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Should the dentist independently assess and treat sleep-disordered breathing?

Sleep-disordered breathing is a chronic problem of the inappropriate mechanical collapse of the upper airway. Symptoms range from mild occasional snoring to severe obstructive sleep apnea. The standard of care for the diagnosis and treatment of sleep-disordered breathing by sleep medicine has been the use of the polysomnogram and continuous positive airway pressure. This approach is burdensome, costly, and ineffective due to lack of compliance with or rejection of treatment. Oral appliances are highly effective in managing the mild snorer to the moderate sleep apneic and are approaching the efficacy of continuous positive airway pressure with the severe apneic. The dentist can and should manage these patients. However, the dental practitioner must acquire sufficient training and knowledge to appropriately treat these patients.

Algorithms↗

Comparisons of oral devices for snoring.

A study was performed on 19 types of oral appliances for snoring/obstructive sleep apnea. The appliances were categorized into two groups, mandibular advancers and tongue advancers. A set of limited criteria was developed by which an appliance could be evaluated, and the criteria were weighted. Evaluations were then performed on the appliances, and they were rated according to satisfaction of criteria. The rating table should help a dentist in selecting an appliance that will be accepted by the patient and effective in treating snoring/obstructive sleep apnea.

Humans↗

Tooth stabilization for orthodontic retention.

This article reviews stability and retention of the orthodontically treated dentition. Factors and conditions that influence post-treatment stability are discussed. Methods for stabilizing and retaining the occlusion are reviewed.

Humans↗

Efficacy of stabilization splints for the management of patients with masticatory muscle pain: a qualitative systematic review.

This study aimed at providing an answer to two clinical questions related to patients with masticatory muscle pain: 1) Does the use of a full-coverage hard acrylic occlusal appliance (stabilization splint) lead to a significant decrease of symptoms? and 2) Is the treatment success achieved with a stabilization splint more pronounced than the success attained with other forms of treatment (including placebo treatment) or no treatment? A systematic search was carried out in different electronic databases, supplemented by handsearch in four selected dental journals and by examination of the bibliographies of the retrieved articles. Thirteen publications, representing nine controlled clinical studies, could be identified. Reporting quality of most studies as assessed with the Jadad score ranged from 1 to 5. Based on the currently best available evidence it appears that most patients with masticatory muscle pain are helped by the incorporation of a stabilization splint. Nevertheless, evidence is equivocal if improvement of pain symptoms after incorporation of the intraoral appliance is caused by a specific effect of the appliance. A stabilization splint does not appear to yield a better clinical outcome than a soft splint, a non-occluding palatal splint, physical therapy, or body acupuncture. The scarcity of current external evidence emphasizes the need for more and better clinical research.

Clinical Trials as Topic↗

Dental occlusion modifies gaze and posture stabilization in human subjects.

Repercussion of dental occlusion was tested upon postural and gaze stabilization, the latter with a visuo-motor task evaluated by shooting performances. Eighteen permit holders shooters and 18 controls were enrolled in this study. Postural control was evaluated in both groups according to four mandibular positions imposed by interocclusal splints: (i) intercuspal occlusion (IO), (ii) centric relation (CR), (iii) physiological side lateral occlusion and (iv) controlateral occlusion, in order to appreciate the impact of the splints upon orthostatism. Postural control and gaze stabilization quality decreased, from the best to the worst, with splints in CR, IO and lateral occlusion. In shooters, the improvement in postural control was parallel to superior shooting performance. A repercussion of dental occlusion upon proprioception and visual stabilization is suggested by these data.

Dental Occlusion↗

Significance of occlusion in the etiology and treatment of early, moderate, and advanced periodontitis.

Elimination of lesions diagnostic of trauma from occlusion is an essential part of complete periodontal therapy and restoration of health in the masticatory system for such patients. This can be achieved by orthodontic treatment, temporary splinting, bite-planes, occlusal adjustment and permanent splinting of teeth. Occlusal therapy may be required during periodontal treatment for trauma from occlusion and to enhance occlusal stability at any stage of periodontitis, but is most often needed in advanced periodontitis. Splinting of hypermobility of self-limiting trauma from occlusion is not indicated. Splinting may be required in addition to occlusal adjustment in moderate to severe periodontitis when trauma from occlusion is progressive.

Animals↗

A survey of treatments for myofascial pain dysfunction.

A survey of all active U.S. members of the American Equilibration Society was undertaken in order to identify the most commonly used treatments for myofascial pain dysfunction. A questionnaire was constructed such that myofascial pain dysfunction was defined, all treatments (including referral) were listed, and a percentage-of-use estimate for each treatment was requested. Results from 302 error-free questionnaires showed that the most common treatments were: interocclusal splints with anterior/canine guidance, occlusal equilibration, flat plane interocclusal splints, diet counseling, anti-inflammatory medication, non-narcotic analgesics, and muscle relaxants. A call is issued for systematic and careful research on the outcomes of these treatments.

Dental Occlusion↗

[Dental and pharmacological treatment options for bruxism].

Bruxism has a multifactorial etiology. The consequences of bruxism, abrasion of teeth and a possible craniomandibular disorder, present themselves periferal. So, treatment can have divers points of action. Counseling seems to be useful in all cases. Treatment with a hard acrylic occlusal appliance (oral splint) is especially useful in those situations where the patient has a lot of abrasion or suffers from a craniomandibular disorder with pain. Pharmacological treatment will have a more central effect. Some drugs are effective on bruxism. However, the real pharmacological mechanisms have not yet been discovered. In the absence of data from double-blind, polysomnographic, controlled studies, pharmacotherapy treatment is only indicated in severe cases on a short-term base. Until new data come available, the dentist has to use conventional therapies only.

Bruxism↗

Health-related quality of life in patients with sleep-disordered breathing: effect of mandibular advancement appliances.

STATEMENT OF PROBLEM: Mandibular advancement appliances (MAAs) are increasingly being recognized in the management of sleep-disordered breathing (SDB). However, there is little available evidence regarding their impact on health-related quality of life. PURPOSE: A prospective, nonrandomized controlled clinical trial was undertaken to evaluate the effect of MAA treatment on the quality of life of patients with SDB. MATERIAL AND METHODS: Two hundred fifteen consecutively referred patients for MAA therapy who had a diagnosis of SDB confirmed by overnight polysomnography were recruited for study. The test group (n=120) received a Herbst appliance, a removable appliance comprised of separate maxillary and mandibular complete occlusal coverage acrylic splints, connected by means of bilateral telescopic arms. Patients in the control group (n=95) remained untreated for 4 months. All patients completed the Medical Outcomes Study 36-Item Short-Form Health Survey at baseline (T1) and at follow-up (T2). Cross-tabulation was performed for each independent variable against the group (control versus test) to determine the number of subjects and the percentage showing improvement and the level of significance (alpha=.05). Data were dichotomized (improvement versus no improvement), analyzed by simple logistic regression analysis, and expressed as the odds ratio. RESULTS: Eighty-three (87%) control and 107 (89%) test patients completed the study. No statistical differences were observed at baseline in any of the parameters relating to severity of SDB, demographic, anthropometric, or quality of life measures between the 2 groups. Significant differences were observed in relation to the energy/vitality (P=.001) and physical role limitation (P=.025) domains following 4 months of treatment with an MAA. CONCLUSIONS: Mandibular advancement appliances have a significant effect on a limited number of health-related quality of life domains for patients with SDB.

Activities of Daily Living↗

Acrylic splints for dental alignment in complex facial injuries.

Twenty-four patients with complex facial injuries were managed by wide subperiosteal exposure, precise anatomical reduction, rigid internal fixation, and immediate bone grafting when indicated, in conjunction with dental impressions, model surgery, and fabrication of dental splints to establish proper preinjury occlusion. The study population consisted of 18 men and 6 women, whose ages ranged from 18 to 49 years (mean, 30.7 yr) at the time of injury. High velocity motor vehicle accidents were responsible for facial injuries in 18 patients, gunshot wounds in 2, low velocity blunt trauma in 3, and falls in 1. All facial fractures involved the occlusion, and unstable and/or comminuted palatal/maxillary and mandibular fractures, often with edentulous segments, were the major indications for fabrication of acrylic splints. Depending on the nature of the fracture pattern, model surgery was performed on the maxillary and/or mandibular models and segmented along fracture lines. These fragments were then repositioned according to dental wear facets and preinjury occlusion. When possible, preinjury occlusal records were obtained before splint fabrication. Models were mounted on a Galetti articulator and palatal, lingual, and/or occlusal splints were fabricated. Edentulous segments were compensated for by local buildup of the splints to produce an occlusal stop. Arch bars were fixed directly to the splint with acrylic. Twenty-six splints were used in the 24 patients to establish proper occlusal relationships before internal fixation of fractures. The types of splints were palatal (n = 8), palatal-occlusal (n = 6), lingual (n = 8), lingual-occlusal (n = 1), and occlusal (n = 3).(ABSTRACT TRUNCATED AT 250 WORDS)

Acrylic Resins↗

The effect of excessive occlusal trauma upon periodontal healing after replantation of mature permanent incisors in monkeys.

The effect of excessive occlusal force upon periodontal healing after replantation of mature permanent incisors was studied in green Vervet monkeys. The extra-alveolar period before replantation was 120 min. Prior to replantation, the teeth were root filled with gutta percha. The material consisted of four groups. In the two control groups, either no splinting or splinting for 2 weeks was used. In the first experimental group, a stainless steel crown was cemented on the antagonist of the replanted tooth, thus elevating the bite 1--2 mm. In the second experimental group, an orthodontic band was cemented onto the replanted tooth, also elevating the bite slightly. All bite elevations were removed after 6 weeks. The animals were sacrificed 8 weeks after replantation and the replanted teeth were examined histometrically. Replacement resorption (ankylosis) was found with the same frequency and extent in all groups. However, a significant difference was found in the pattern of replacement resorption activity among the experimental groups. Thus, active replacement resorption was more common in the groups with no splinting or traumatic occlusion as compared to the splinted group. Furthermore, linear replacement resorption, a process which apparently removes established ankylosis areas, was significantly more frequent in the non-splinted groups than in the other groups. It is concluded that excessive occlusal forces cannot prevent or eliminate ankylosis in replanted teeth after prolonged extra-alveolar dry storage.

Animals↗

Temporomandibular joint repositioning and exercise performance: a double-blind study.

In the present study, the effects of temporomandibular joint (TMJ) repositioning by use of an acrylic appliance on maximum and submaximum physiologic and performance measures were evaluated in seven male and four female volunteers with documented TMJ malalignment. In an attempt to remove design inadequacies of previous research in this area, a double-blind strategy was utilized. Subjects were randomly assigned to each of four conditions: 1) normal, without a bite splint, 2) with a placebo splint with no occlusal contact so as to maintain normal jaw position, 3) with a splint that optimized jaw position, and 4) with a splint that magnified the subjects normal degree of malocclusion. Measurements were taken of visual reaction time and movement time, muscular strength of the grip, elbow flexors, and leg extensors, submaximal and maximal oxygen uptake, perceived exertion, anaerobic power output, and all-out working capacity in both arm and leg exercise on a cycle ergometer. Analysis of variance for repeated measures indicated that in no instance were the differences in mean scores on physiologic and performance measures with TMJ repositioning or placebo statistically significant when compared with the normal condition. This was the case for the group as a whole or when the five subjects with the greatest TMJ dysfunction were analyzed separately. These findings strongly support the contention that the beneficial effects of short-term TMJ repositioning on exercise performance noted in previous reports may be the result of inadequacies in research design and evaluation rather than the true effects of the bite splint.

Adolescent↗

Quantitative analysis of masseter and temporalis EMGs: a comparison of anterior guided versus balanced occlusal concepts in patients wearing complete dentures.

The lack of easily measurable, objective physiological activity parameters of the masseter and temporalis muscle during jaw movements in humans has led to the consideration to revise data of surface electromyographies (EMGs) by applying a computerized quantification method. The aim of this follow-up analysis was to get quantitative data out of EMG-records of an earlier study. These records were obtained with two different splints, splint 1 providing an anterior front-canine guidance and splint 2 providing bilateral balanced occlusion. Utilizing a computer aided integration method led to numeric results which statistically proves the prediction of the previous investigation. Applying the integration method, the EMG raw signal was transformed into area-values which enabled a statistical work up of the data. Wilcoxon test statistics shows a significant (P<0.05) lower muscle activity in patients wearing dentures providing anterior front-canine guidance compared to those with balanced occlusion. It is concluded that the neuromuscular activity of the elevator muscles is highly reproducible and that the neuromuscular function is similar in edentulous subjects to that found in people with natural teeth. Furthermore, the study statistically proves earlier visual data that all those subjects, whose muscle activities were observed with anterior guidance (splint 1) compared to bilateral balanced occlusion (splint 2) showed significantly lower values with regard to subjects wearing splint 2.

Centric Relation↗

Histologic evaluation of the LaminOss osteocompressive dental screw: a pilot study.

This animal study compared the response of canine mandibular bone using the orthopedic principle of osteocompression by the function of an immediately loaded dental implant vs an unloaded dental implant of the same design and size. Two dogs were partially edentulated in the mandible. A total of 8 osteocompressive screw implants, 2 per quadrant were placed and evaluated histomorphometrically after 3 days in 1 dog and after 3 months in the second dog. The second dog had a two-unit fixed bridge placed immediately postsurgically in occlusal function on the right side; on the left side, the implants were splinted out of occlusion as a control. Histologically, no bone necrosis was observed at the implant interface by any of the 8 implants for either period as a direct result of the 4-mm-diameter by 13-mm-length implant design. Clinical parameters did not differ among the implants; however, at 3 months, the immediately loaded implants demonstrated more than twice the amount of bone density at their surfaces compared to the unloaded implants of the same design. Future human clinical research would be necessary to provide a meaningful statistical analysis to validate the importance of this implant design and the function of osteocompression.

Animals↗