Dental Sleep Medicine is a relatively new field that is rapidly growing and changing. Many dentists are deciding to incorporate Dental Sleep Medicine into their clinical practices, with some focusing entirely in this area.
The formal medical specialty of Sleep Medicine in general has a relatively short life. It encompasses all clinical conditions pertaining to sleep and arousal disorders. This includes those disorders involving initiating and maintaining sleep (dyssomnias) and behaviors and movements that occur during the course of sleep (parasomnias). Obstructive sleep disorders result from airway obstructions occurring during sleep and are classified as dyssomnias. The International Classification of Sleep Disorders, originally written in 1990, was more recently revised in 2005.
Sleep disorders are quite common in the general population but often go un-recognized. This is important because some, like obstructive sleep disorders, are associated with substantial morbidity and mortality. Treatments for obstructive sleep disorders, such as Obstructive Sleep Apnea (OSA), can vary from conservative approaches such as sleep position training and weight loss programs to continuous positive airway pressure (CPAP), oral appliance therapy (OAT) and various types of surgery.
According to the American Academy of Dental Sleep Medicine, Dental Sleep Medicine focuses on management of sleep-related breathing disorders (SBD) which include snoring and OSA, which can be a life-threatening medical condition. These are considered medical disorders and the diagnosis of SBD should be determined by sleep physicians. The treatment of certain SBD with Oral Appliance Therapy (OAT) are performed by qualified dentists and upper airway surgery by qualified surgeons.
OSA is caused by repetitive collapse and blockage of the upper airway while asleep. This can result in reduced oxygen supply to various organs such as the heart and brain. The two most common symptoms of OSA are snoring and daytime sleepiness although headaches, irritability, impaired concentration, depression and others symptoms can occur. If left untreated, OSA can lead to hypertension, heart attack, stroke, automobile accidents due to drowsiness, and death.
The scientific research and clinical development of Oral Appliance Therapy (OAT) for SBD has been carried out mainly by dentists. OAT has to do with the proper selection, fabrication, fitting, adjustment and management of oral devices, worn during sleep, that anteriorly reposition the jaw and tongue with the goal of enlarging and stabilizing the airway.
This brings us to the important understanding that such repositioning results in increased tone to, and therefore strain on, the craniofacial structures including the TM joint and muscles of mastication. This can result in malocclusion and temporomandibular joint disorders (aka 'TMJ'). It is therefore incumbent upon the dental practitioner involved in Dental Sleep Medicine to become proficient in diagnosing and effectively managing these complications or knowing when to refer for further management. These possible complications must of course be discussed with patients from the start so they can understand the nature of the treatments, the risks and benefits of proceeding, and give informed consent.
It is extremely important, both from a clinical and dental-legal perspective, for the dentist practicing Dental Sleep Medicine to conduct a thorough pre-treatment screening for the presence of TMJ. Taking a brief oral history or cursory exam is often not sufficient to arrive at an acceptable level of accuracy in making this determination. This is especially true for dentists who have not received adequate training in the area of anatomy, physiology and dysfunction of the temporomandibular apparatus.
Testing for and documenting the 'absence' of a TMJ disorder prior to OAT is just as important as documenting 'presence.' In addition, testing for and documenting 'absence' or 'presence' of TMJ after OAT is also highly important. If standard-of-care treatment has been followed in the course of OAT and a TMJ disorder arises, it is imperative that the dentist be able to recognize and document this occurrence and then initiate appropriate action to deal with this complication. Patients must be educated and understand, prior to embarking on treatment, what the potential risks are, including possible development of TMJ. When a dentist fails to educate their patient and conduct such a thorough evaluation, they place both their patient and themselves at risk.
This is where the TMJ Scale can play a significant role in Dental Sleep Medicine. It provides a systematic, highly repeatable and thorough assessment of potential TMJ symptoms. It makes a direct prediction as to the 'presence' or 'absence' of a TMJ disorder (no other clinical tool does this) and with excellent accuracy and reliability. It provides the dentist practicing Dental Sleep Medicine with essential documentation both for clinical decision analysis and for proper dental-legal risk management.
Based on the above considerations, the TMJ Scale can be conveniently used on every patient, before and after Oral Appliance Therapy, during the practice of Dental Sleep Medicine. Using this advanced, State-of-the-Art , TMJ Disorder clinical detection tool will help to ensure the necessary thoroughness of the clinician's practice for the benefit of both the patient and the dentist.
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