Dental sleep medicine is a fast-growing area of dentistry. There are approximately 40 million people in the United States with obstructive sleep apnea (OSA), with 90% of those undiagnosed.

Dental sleep medicine is a fast-growing area of dentistry. There are approximately 40 million people in the United States with obstructive sleep apnea (OSA), with 90% of those undiagnosed. Simply put, OSA is a medical condition in which there is a physical obstruction (tongue, pharyngeal muscles, epiglottis, vocal cords, as examples) that blocks the airway, which then stops the patient from breathing during sleep. An apnea is an event where the patient stops breathing for a minimum of 10 seconds during sleep. A hypopnea is an event where the patient has significantly reduced airflow because of a partially blocked airway for at least 10 seconds while sleeping. Patients with OSA will have multiple apneas/hypopneas every night while they sleep, with the potential to severely impact their health. OSA is co-morbid, dramatically increasing the incidence and severity of diabetes, hypertension, stroke and heart attacks in patients. (Let’s not forget that dentists are patients, too, by the way.)

Patients with OSA will have multiple apneas/hypopneas every night while they sleep, with the potential to severely impact their health.

OK, so we agree that OSA is a very significant health problem; why should the dental profession care? One reason is that we certainly care about our patients, and we should be screening for OSA with simple self-tests as part of a patient’s medical history. The other reason is that moderate to severe bruxism is co-morbid with OSA. What is the connection? The brain’s mechanism to get the patient to breathe when he or she has a blocked airway causing an apnea is as follows: The brain needs to open the airway and gets the muscles of mastication to start working hard and fast, a process we know as bruxism. The masticatory muscles move the jaw forward, the airway opens, and the patient takes in a deep rescue breath. Then, the patient falls back asleep, the airway gets blocked again, and the process repeats itself over and over many times during the night. This is known in evidence-based studies as sleep bruxism.^2,3

This same patient wakes up in the morning, the jaws hurt, the facial muscles hurt, and the patient has headaches. The individual then comes to your office because he or she has TMD, and it is clear from an examination that the patient is bruxing. If you don’t have any knowledge about OSA, or whether the exact origin of the pain is in the TM joint (TMJ) or the head and neck muscles, how would you know what kind of appliance to make? Let’s say your patient has OSA and you choose your favorite bruxism appliance, which may position the mandible posteriorly; you will hopefully realize that this “bruxism” appliance will close the patient’s airway farther at night, making the OSA worse and most likely resulting in an increase in bruxism activity. Additionally, if the patient’s orofacial pain is coming from either the TMJ and/or muscle trigger points and you make the wrong kind of appliance, the pain will get worse, not better.

This is why I and the AAFE faculty all teach that there is no such thing as just making a “bruxism” appliance for patients. You need to consider all of these questions before you put an appliance in your patient’s mouth:

• Does the patient have sleep apnea?
• Does the patient have orofacial pain caused by muscles?
• Does the patient have orofacial pain originating in the TMJ?
• Does the patient have prior restorations, such as implants, veneers, crowns, bridges and/or large restorations? (Note: This will determine appliance design.)
• Does the patient only have bruxism? If only protection of the dentition is needed with no other conditions, use the appliance of your choice.

In the past, many dentists have invested in a sleep monitor that only measures for OSA. Because OSA is a medical condition, which requires a diagnosis by a physician, and the dentist could not directly relay any kind of data regarding bruxism, these cases were handed over to the physician, who might not have been knowledgeable about dental sleep medicine or bruxism. Dentists also did not receive any information about the patient’s bruxism from these monitoring units.

The STATDDS Bruxism and Sleep Monitor is a very cost-effective home test device that the patient wears at night while sleeping.

I use a “rule of 5” when looking at these numbers: If the BEI is greater than 5, the patient has clinically significant and destructive bruxism that needs to be addressed not only with an appliance, but also in my choice of dental materials if any restorative dentistry is needed (such as crowns, bridges, implants, etc.). If the AHI is higher than 5 and less than 30, then a mandibular advancement appliance for obstructive sleep apnea is now considered primary therapy. (Note: Remember that OSA is a medical condition that requires a diagnosis by a physician.) I can now show a physician that the patient has bruxism, for which I am the primary provider as a dentist and, if the sleep apnea is diagnosed as mild to moderate, I can take care of both conditions with the right appliance.

I can now show a physician that the patient has bruxism, for which I am the primary provider as a dentist and, if the sleep apnea is diagnosed as mild to moderate, I can take care of both conditions with the right appliance.

Thousands of dental professionals are now using BOTOX^® for relief of bruxism and orofacial pain. With the STATDDS monitor, we can now quantify the successful results as well as manage the dosage needed, depending on the test results.

Figure 6 shows the pre-op photo of a patient who came into the office with a 10-year history of orofacial pain. Her test results (Fig. 7) showed a BEI of 5.2 and an AHI of 4.8. After trigger point injections with approximately 60 units of BOTOX, her postoperative test and the results were impressive (Fig. 8). The patient’s BEI fell to 0.6. Interestingly, the patient’s AHI also dropped significantly. (Both the BEI and AHI results in patients are a development currently being studied by the AAFE in a multilocation study.) Figure 9 shows the patient’s esthetic results after therapeutic injections with BOTOX, as well as the elimination of her orofacial pain for the first time in 10 years.

Cases like this clearly demonstrate to both the patient and the clinician how successful BOTOX therapy can be in the treatment of bruxism and orofacial pain. I use BOTOX routinely in most of my restorative cases to control the masticatory muscles to achieve long-term success for the dentistry I place in patients’ mouths. With the ability to now obtain objective and reliable data, I can now quantify and titrate my BOTOX dosages for maximum effectiveness.

I use BOTOX routinely in most of my restorative cases to control the masticatory muscles to achieve long-term success for the dentistry I place in patients’ mouths.