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Dental Sleep Medicine A Clinical Guide G. Gary Demerjian Mayoor Patel Francesco Chiappelli André Barkhordarian Editors 123 Dental Sleep Medicine G. Gary Demerjian • Mayoor Patel Francesco Chiappelli • André Barkhordarian Editors Dental Sleep Medicine A Clinical Guide Editors G. Gary Demerjian Mayoor Patel Center For TMJ & Sleep Therapy Craniofacial Pain & Dental Sleep Center Glendora, CA, USA Atlanta, GA, USA Francesco Chiappelli André Barkhordarian Dental Group of Sherman Oaks Department of Oral Biology and Medicine Los Angeles, CA, USA UCLA School of Dentistry Los Angeles, CA, USA ISBN 978-3-031-10645-3 ISBN 978-3-031-10646-0 (eBook) https://doi.org/10.1007/978-3-031-10646-0 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and trans- mission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Foreword Dental Sleep Medicine is the fastest expanding field of dentistry, requiring a wide- ranging knowledge of dental education, research, and clinical practice. In my travels around the world, I have found that sleep apnea is one of the most problematic and least treated medical disorders, with dire consequences for many individuals. And yet, it is still an area that is rarely taught in the context of a normal 4-year dental school curriculum. As a result, students interested in this fascinating field are left to figure it out piecemeal, largely relying on continuing education courses on their own to understand a highly complex topic. And complex it is—over my 45 years as a practitioner and educator, I have found this field requires the ability to work across the medical and dental spectrum of disease and disorders more than almost any other. My personal entry into dental sleep medicine was through the use of dental appliance therapy for Bruxism and TMD therapy. Patients would claim that they felt they were sleeping better with the night guards that kept their mandible in a more forward position. In the 1970s, we believed this was due to a reduction in bruxism and consequent masticatory muscle relaxation. But as dental sleep research took a deeper dive into the treatment results of anterior positioning of the mandible, it became more evident that occlusal guards that kept the jaw forward at night had more effect on the posterior airway, subsequently increasing the breathing capacity of individuals that have maxillomandibular insufficiencies. Such findings prompted the concept of a three-dimensional maxillomandibular position to help titrate an oral appliance for an appropriate sleep jaw posture. Once the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine understood the importance of opening posterior airway during sleep, the dentist’s involvement in a sleep team became invaluable. This opened up doors for a whole new category of dental patients and practice opportunities in dentistry, to the point that Orofacial Pain and its extension into sleep medicine is now considered a full specialty in dentistry by the American Dental Association. All of which is to say: this is a growing field requiring a breadth of knowledge that any one person, on their own, would struggle to wrap their hands around. Thankfully, after years of piecemeal information scattered across dental offices, what you hold in your hands should serve as a truly authoritative guide to Dental Sleep Medicine. v vi Foreword Written by highly knowledgeable individuals in the fields of dentistry and medicine, this textbook is an excellent overview of dental sleep medicine, with chapters designed to take the student through the interdisciplinary and interprofessional importance of the medical/dental collaborations needed to be able to assess and manage dental patients who have sleep problems. It is smartly laid out. Part I focuses on science and research and incorporates metascience, physiology of sleep, and a current classification of the various sleep disorders. This part also includes imaging, dental risk factors and other comorbidities of sleep apnea, as well as the importance of sleep diagnostics using laboratory- based polysomnography and various home tests currently available. Part II deals with the clinical aspects of examination, followed by various dental and surgical techniques for the management of adult patients diagnosed with dental sleep apnea. The last few chapters incorporate pediatric sleep apnea and the orth- odontic aspects of occlusal management of the growth and development of the oral cavity. Being personally involved in both the teaching and the practice of TMJ disorders and later dental sleep medicine for over 45 years, I find that this timely clinician’s guide is a must for dentists wanting to know more about the relationship of dentistry and sleep medicine and how to incorporate it into their practice. Craniofacial Pain and Sleep Center, Tufts Noshir R. Mehta University School of Dental Medicine Boston, MA, USA Preface There is a vast body of research and information available to students, researchers, and dental professionals in the broad field of dentistry and specifically in the expanding field of Dental Sleep Medicine. The purpose of this book is to disseminate and discuss research, clinical relevance, and treatments. There is a need for students and dental professionals who get into the field of Dental Sleep Medicine where there is not much information and training in a sys- tematic approach as a guide. Previously published books have been very informa- tive, but are missing the clinical relevance of how to treat, identify, and manage side effects that arise due to dental sleep appliance therapy. This is an evolution from our first book Temporomandibular Joint and Airway Disorders: A Translational Perspective on this subject of airway disorders, an evolution that was strongly suggested and encouraged by Springer and a special thanks to Alison Wolf. This book will be structured as per NIH recommendations of the intertwined nature of research and clinical relevance. Special thanks to the coeditors for their time and guidance in putting this manuscript together. A heartfelt apprecia- tion goes to the chapter authors for accepting our invitation, who are either clini- cians or researchers in the field of medicine and dentistry. There must be a multidisciplinary collaboration among physicians who diagnose and manage obstructive sleep apnea (OSA) through several treatment modalities (positive airway pressure therapy, surgical interventions, dental sleep appliance therapy, and ancillary treatments) and are responsible for the patient’s health and well-being. Dental professionals who are a part of the medical team who manage OSA are responsible for selecting the best possible dental sleep appliance to not only manage the OSA but have knowledge of dental comorbidities such as jaw pain, muscle pain, dentition, and periodontal health. Being a clinician and a researcher for several years in the field of TMJ disorders and Dental Sleep Medicine, the term oral appliance, oral appliance therapy, mandibular advancement device, mandibular repositioning appliance, or splint therapy has many different meanings based on the context that they are used for in the field of Dentistry. There are many kinds of appliances and splints, each serving a different purpose based on the mechanical forces being placed on the mandible. We will be using the term dental sleep appliance which is worn in the mouth during sleep to maintain a patent oropharyngeal airway to manage OSA and/or snoring. By increasing the vertical dimension and advancing the mandible we are moving the jaw vii viii Preface three-dimensionally creating tension on the palatoglossus muscle causing the oropharyngeal space to expand laterally, hence creating a patent oropharyngeal airway. There are two main parts that will be covered in this book: research and clinical. Within the research part, the subjects that will be covered are meta-science of Dental Sleep Medicine, physiology of sleep, classifications of sleep disorders, cone beam imaging for sleep disorders, medical comorbidities, dental risk factors and comorbidities, and sleep diagnosis. In the clinical part, the topics covered are dental sleep examination and documentation, CPAP therapy, dental sleep appliance therapy, surgical approaches to OSA, adjunct therapies for the treatment of OSA, orthodontics and airway development, pediatric dental sleep medicine, myofunctional therapy, and case studies to be used as a sample guide for the clinician in this field. The purpose of publishing this book is to provide comprehensive research to a didactic guide for the field of Dental Sleep Medicine. It is intended as a guide for dentists interested in understanding their role in the field of sleep medicine from a beginner’s perspective to a well-seasoned clinician to use as a reference. Glendora, CA, USA G. Gary Demerjian Atlanta, GA, USA Mayoor Patel Contents Part I Science/Research 1 Metascience in Dentistry and Medicine . . . . . . . . . . . . . . . . . . . . . . . . . 3 Francesco Chiappelli, Juliette Tamkin, and Grace Giordano 2 Physiology of Sleep and Diagnosis: Basic Information for Dentists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Deepak Shrivastava, G. Gary Demerjian, and Mayoor Patel 3 Current Classification of Sleep Disorders . . . . . . . . . . . . . . . . . . . . . . . 71 Jagdeep Bijwadia 4 Cone Beam Computerized Tomographic Imaging for Sleep Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Dania Tamimi 5 Medical Comorbidities of Obstructive Sleep Apnea . . . . . . . . . . . . . . . 125 John Kim, G. Gary Demerjian, Mayoor Patel, and André Barkhordarian 6 Dental Comorbidities and Risk Factors of Sleep-Disordered Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 G. Gary Demerjian, Pooja Goel, Mayoor Patel, Anthony Sims, Rachel-Marie Demerjian, and André Barkhordarian 7 Sleep Diagnosis: Polysomnography and Home Sleep Apnea Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 Domingo Rodriguez-Cue Part II Clinical 8 Examination for Dental Sleep Medicine . . . . . . . . . . . . . . . . . . . . . . . . . 201 Mayoor Patel and G. Gary Demerjian 9 Beneficial Effects of Continuous Positive Airway Pressure Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 Deepak Shrivastava ix x Contents 10 Dental Sleep Appliance Therapy for the Treatment of Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 Harmeet K. Chiang, Mayoor Patel, David J. Lesczyszyn, and G. Gary Demerjian 11 Surgical Approaches to Treatment of Obstructive Sleep Apnea . . . . . . 267 Maria V. Suurna, Arron Cole, and Joshua Sturm 12 Adjunctive Therapies for Dental Sleep Appliances . . . . . . . . . . . . . . . . 279 Charolte de Coursey and Karen McCloy 13 Oropharyngeal Development Through Dental Orthopedics and Orthodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327 William M. Hang 14 Pediatric Obstructive Sleep Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . 365 Karen Wuertz, Aaron Glick, Jerald Simmons, and Emily Hansen-Kiss 15 Orofacial Myofunctional Therapy for Sleep-Related Breathing Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403 Rochelle McPherson 16 Dental Sleep Medicine Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417 Terry Bennett and Chase Bennett