaw

tongue spacehellip


















OFF LABEL







Off Label



















25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




25






1479-1486


+ in 712 cases

and ++ in 412

Then

phenotype

of SB GERD

and OAS

Future of DSM

If REFLUX



- Diet advices





Invasive


Self management








Dental exam SB




Epilepsy




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












26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration




26





Control

47 higher RMMA

Low frequency SB

Reduction in

59 subjects (556)

High frequency SB

Reduction in

811 subjects (72)





Sleep Recording



Or


Presence of Sleep



+ PSG (Md home)


(0 to 70 titration)

Or CPAP


Absence of

Sleep Disorder

Breathing

(SDB)





breathing

Medical

collaboration



Documents

Dr. Gilles Lavigne, Faculté de médecine dentaire, Université de … · 2020. 1. 7. · Dr. Gilles Lavigne, Faculté de médecine dentaire, Université de Montréal, copies réservées