The Impact of Identifying Comorbid Conditions and Screening of Obstructive Sleep Apnea for Treatment of Temporomandibular Disease

Clinical Problem
A 63-year-old female visited the dental clinic at the Jewish General Hospital with chief complaints of jaw pain, bilateral clicking, limited mouth opening, had migraine of 8 years duration, feeling fatigued and unrefreshed in the morning. The patient complains of TMD pain symptoms that began two years ago, involving both sides of the face. Clinical examination revealed eccentric mandibular opening and closing in occlusion with anterior contacts. After examining the patient’s masticatory muscles, the dentist made a diagnosis of masticatory myofascial pain, a subtype of temporomandibular disorder (TMD). With careful history taking, it was determined the patient also had several comorbid conditions and sleep related disturbances. These are often found in patients with chronic pain and include headaches, back and neck pain, depression, clenching, high blood pressure and poor night sleep. Before initiating treatment, it was determined that these conditions would affect the patient’s TMD.

Explanation
TMD pain is the second most common musculoskeletal pain condition after chronic back pain, affecting about 5-12% of the general population.1 A large proportion of these patients often report significant disability, psychological distress, and negative quality of life.2-3 These potentially debilitating health outcomes are more pronounced in patients with headaches, migraine, fibromyalgia and widespread pain involving the neck, back and extremities. These patients are more complex to treat and often show signs of delayed recovery and persistent chronic pain.4-8

It was recently demonstrated that individuals with symptoms of obstructive sleep apnea (OSA) have an increased risk of chronic TMD.9 OSA prevalence ranges from 3 to 14% in the general population.10-11 A high prevalence of TMD was reported in clinical patients with mild to moderate OSA,(12) and sleep studies have shown that patients with myofascial TMD pain had more sleep disturbances, sleep bruxism and lower sleep quality than control subjects.13 Comorbid diseases caused by OSA are stroke, hypertension, coronary artery disease, atrial fibrillation, and congestive heart failure.14-16 OSA patients beside a decreased quality of life, increased mortality, often suffer from motor vehicle accidents due to excessive daytime sleepiness.17 Clinicians, while managing their TMD symptoms, may also screen for OSA. TMD symptoms can be treated with a medication regiment and/or an oral appliance therapy while referring the patient to a sleep physician for diagnosis and treatment of OSA. This may not only prevent acute TMD from developing into chronic cases, but may also improve the standard of care towards these patients.

Clinical epidemiological studies have demonstrated that participants with the aforementioned comorbid conditions are at an increased risk of experiencing progression from acute to chronic TMD. This development can cause a delayed or incomplete recovery with standard TMD treatment with increased chronic pain.5-8 Comorbid conditions such as fibromyalgia, headache, anxiety, depression, and sleep disturbance can act on the brain through the central nervous system in altering pain regulation.13 Peripherally acting conditions include teeth clenching, postural tension and trauma (18-19). Therefore, identification of comorbidities is crucial for selecting effective management and a more personalized treatment approach.

Theories that suggest how comorbid conditions can increase the risk of progressing from acute to chronic TMD are not clear and should be further explored. Chronic pain can alter normal sleep patterns and functions causing the chronic pain patient to cycle between periods of poor sleep and more intense and variable pain. Patients with chronic pain tend to be short sleepers (<6 hrs) or long sleepers (>9 hrs). The long sleeping duration was suggested to be explained by depressive mood (13). The presence of comorbid conditions in patients with TMD also may explain why 30% of people seeking care for TMD pain still report pain five years later, and 20% of patients experience long-term disability.20 For example, oral appliance therapy was not effective in patients with widespread pain.21

Clinical Implications
Because both central and peripherally acting comorbid conditions increase the risk of treatment failure, they need to be addressed as part of an overall treatment plan. Comprehensive clinical examination for all patients with TMD is warranted to identify and address comorbid conditions as well as to screen for OSA.

Clinically, intraoral signs of OSA include generalized occlusal wear patterns with an enlarged and scalloped tongue on the lateral boarders. Many patients with OSA will also have marked acid erosion on the lingual surfaces of their teeth due to acid reflux. Sleep bruxism is often seen in patients with OSA which will manifest as worn teeth, gingival recession, and abfraction lesions.13 OSA patients may present with enlarged tonsils, edema and erythema of the soft palate and surrounding structures.22 Red and swollen gingival tissues with dry mouth may also be a sign of mouth breathing which are indications of a breathing disorder.22

The treatment plan should consist of medical, physical and behavioral therapies. The dental clinician should be able to use screening instruments such as the Epworth Sleepiness Scale (ESS) and STOP-BANG Questionnaires.23-24 This will increase the potential for success in reducing pain and dysfunction at an earlier stage of chronicity. A multidisciplinary approach is highly recommended to treat both the musculoskeletal condition and its contributing factors (e.g. depression) tailored specifically to the patient. Matching the complexity of the patient’s condition with those of treatment strategies are essential for success.

A patient with mild TMD pain and no comorbid conditions may be treated with self-care strategies such as relaxation, massage, hot/warm facecloth or cold packs, stretching, exercise or a combination of these to encourage healing. A patient with TMD coupled with fibromyalgia, persistent clenching, anxiety, and depression should be treated in a multidisciplinary orofacial pain clinic setting in which a team of clinicians addresses different aspects of the patient’s symptoms. Multidisciplinary teams that include a dentist, sleep physician, physiotherapist and a psychologist can address all contributing factors, including comorbid conditions, in a supportive environment. This will result in greater success in long-term treatment of chronic pain. Limited approaches that do not address the full scope of a patient’s condition are likely to fail and complicate future therapy.

Resolution Of Clinical Problem
Our patients’ migraines are controlled by imitrex. Injection of one carpule of 1.8 mL of 2% lidocaine 1: 100,000 epinephrine to the right tuberosity involving lateral pterygoid and temporalis muscles reduced pain on both sides. Patient lower teeth shows wear and admits clenching. She was prescribed diazepam 5mg for 30 days, 1 tablet 30 minutes before sleep and to keep a daily log of any daily painful episodes 30-day follow-up. Excellent results were recieved for her myofascial pain but not for migraine. We discussed life style changes and it was determined she may have obstructive sleep apnea. A referral to a physician for a sleep study was issued. Moreover, we decided to make an oral appliance modified for sleep apnea pending results of the sleep study. The appliance was inserted and she now reports pain 2 in a 0-10 pain scale. The patient was sent for blood test which resulted in low ferritin levels. Iron supplements were suggested and she was pleased with the overall results.

Conclusion
Comorbid conditions that range from muscle tension, depression, widespread pain, OSA and fibromyalgia may contribute to the progression of acute TMD to chronic TMD and result in treatment failure. This area of research needs to be further investigated. Dentists should identify patients with comorbid conditions including OSA screening as well as seek assistance from the patient’s physician to issue the appropriate referral for a sleep study. This will aid in ensuring the highest standard of care to TMD patients and managing OSA. This brief clinical report summarizes the research and clinical implications regarding the relationship between TMD, OSA and comorbid conditions. OH

Oral Health welcomes this original article.

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Dr. Mervyn Gornitsky is Research Director of the Department of Dentistry at the Jewish General Hospital. He is a Professor Emeritus at McGill University, Faculty of Dentistry, and Chief Emeritus of the Department of Dentistry at the Jewish General Hospital. Dr Gornitsky’s distinguished careers in academic dentistry and oral and maxillofacial surgery have spanned over 50 years. He was granted a fellowship at the inception of examination by the Royal College of Dentists of Canada in Oral and Maxillofacial Surgery in 1967. He has contributed more than anyone in Canada to the development of departments of dentistry in Canadian hospitals. He was chair of the Hospital Dental Services Committee for Quebec for 15 years and Chair of the Council on Hospital Dental Services for the Canadian Dental Association for six years. Dr. Gornitsky was awarded the Le Prix Micheline-Blain in 2014 in recognition of his leadership in research and the promotion of education in Dentistry in Quebec and for his clinical and epidemiological studies.

Dr. Ana Velly is an Associate Professor with the Faculty of Dentistry at McGill University. She was the Director of the Registry for NIH/ NIDCR’s Temporomandibular Joint Implant Registry and Repository from 2006 to 2011, and President of the Neurosciences group of the International Association for Dental Research from 2007-2009. Dr. Velly is a dentist with an MS in Neurologic Science and a PhD in public health with an orientation in epidemiology from the Université de Montréal, followed by post-doctoral training in epidemiology from the Department of Epidemiology, Biostatistics and Occupational Health, McGill University.

Dr. Sherif Elsaraj graduated from the University of Manitoba with a DMD in 2010. He holds a B.Sc. in Biochemistry from Carleton University and a Masters of Science in Oral Biology from the University of Manitoba. In 2012, he completed a year of training at the Oral and Maxillofacial Radiology residency program at the University of Toronto, Dr. Elsaraj is currently doing research towards a PhD in Temporomandibular Disorders and Craniofacial Pain at McGill University. He is an active member of the Canadian Dental Association, Ontario Dental Association, and the Ottawa Dental Society. He has limited his practice to treating patients with temporomandibular disorders and sleep apnea.