If you are considering inserting a mandibular advancement device to treat sleep apnea, it is important to screen for the presence of a temporomandibular disorder, or TMD, in order to set that patient up for success. Subjective history questions can include information about habits. Does the patient clench or grind their teeth throughout the day? Do they find themselves touching their teeth together? Do they chew gum, or do they chew their fingernails, maybe their lips, cheeks, or even hair? We all have these habits that we do, but that becomes overuse for the jaw, and if they have muscle tension or any joint problems as a result, it might slow the progress of their therapy and make it difficult for them to wear the device. It's also important to ask about whether they have a history of clicking and catching, possibly even locking. They may not think to tell you that, especially if it's not painful, but that can indicate some mechanical considerations that we need to be aware of. Ask if they have a history of pain in the jaw, face, or even the ear or the temple. Sometimes having ear clogging or plugging can be a sign of a temporomandibular disorder. Ask if they have limited range of motion, limited function. There's a TMD screener available for use, which is very short and easy to use in the clinic, but will pull up those red flag items that can help you decide how you want to progress with your care. Medical history questions are important because there's a lot of comorbidity with chronic pain, fibromyalgia, and other psychosocial factors, including depression, anxiety, or even PTSD. Presence of any of these, or a TMD in general, can affect your prognosis and your decision making regarding the speed of your device progression. However, if TMD is present, it does not preclude you from being able to use oral appliance therapy. Many of these people either are already using a mouth guard at night to protect their teeth, or they would benefit from one. They may not be able to tolerate a CPAP, and being able to have a device that can both protect their teeth and take some pressure off of their joints and muscles while pulling their jaw forward to open the airway could be really beneficial for them. Applying the right elements of care and preparing them, educating them about expectations can set you up for some really good success, and this is a mode of treatment that can be helpful for these individuals. I always begin by observing movement, so then I can get a sense of what I need to watch for, especially when I'm measuring. To do that, I'm feeling over her joints, and I will be starting with looking at how her teeth fit together. So, can you touch your back teeth together, please, and then show me your teeth? Okay, very good. And her midline doesn't perfectly line up, just about a millimeter to the right. Okay, now I'm going to have you open your jaw, please. Beautiful, and close, and open again, close, and last time, and close. And she has a little bit of a deviation where her jaw is shifting off to the right as she opens. Okay, now I'm going to have you move side to side, so go ahead, whichever side you want. You can move, yep, to the side, back to the middle, same side again, good, one more time, and then back to the other side, okay, good, a few more times that way, good. And I'm feeling to see if there's any clicking or popping with her movements. And then the last one is for you to bring your chin forward toward me, and then back, and forward, and back, and last time, forward and back. And she is drifting a little bit off to the right-hand side, and I can tell that her condyle's moving earlier over there on the left. So that's setting up some discrepancy side to side. So for opening, we are going to measure selecting our midline from the bottom teeth. I have a millimeter ruler. These are stainless steel, so we can sterilize them. Ideally, we need to make sure they can open between 35 and 40 millimeters to tolerate impressions and mandibular advancement device use. So go ahead and show me your teeth again together, good. And she is about a millimeter off to the right. So I'm going to then place my ruler, go ahead and drop your jaw slightly open, I'll be placing it about a millimeter off from her midline. Okay, so first I want you to open as far as you feel comfortable. Okay, I place it on the bottom, and she is opening to about 48 millimeters. So she's clear. If she was tight, then it might see it at 30, 35, and we'll talk about what to do with that. Next, we can measure side to side, so start, look at, touch your teeth together, there you go. I'm going to line up underneath her midline of her top teeth, drop your jaw slightly open for me, move to one side, you get to pick. All right, good. So she's going to about eight millimeters, back to the middle, touch your teeth again together, there you go, I'm lining up, beautiful, drop your jaw open, and then move to the opposite side. Okay, on there, she's going about 11, and then back to the middle, good. And if she's restricted to either side, I'm going to be concerned about what happens when our device starts to pull her forward. So it's still valuable information to have. And then our final measurement is protrusion, to see if there's restriction. For that, start with your teeth together, okay, and I'm going to look at the overlap. She's just a few millimeters of overlap, it's pretty normal. Okay, now bring your jaw all the way forward, and I'm going to look over the ruler, and she is right around six millimeters of forward protrusion. So she has eight total millimeters of available movement, which falls within our normal range. If there's no ruler available, you can have them check with their fingertips. So go ahead and take two fingertips, and hold them right in front of your teeth, and open, stacked up vertically, there you go, yeah. So now she's demonstrating if someone is restricted, two fingertips is about 30 millimeters, go ahead and take your fingers out, and she's a little bit underneath that. So we may want to consider giving her some stretches. Two knuckles, so two stacked knuckles is about 35 millimeters, three stacked fingertips will be about 40 millimeters. So if your patient cannot fit two knuckles or three stacked fingertips between their teeth, you're going to want to give them some stretching. And we will be discussing stretching in a later video.

temporomandibular disorders

screening

mandibular advancement device

sleep apnea treatment

TMD screener