Lesson 1, Topic 1
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What You Will See – transcript


So my name is Dr. Karina Patel and I’m from the TMJ and Sleep Therapy Centre based in London. I’m just going to go through a case. We obviously deal with a lot of patients with craniofacial pain and sleep breathing disorders. When you’re looking at TMJ, TMD, craniofacial pain, things that you’ll come across quite a lot, are neuropathic disorders, muscular disorders, headaches, undiagnosed pain of the head and neck, breathing disorders that include snoring, sleep apnoea, insomnia, and all the rest of it. There’s a hundred different types of sleep breathing disorders as well. So I’m just going to go through what your signs are when you’re actually looking for sleep breathing disorders in your clinic. Then we’ll go through an actual case study as well.


So, with your tongue, what you’re looking at is, is it coated? Is it enlarged? Do you have scalloping at the lateral borders? Does it obstruct the view of the oropharynx? Now, if it’s coated, that could mean you’ve got a risk of gastroesophageal reflux or mouth breathing. Also, if it’s enlarged, that could mean increase in tongue activity and a possible risk of obstructive sleep apnoea. If it’s scalloped at the borders, that is actually predictive in ENT literature. It’s up to 70% predictive of having obstructive sleep apnoea. If it’s obstructing the view of the oropharynx, there’s actually a score you can use called the Mallampati score. Now, if they score a one to two, it’s a lower risk of obstructive sleep apnoea. If they score a three to five, then you’ve got a increased risk of OSA. Now, it’s usually a score up to four, but I’ve added a extra one myself just because we do often see people where you can’t actually see to the back of their throat and it’s completely occluded.


With your teeth and periodontal structures, you’re looking for gingival inflammation. If they’re a mouth breather, if they’ve got poor oral hygiene, gingival bleeding on probing, dry mouth, gingival recession, tooth wear, which might indicate bruxism, a fraction, which also leads you to think that they might have an increased in parafunctional activity. With the airway, you can actually have a look again, along with the Mallampati score. If they have a long, soft sloping palate, or if they have enlarged swollen elongated uvula, again, a risk of a sleep breathing disorder. Extra orally, do they have cracked lips, dry lips, poor lip seal, mandibular retrognathia, long faces and large masseters; all of those could show a risk.


When you’re looking at the nose, which again, dentists don’t usually look at, but if you are there, you might as well. Small nostrils, difficulty breathing through the nose maybe, an alar or rim collapse on forced inspiration. So you just ask them to take a normal breath in normal breath out. If they’re having any, or if you can see any movement in the alar rim, then there is a sign that there might be some destruction there. With the posture, forehead posture is also an indicator, loss of lordotic curve in the spine as well, and also posterior rotation of the head. Okay.


So when we’re looking at chronic orofacial pain, this is a good article on trigeminal neuralgia, which will come up a fair bit. So with trigeminal neuralgia, it’s classified as a disease of severe stabbing neuropathic pain of the second and third divisions of the trigeminal nerve. It’s estimated that maybe one in 1500 people suffer from it, but the numbers could be significantly higher due to frequent misdiagnosis. The incidents is supposed to be greater in over the age of 50 and more in women than in men. Now, we do need to know a little bit of anatomy to go with that. So obviously, you’ve got your trigeminal nerve, the three branches, the ophthalmic, maxillary and mandibular division, and then all of its branches as well. We also need to know the sensory distribution of the fibers because that’s where the patients will feel this sort of short, sharp, stabbing pain. We also need to know where the actual nerves are emerging from their relevant foramen as well.


So we’ve got all the nerves, all the cranial nerves, and it will actually enable us to identify if it is a true joy trigeminal neuralgia, if it’s a hypoglossal neuralgia or whichever neuralgia it might be, there might be compression around these forumen and all these exits. Now, the most common source that people usually find for trigeminal neuralgia is peripheral nerve entrapment by the muscles that it innovates or by mechanical injury or trauma. This is how it actually works. So you’ve got your normal nerve. It then becomes compressed, which leads to some degeneration or sheath loss, disconnection, and eventually total degeneration, which can basically give you that pain.


Now, traditional medications for trigeminal neuralgia would be membrane stabilizing drugs, anti-convulsants, muscle relaxants. What we can see though, is that you can also use a laser. So with the laser, we’ve got many different articles that suggest that it can actually be used in neuropathic pain. This is just from the last time that I was here when there wasn’t a coronavirus. I was out exploring Heron Island. Then the time before that, in Perth with the quokkas.


All right. So a case. This is a typical craniofacial pain case of mine. We use these intake forms. So we’ve got what the chief complaint is. We ask the patient to identify which complaint is recent, which complaint is chronic or greater than six months. Then we also ask them to put that in order from one to 10. We’ve actually separated it, but though the patients don’t know this. So these are the pain symptoms and then on the other side, we’ve got the sleep symptoms as well. The most important line of our intake is this line at the bottom. So what are your results that you’re seeking from treatment? So if the patient has ticked actually 10 things on here, which they often do, they’re only actually interested in what you’re going to be able to do from them about this one main problem. So you can fix all these other things, but that’s the main one that they’re going to want help with. So don’t overlook that one.


Medical history, we ask them if they’ve got any allergies. Your normal medical history: smoking, drinking, and medications as well. It’s really important to know about those medications because all medications have side effects and some of the side effects unfortunately, compound some of the issues or the other problems that the patients have. So she’s taking diazepam 10 to 20 milligrams as needed, and also ibuprofen 600 milligrams as needed. The other thing was she had 16 trips to the physiotherapist with no relief. Now, medication, diazepam, it’s a short acting benzodiazepine and it works by binding to a GABA receptors and it enhances the effect of GABA. So it’s an inhibitory neurotransmitter. One of the common side effects of coming off of a benzodiazepine though, is rebound insomnia. She’s actually indicated to us that she can’t sleep either. So it is really important to look at these medications.


So other signs, she’s got irregular blood pressure, bruises easily, cold hands and feet and frequent awakenings of up to four or more times a night. These are all signs of possible sympathetic dystrophy. Now, sympathetic dystrophy is where you’re stuck in that sympathetic rather than parasympathetic state where your body is able to regulate properly. So if you’re stuck in a sympathetic state, it’s sort of almost fight or flight all the time. Patients can be highly anxious. They will have things like cold hands and feet because their blood is moving away from the extremities to their vital organs like their heart. These are just things that you need to look out for, also bruising easily because the blood flow isn’t quite getting to everywhere.


We use the vast scale to identify pain, which a lot of other practitioners do as well already. So we’re looking at a scale from zero 10; 10 being when they’re in extreme pain and zero being nothing. It’s not very often that they say nothing. So her pain scale was at an eight, and she’s also marked on there her areas of head and neck pain as well. So she’s got occipital, temporal, generalized head pain as well and that’s been, she’s put on there recent, but we have to go over these questionnaires with the patients as well. She was actually chronic. It was longer than six months. Have jaw joint symptoms, quite important. So is she clenching or grinding? She’s actually aware that she’s grinding her teeth at night and she’s aware that she feels like she’s got a foreign body in the throat, which indicates there might be some sort of restriction in the airspace there.


So shoulder symptoms she’s got as well. So pain there, pain in the back, pain around the head and neck area. So all those things together start to paint a picture. The sleeping position, she sleeps on her side. She says it’s easy for her to fall asleep. She doesn’t stay asleep and she doesn’t wake up rested. Those are three really good questions that you can add to a medical history. If you’re looking to ask anything and you don’t want to add too much to your intake forms, those are three good three really good questions. So can you get to sleep easily? Can you stay asleep? And do you wake up rested? We then found out as well that she had a motor vehicle accident where she was rear-ended by another vehicle. That therefore, she resulted in her having a cervical hyper flection injury, which all starts to add up to all the symptoms that she’s feeling.


So she’s actually marked on here for us where she’s getting the pain up here and also around the temples, around the trapezius area. We can see with Tavelon Simmons, my facial pain and dysfunction manual where these pictures are taken straight out of, it’s almost identical. Now, they have mapped out a series of trigger points and where their referral patterns are. For those of you who don’t know what a trigger point is, it’s basically a palpable nodule, a taught band of muscle that when it’s palpated, it can elicit a jump response, or it can radiate pain to other sites, which is all marked out here. That’s what she’s got. There’s a series of a whole different type of referral patterns. This is just the one that matches with what she’s experiencing.


So when we’re actually doing our intake, we check everything from the vitals. We check mandibular ranges of motion, dental full exam as well. So with her mandibular ranges of motion, the only thing to really note is that she’s got a deflection to the right-hand side. Also, if there’s been any appliance history in the past. Okay. I’ll go back to that. All right. So with the cervical ranges of motion, we check if they’re within normal ranges. So 85 to 90 degrees of rotation is normal. 55 to 60 degrees of flection or extension is normal. We also check if she’s got any facial asymmetry, which can give us an indication on which muscles might be tighter, which ones might be overworked, overused. She’s actually got a cant up to the left-hand side, which you can see here. So that means that the muscles on the left-hand side will have grating restatonis and also her posture.


So does she have splayed feet? Is she leaning forward? Does her head come forward from her spine? Are her shoulders different on one side compared to the other? Does she have a hip tilt? All of these things give you an indication of muscle imbalance, which can give you pain. So what does that have to do with your jaw joint? So an improvement in the actual condyle facial relationship can actually be seen to improve your forehead posture. This is just demonstrating that as well. So every inch that of your forehead, your head comes forward from your spine, it adds an extra 10 pounds of weight to your back. Now, with the sleep, we take a slight diverged angle on this. So if you are looking at sleep, this is the sleep scale that everybody uses most often.


Now, the only issue with that is it’s a scale on fatigue. So it’s really great to be able to decide whether you need to send someone off for a sleep study or contact a sleep physician, but patients aren’t often great at answering it truthfully. Sometimes they don’t understand what the question is actually asking. So we do actually have to go through this with the patient. It’s more of a case of if they’re falling asleep, that’s completely different, but most of them won’t fall asleep if they’re sort of in that sympathetic state still. So it’s asking if they feel tired while they’re doing these certain activities, rather than if they would actually doze off. We’re looking for a score of above nine to be able to indicate whether they need to have a sleep test or not.


Just a little bit of a note about the sleep test, there’s multiple different sleep tests out there. You can get some that have just a oxygen saturation measuring. You can get some with sort of five, six channels. Ideally, you’re looking for someone that measures respiratory events alongside your heart rate, your pulse, so you can actually measure up if they’re having any sleep disturbances, as well as respiratory events to be able to fully look at everything. There’s a few on the market like that. Some of them are available in Australia as well. There’s the MediByte that’s available. You can get the WatchPAT in Australia, but it doesn’t have all those features. It doesn’t have all those channels. I found that the MediByte is actually quite easy to use. It’s easy for the patients to take home and use themselves. Then it just comes with a little card that you can plug in and get some good data from as well. That’s what we actually used on her.


With the questions again, like I said, is she getting to sleep easily, staying asleep, waking rested? Then all your intro oral ones that we were talking about before, so your Mallampati score, how much of a black space you can see when you’re looking down at the back of the throat. This is showing that you can actually predict, using tongue scalloping, if someone might suffer from a sleep breathing problem and that’s in the ear, nose and throat literature. When you’re doing your muscle palpations, you want to ask them if there’s any pain; from no pain to severe pain. There’s a list of different muscles that we actually palpate. You can see here that she actually has pain in most of those muscles, and there’s no area really, apart from a couple of nerves, where she’s got no tenderness.


We also do CBCT imaging. So this is her frontal panoramic. Then we do a closer view of the condyle as well. So we’re able to see here that she’s got mild flattening of the posterior surfaces of the condyle, thickened borders of the condyles, and the articular eminence. We can also see that she’s got concha bullosa, which is a bubble of bone. What that means is that, although it looks like it’s painted, that middle turbinate is actually blocked and it stops air from getting through. Also, on the left-hand side, she’s got a deviated septum on this view, as well as this view. So all of those things are stopping air from getting through. Nasal valve collapse, so again, on that forced inspiration that alar rim collapse can indicate whether there’s a restriction in airflow and we get a 3D measurement as well. So essentially, if you’re just looking at the colours, red is bad, green is good, and most of that area is red.


So we’re looking for something around 300 millimeters squared is ideal. Hers is that 112 millimeters squared, so it’s less than half of what it should be during the day. At night, that will reduce by up to half as well. So that indicates that at night, it might be close to down to 50. Her diagnosis, preliminary diagnosis before we get any sleep test results back is anterior disc displacement without reduction, possible sleep disordered breathing, facial and cervical myositis. Her goals or treatment to reduce any inflammation, pain in the joints, reduce any adverse loading, muscle pain, improving mandibular ranges of motion and also in strengthening the musculoskeletal system. We did this using two different types of appliances; a day and a night appliance. In the interim while those were being made, we provided her with an Aqualizer, which is a water bed for your jaw to start allowing your muscles to relax over the two weeks while the appliances were being made. We also introduced into her treatment plan, the cold laser therapy using the MLS laser. We then also introduced nutritional counselling and gave her a soft diet recommendation as well.


So we also recommended she see that sleep physician and also the ear, nose and throat specialist for all those bony obstructions noted on her CT scan. So using the laser, we use that at 50% intensity at hundred hertz for two to three minutes. That was for a period every week, actually for 10 to 12 weeks during the actual appliance phase of her treatment. What we saw, so at week four, using the appliance with the MLS laser, there was a 40% to 50% reduction on pain when chewing and also face and jaw pain. That’s just a picture of the laser there. This is the results from her MediByte. So it did turn out that she actually had moderate sleep apnoea. Sleep apnoea is ranged from anything above five is not normal. So that would be a mild. Five to 15 is the range for mild sleep apnoea. Then you’ve got 15 to 30 as moderate, and then above 30 is severe. So her reading is down the bottom there. She had 15.6, which basically brings her into that moderate category of sleep apnoea.


Now, as dentists using appliances and things like that, we are usually limited to mild or moderate cases, but there are those odd cases where patients can’t tolerate a C-PAP machine and then they would end up seeing us as well as some sort of intervention. Also the pain, so the pain went down. There was no areas by the end of it that had anything more than mild tenderness on palpation. You can also see the change in her facial symmetry as well by the end. So this is on you after three months. I know some people might treat patients for a lot longer, maybe up to six months, but after three months, that’s a massive change. We can also see an improvement in her posture. So she’s standing up straighter, her feet aren’t spayed anymore, her hips aren’t tilted anymore, and her shoulders are more balanced.


After, we also did another MediByte sleep apnea test, and that took her score down to two, which is basically well below the normal ranges. After 12 weeks, we could see that the facial pain, chewing pain, jaw pain had all reduced by up to 95%. So this is an article from the laser company, energy for health and it does show that there was a study done on the actual laser and its use in craniofacial pain. We can see that the reduction in pain was 49.9% right from the first treatment. That’s just eight minutes per session. There’s just a short video to close on airway TMJ and its management.


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