Sleep Bruxism: Occlusal Splint or OSA Appliance, That’s the Question
I attended the Henry Schein Sleep Complete meeting in Dallas this weekend, and presented Nox T3 sleep diagnostic device and sleep bruxism monitor for the group. This is a dental meeting taught by Dr John Tucker DMD an excellent presenter and SleepScholar contributor. I have been in the dental sleep medicine arena for over twenty years and continue to be impressed with how much passion attendees show at these meetings. I tested 12 Drs with the Nox T3 overnight and we had many spirited discussions about the results.
Since the discussion of home sleep testing for dentists is largely a discussion of appliance titration or calibration we discussed in depth the scoring functionality and low per patient cost of the device, all what you would expect in this setting.
The discussion of Sleep Bruxism on the breaks sent me
scrambling for my “Sleep Medicine for Dentists” textbook which is always in my briefcase (if you don’t have it you should get it).
I had just completed a talk where I demonstrated Nox T3’s electromyographic (EMG) leads for testing muscle activity during clenching and grinding while asleep. This is accomplished with an electrode on the masseter and one on the zygomatic arch with a ground behind the ear. The Noxturnal software scores these electrical signals and presents an easy to read Bruxism report. As usual in this discussion I mentioned the research paper by Gagnon et al “Aggravation of respiratory disturbances by the use of an occlusal splint in apneic patients: a pilot study”. This study is widely quoted and presents the notion that, an occlusal splint when made for a patient suffering from sleep disordered breathing may actually aggravate the patients existing condition.
It is not hard to imagine that this group of Drs. who have made occlusal splints for their patients for their entire careers were interested to discover that there is a whole range of unconsidered elements to this practice. Dr Gordon Christensen in January of 2014 released an excellent video where he suggested EMG testing as a next step for patients with tooth wear before a restorative treatment plan is adopted.
To quote Dr Christensen “Is there a more frustrating situation than when you observe patients destroying their dentitions without any knowledge about the seriousness of the condition? This DVD includes Gordon’s clinical observations, techniques, and experiences over several decades of preventing and treating bruxism and clenching. Yes! It is possible to reduce or sometimes eliminate tooth destruction with proper techniques.”
The text book I used, cited an excerpt from Dr Landry et al, Reduction of sleep bruxism using a mandibular advancement device: an experimental controlled study. “The short term use of an occlusal stabilization appliance (for 6 consecutive nights) reduced the frequency of SB-related events by 42%. The use of a double arch appliance without any mechanism on place to move the mandible forward produced a similar reduction (approximately 40%). However the reduction in SB motor activity obtained with a temporary mandibular repositioning appliance (MRA) – commonly used to manage snoring and sleep apnea – was set in a 25% or 75% protrusive position nearly doubled the reductions found in other appliances (77% and 83%) respectively.”
I have heard many lecturers over the years speculate that sleep bruxism plays some role in reestablishing airway patency during sleep disordered breathing events. It is clear that the treatment of sleep bruxism should include a discussion about sleep apnea. As we have seen above, patients with OSA may in fact have a better result in an OSA Appliance rather than a single arch Occlusal Splint due to these coexisting conditions.
The use of the Nox T3 with EMG to evaluate sleep bruxism before pursuing the fabrication of an occlusal splint may completely change the approach to patient care. At very least an Epworth Sleepiness Scale or a Stop Bang questionnaire will help identify patients with tooth wear who are in need of further diagnostic investigation. In many cases the patient may require a sleep medicine consultation to exclude at secondary finding of sleep disordered breathing.
If you would like more info on the Nox T3 please send me an email Randy,Clare@carefusion.com
Landry ML, Rompre PH, Manzini C, Guitard F, de Grandmont P, Lavigne GJ, Reduction of sleep bruxism using a mandibular advancement device: an experimental controlled study, Int J Prosthodont (in Press)