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Sleep Apnea

Integration of SOT cranial therapy with an occlusal splint for the treatment of obstructive sleep apnea: A case report. Thomas Bloink, DC, Mamal Rahimi, DDS, and Charles L. Blum, DC

Introduction: Obstructive sleep apnea (OSA) relates to an obstruction to the continuum of airway expressed as sleep-disordered breathing. This spectrmn ranges from slight vibration of tissues at its mildest to death from asphyxiation at its severe extreme. Between lies pathologic snoring and periods of complete airway closure and breathing cessation called “apnea”. Some of the most serious chronic diseases of man have been associated with snoring and sleep apnea, including: stroke, hypertension (high blood pressure), myocardial infarction (heart attack), arteriosclerosis (hardening of the arteries), cardiac atrhythmias (irregular pulse), diabetes, gastro-esophageal reflux disorder (GERD), polycythemia vera (thickening of the blood) and others.
Sleep disordered breathing also disrupts the normal patterns of brain activity and relaxation, precluding restorative sleep. Overwhelming daytime sleepiness contributes to the risk of accident and injury from decreased attention span, judgment and retlex. The risk of automobile accident in the Untreated sleep apnea patient is about 8 times as compared to that of a normal sleeper. Therefore as might be expected work productivity and safety suffer.

Common treatments for OSA usually start with a continuous positive airway pressure (CPAP) machine and can progress to surgery to facilitate airway expansion and/or increase function. Surgery is costly and invasive yet patient compliance with CPAP machines is estimated at only 40%. From a dental perspective oral apnea appliances (e.g., TAP, SOMNIMED, OAYSIS), which are based on the concept of mandibular advancement, have shown promise but are also expensive and may adversely affect occlusion or condylar position. The following is a case report of a patient presenting with symptomatology of sleep apnea and relates the treatment rendered to facilitate her recovery.

Case History: A 56 year old female patient presented for chiropractic and dental care with symptoms of short tenn memory loss, foggy-headedness, temporomandibular joint (TMJ) pain, chronic myofascial neck and shoulder pain and fatigue. She also had a history of vertigo along with poor quality of sleep and significant excessive daytime sleepiness.

Methods/Intervention: Cranial-dental exam revealed a dental class II with narrow arches and premature anterior contacts. Decreased translation of the right TMJ with crepiits and clicking upon opening and lateral movements of the left TMJ. Pain was reported upon palpation to the medial pterygoids, masseters, and temporalis muscles. Examination of the teeth showed evidence of clenching and bruzism. Cervical spine range of motion was limited and painful. The right temporal bone was subluxated in extension (internal rotation) and spheno-maxillary distortion pattern as described by Buddingh [1] was noted.

Following this evaluation a sleep study was advised to rule out sleep apnea, however her history and presenting symptoms were consistent with sleep apnea and the sleep study could help differentiate between OSA or if related to central nervous system dysfunction. The sleep study did reveal a Respiratory Disturbance (RDI) Index of 17.1 a.nd an Apnea Hypopnea Index (AHI) of 16.3. Also it was noted that there was Iowest oxyhemoglobin saturation (Sa02) of 89% during sleep.

Treatment consisted of six SOT chiropractic cranial-dental treatments incorporating SOT intraoral cranial adjustments [2] and spheno-maxillary craniopathy [1] in conjunction with occlusal balancing by a lower flat plane splint [3] by Dr. Rahimi. The treatment was performed over a 4 week period of time.

Results: Following treatment the patient reported significant reduction of all symptoms, Follow-up polysomnogram was performed one month following prior study and with the dental appliance in her mouth she showed improvement as RDI and AHI were both reduced to 2.9 and lowest Sa02 was 92% during sleep. The patient had significantly reduced TMJ pain and the chronic myofascial neck and shoulder pain had gradually resolved over the 3-4 weeks of care. Due to’ her increased ability to sleep and increased oxygenation, she was also less fatigued and fumctional during the daytime.

Discussion: The combination of SOT cranial therapy with a flat plane lower GELB type occlusal splint not only resolved this patient’s apnea a.nd accompanied symptoms but was also minimally invasive, less costly, and only required a 3 to 4 week treatment program. Splint type therapy has been found to helpfulfor t)SA patients and one prospective randomized study found “that a dental appliance could be an alternative treatment for some patients with severe OSA [3].” In addition to the standard SOT cranial therapy a portion of the cranial therapy rendered was based on a method of adjusting the sphenomaxillary suture as developed by Buddingh, which essentially attempts to balance tensions of the pterygoid muscle and related cranial bones. Buddingh has determined that “The sphenoid bone is influenced to the anterior by the pterygoid process at the maxilla suture, the occiput to the posterior at the sphenobasilar articulation. Hypertonicity ofthe pterygoid muscles occurs when the patient’s body requires the pterygoid muscle to balance the reciprocation of the anterior falx to the general dural tensions. The hypertonic pterygoid and the concomitant tension into the TMJ will purportedly be reduced via the spheno-maxillary adjustment. Clinical studies have noted that balancing the sphenomaxillary suture causes a reduction of the hypertonicity of the related muscles affecting occlusal relationships. This change appears to have an affect also on the dental cone, the curve of Wilson and the curve of Spee [1].”

Working together the dental and chiropractic profession can help determine if dysfunctional postural patterns or OSA have predominant descending or ascending influences. In an important study investigating this ascending and descending contribution of posture and TMD imbalance, Sakaguchi et. al., while evaluating 45 asymptomatic subjects, fomid that “Body posture was more stable when subjects bit down in centric occlusion. Changes in body posture affected occlusal force distribution. Altering body posture by changing leg length shifted the occlusal force distnbution to the same side that had a heel lift [4] .”

While for the sake of clarity and ease in clinical assessment We would prefer patients to have either an ‘ascending or descending contribution to postural influence, more commonly, they present with a mixture of both patterns. It is in these “mixed” presentation patients that chiropractics and dentistry can offer improved patient outcomes. The typical patient, such as the patient in this case report, that may likely need chiropractic dental co-treatment will usually present with a low pain threshold, low physiological adaptive range, and a history of musculoskeletal pain or injuries. Patients with OSA will also tend to have general poor health due to the lack of rest and oxygenation, which will predispose them to various chronic presentations. Future research may need to determine Whether the patient could achieve improved function With only chiropractic care or dental care and whether the optimal care would be a co-treatment methodology. Clinically many chiropractors and dentists are realizing that the relationship between posture and the stomatognathic system makes collaborative efforts necessary [5].

Conclusion: With any case report the finding however apparently significant need to be evaluated from a cautious’ perspective because of the bias of the research clinician, the lack of a control group, as well as comparative sham procedure. The pre and post sleep study findings do show some objective change and the patient did report significant clinical improvement relating to reduced pain and function. However follow up studies with this patient are indicated. Greater study is needed to identify the subset of apnea patients that could benefit from this approach.

References:
1. Buddingh CC, The Spheno-Maxilla Distortion Today’s Chiro: 1988 Jul/Aug; 17(4): 31-2
2. Blum CL. TMD Functional Integrative Approach: Dental and Chiropractic Approach to Posture. Journal cf the American Academy of Craniofacial Pain. Fall 2009; 22(2):18,31,39.
3. Walker-Engstrom ML, Ringqvist I, Vestling O, Wilhelmsson B, Tegelberg A. A prospective randomized study comparing two different degrees of mandibular advancement with a dental appliance in treatment of severe obstructive sleep apnea. Sleep Breath. 2003 Sep;7(3):l 19-30.
4. Sakaguchi K, Mehta NR, Abdallah EF, Forgione AG, Hirayama H, Kawasaki T, Yokoyama A. Examination of the relationship between mandibular position and body posture. Cranio. 2007 Oct;25(4):237-49.
5. Blum CL, Globe G. Assessing the need for dental – chiropractic TMJ co-management: The development of a prediction instrument. Journal of Chiropractic Education. Sum 2005; 1 9(2).