As you know, I do a fair amount of sedation in my practice and I see (and create) a lot of obstruction. Thus, I am very familiar with opening & managing airways… For 90+% of my sedated patients, even the deeply sedated patient, managing airway is very simple and takes a very small amount of manipulation to the jaw or tongue; I can usually open an airway by just turning the head slightly or simply by closing the mouth, i.e. putting the patient into MIP (maximum intercuspal position).
- The only time the patient obstructs or snores is when their mouth is open.
“Do any of you feel that all these sleep appliances being advocated more recently than the past 15 years are only necessary because there is no orthotic appliance that is properly adjusted? Because of the effects of gravity the mandible wants to retrude when a person is supine and, when compared to the normal (sitting/standing) manidbular physiologic rest position, this retruded position would put stress/restrictions on the airway and jaw muscles/joints.” It seems to a few dentists that the optimized bite position would be more “restful” for the supine patient… minus nasal oral pharyngeal insufficiency (deviated septum, turbinate abnormality, hypertrophic nasal tissues and hypertrophied tonsils that effect tongue position ) a properly adjusted GNM orthotic should allow the patient to sleep with their mouth closed and teeth touching, right? So, based on the assumption that the closed mouth position is more restful than an open mouth position, the reason people sleep with their mouths open is because the bite is more stressful? – that is, the bite is not optimized ? A question I would ask is:
- Is the reason patient’s continues to sleep with their mouths open maybe because they do not have a properly optimized the bite (like retrusive interferences maybe existing with the various occlusal appliances used)?
- Would the patient benefit more if the dentist takes time to properly detail and adjust the orthotic rather than conclude all these various grinding and bruxing night time issues is in need of a sleep appliance that may only mask the underlying issue?
Clinical Thoughts and Observations by a Dentist Who Does Sedation Dentistry It’s interesting because what got me thinking about this topic wasn’t the patient who wanted the sleep appliance, but two patients I had this week. The first one was a TMD consult I had earlier in the week and the second was a sedation patient that has many of the musculoskeletal signs and symptoms (but not interested in TMD treatment). One of the questions on the TMD questionnaire (which I copied from your handouts) is “Mouth breather at night?” I had never really considered this question, but for some reason, as I was reviewing my notes, I started to wonder why this question was on the questionnaire. I decided that a mouth breather might have nasal issues so I should look for nasal insufficiency if they said yes. Then, the next day as I was working on this sedation patient that had all the signs and symptoms, it hit me – people breathe better when their mouths are closed! My sedation patient, diagnosed with OSA and with almost every clinical sign and symptom of TMD, obstructed when her mouth was open, but was not obstructed when she was in MIP. The entire 2 hours under sedation I would work until her saturation started to drop and then just close her mouth – no head tilt, no jaw thrust, no tongue pull, just closed her into MIP. All her vitals (heart rate, O2 saturation, CO2 waveforms) were so much better when her mouth was closed. That got me to wonder, if this patient’s vitals and airway are so good when her mouth is closed, why doesn’t she just sleep with her mouth closed?… she would no longer have OSA! Then I had my epiphany, it’s because her bite is terrible and is more stressful for her to stay closed than open! – Thoughts of Dr. Paul Chung, DDS, – Portland, OR (A dentist who practices GNM dentistry)