So as we go forward, these are what we would consider to be the most common adverse events. And what I would say is the top four, the excessive salivation, drooling, the xerostomia, the muscle soreness, and the TM joint concerns are probably going to be the primary ones that you see initially during your active protocol with the patient. The following ones there, tinnitus, tooth mobility, open contacts, clenching, grinding, occlusal bite changes, you may see that happen over time with the appliance. But each one of those, again, you want to identify why is it happening, what's the main source of it, and what can I do to manage it so that the patient doesn't get discouraged to stop using the appliance. So these are the, what I would call, the more uncommon adverse events that you may run across too. And this doesn't mean when these things happen that it's time to run for the hills. Because you may come across a few patients that have these things happen, I want to explain to you why they might happen and what you might do to manage the situation. Again, not to discourage the patient that this isn't that big of a deal. Most of these things are transient. And again, we know from the literature that some of the, as Michelle again referenced also, some of these side effects that patients may have long term from using the appliance for years are going to be permanent. But if we can identify some transient side effects or some side effects in the early on process of active protocol, or even in our recares, we may be able to offer some things to the patient that can negate them getting any worse, or even to reverse some of them that do happen. So let's talk first about the more common ones. So with xerostomia and excess elevation, again, these can be very self-correcting. When you first put an appliance in place, what you'll notice is you're going to have a little bit excess vertical between the upper and lower trays, whether it's closed or open. So the patient normally, without a tray in place, is typically going to be able to develop a lip seal between their upper and lower teeth. When you put some trays over their teeth, that lip seal might be a little bit compromised. So they may end up initially with a little excess salivation because they haven't initially developed a lip seal, or at the same time, if there's an opening between the upper and lower trays, and they haven't developed a lip seal initially because there's now trays over top of the teeth, then they may be breathing more air in through their mouth and they may have some dry mouth. So we can manage these things if they don't pass. If they pass, usually within a couple of days, and we again, going back to the informed consent, we explain to the patient that these are short-term complications that may develop that can pass, but if they don't pass, then we have ways to be able to treat that. So what we would do if it's persistent, if it's serostomia, before we jump the gun and think about reducing the vertical, whatever vertical we may start with, we want to look at a couple things. So one is, if you do have an opening in your appliance in the trays, so one of the things you may consider is just closing that opening. Some people, again, as I mentioned in the first lecture, that you may have an opening because you want the tongue to have the ability to do some passive movement forward beyond what would be normal active movement with the advancement of the appliance. You may also, even if you have a closed opening in the anterior part with the two trays coming together, you may prevent the lower jaw from just falling open in the dead of the night and allowing the jaw to fall open to the point where the patient starts to mouth breeze. So your correction then would be, consider putting the cross elastics that we mentioned as a feature for the appliance. You may add that on to the appliance if it's not there standardly when you request the appliance so that the lower jaw doesn't fall open and the patient starts to mouth breeze. In addition to that, we treat the patient, if they say they've had some dry mouth initially before we start to make changes, we may also recommend to them to use some over-the-counter natural salivary stimulants. So a lot of people like to use a product called Biotin. I don't particularly care for that because it's a synthetic moisturizer and adds kind of a slimy film to the patient. So I will have the patient get a hold of a product called Spry or another product called Xylomelt. So they're natural salivary stimulants. So you can buy these things in the general nutrition centers or health food stores. They come in a canister of about 180 tablets and they do naturally stimulate your saliva. So we have the patient use typically at nighttime, if that's when the issue develops, primarily secondary to using the appliance, three tablets, each tablet's a milligram of Xylitol and have them use that and see if that makes a difference for them. It also comes in a mouthwash form if you use the Spry so they can rinse their mouth with the Spry, then put their appliance in place. They can top that off with taking three of the tablets at nighttime of the Spry and see if that makes a difference. Xylomelt is a little bit different. It's again one gram of Xylitol per Xylomelt and that actually has an adherent surface to it that you can place on the inside of the cheek and have the patient use those things in lieu of using the Spry. If neither of those things work, again, before I jump the gun and start to close the vertical more, then you may have the patient use a prescription. A prescription that we commonly use for patients that we have to get to that extent would be a five milligram prescription of a product called Salogen and we typically prescribe that for 30 days, one tablet for 30 days at bedtime. It usually does the trick in stimulating natural saliva if the over-the-counter products don't work. If all else fails, then it may be that you have to close the vertical because the vertical that you started with at that point needs to be reduced so that the patient can develop a lip seal. A lot of times you can tell that if you feel that you may have started with too much of a vertical. When the patient tries to tense their lips over top of the appliance and you see some lip strain, then you know you probably started with too much of a vertical. Your vertical can range anywhere from say four millimeters up to 12 millimeters. That's being excessive to go to 10 and 12, but if you start to see a lip strain with them even trying to close their lips over top of the trays, over top of the teeth, then you know you probably started from the get-go with too much vertical. If you can see that they have a lip strain right from the get-go and you started with a higher vertical, the question was, is that the problem from the start? Well, yes. You don't want to go through all the other options of treatment if you can see right from the get-go that even when they strain, they can't close their lips together. So excessive salivation, again, before you go and have to change the vertical to reduce lip seal, the first thing you want to do is reduce as much as you can with your appliance, the palatal acrylic and the lingual acrylic without compromising the retention as much as you can and see if that makes a difference. If it doesn't make a difference, then your next step would be, again, to consider reducing some of the vertical. And feel free to ask questions as we go along, too. We can have some question-answers afterwards there, but feel free, if you have a question that's pending, to ask me right away. So the next thing we get into is jaw muscle soreness. So again, this is usually short-term. Most commonly, it's going to affect a few muscles in particular, and it's going to be the masseter muscles, the deep and the superficial masseter, and the lateral pterygoid muscles because these are the muscles we most often employ when we're making an oral appliance, whether we're changing the vertical and or the horizontal. So again, before we jump the gun and start reducing vertical, because if you have too much vertical, you can be straining the muscles beyond their normal resting length, and you might have to end up, in the end, adjust the vertical if you started with too much vertical. But before you do that, you want to look at a couple other sources that might be the problem. So initially, when you put something in place, it's just the body's natural reaction to clench against the posterior pads, especially if you have posterior pads on your appliance. So you want to consider that for one. Secondly, you want to consider are the pads when you insert the appliance. So Dr. Adame mentioned that you want to check and make sure that you have bilateral contact on the posterior pads of your appliance if that's the type of appliance that you're using, but you want to make sure that the pads are not uneven. And by what I mean with uneven is from right to left, the contact has to be even, but also from front to back, the contact has to be even. So you use some articulating paper, put it between the posterior pads on both sides. Of course, you're going to check the vertical that you're requesting from your bite registration and make sure that's correct, but you also want to see that you can see contact from the most posterior to the most anterior part of those posterior pads. If you don't have that, that may be a reason why you start to develop some muscle soreness when you put the appliance in place. And then the other thing which is most important, again, as I go back to the initial workup on a patient is when you're doing a muscle exam, nobody really expounded on this, but the most important thing to do when you do a muscle examination on a patient when you're doing your workup is to feel various muscles, again, employed that we use with the appliance and find out if they have what we call any latent muscle spasms. So a latent muscle spasm means that the patient doesn't necessarily feel it, it's not an acute muscle spasm, but a latent muscle spasm means when we start to touch the belly of that muscle, if it's tender, then they may have a spasm in the muscle that we may exacerbate when we put the appliance in place. So we want to be able to identify that in our initial workup. So going forward, if we're trying to treat the issues with muscle soreness that develops, and again, it's not something that we should panic about because a lot of times all these symptoms, especially these first couple are transient symptoms that the patient may have. And again, before you decrease the vertical, you want to make sure that you're adjusting those contacts, as I mentioned, bilaterally right to left and front to back, right to left. So all the contact, if that's what you're requiring, is the fact that you're having that contact with the posterior pads evenly front to back and right to left. Another option that you may have, if you understand what an anterior deprogrammer is, so if the patient would start to develop muscle soreness, typically it's because their elevator muscles are closing and contracting when you put the appliance in place. So if you're trying to relieve and relax the elevator muscles, again, you're talking about the masseter muscles, the deep and cervical superficial masseter. You're talking about maybe the medial pterygoid, maybe the anterior temporalis. What you want to do is you can put on the front part of your appliance what we call an anterior deprogrammer. An anterior deprogrammer means that you're discluding the posterior pads on your appliance. So you may have to adjust the contact, excuse me, of the posterior pads so that only the anterior touches, and you may have to add a little bead of acrylic on the anterior part of your appliance so that the posterior pads no longer disclude, or no longer occlude, that they're discluded. So when they contact, then normally if they had no appliance in place and they closed down, then all the teeth are in contact, those muscles are going to contract. When you put an appliance in place, the same thing applies. When you put the upper and lower trays together and they start to clench on them and they start to have muscle soreness, you want to disclude the part of the appliance that would cause the muscles that would be contracting when that part of the appliance is in contact. So if you place an anterior deprogrammer, you're putting anterior acrylic in the area of the incisors and not having the rest of the original posterior pads in contact. One other thing that I do to support the TM joints is, in addition to having that little anterior deprogrammer, I also put a little contact on the most distal part of the posterior trays to make sure I have support for my TM joints. Does everybody understand what I'm getting at with that? So you know what an anterior deprogrammer is, put a little posterior support in it, everything in between would not touch, and that's a good way to relieve muscle soreness when the patient comes in and says all of a sudden they have some muscle soreness, especially in their mass or muscles, but it may be in a few others. So another thing that we can employ is doing what we call therapeutic exercises. I'm going to get into this a little bit later, but primarily again you're going to work with exercises for the main elevator muscles, the masseter, and for the lateral pterygoid, and I'll go through at the end of my lecture some of the exercises that we commonly have the patients do. And one other thing again that we do, again before we decrease vertical, is I use a topical prescription of either a muscle relaxer or an over-the-counter muscle relaxer. So I don't like to use systemic muscle relaxers. So a lot of times people jump the gun and they have a patient start to use 5 or 10 milligram Flexeril, 5 or 10 milligram Baclofen, they use 5 milligram Valium. You don't really want to do that on a patient that has OSA for a couple reasons. One is, one of the side effects of using a muscle relaxer is it muscle relaxes. So it's going to be relaxing the dilator muscles that you're trying to tone with your appliance. So if you use a systemic muscle relaxer, you're going to get that effect on your airway dilator muscles and it's really going to aggravate the apnea. Another reason is a lot of the side effects of using those systemic muscle relaxers is, if you read this fine print, is excessive daytime sleepiness. So you're kind of working and spinning your wheels if you're having a patient using a muscle relaxer that's systemic because it can cause all these secondary side effects or aggravate the OSA. So what I use is, if I use a topical cream, I use a compound pharmacy that puts together a cream that is 10% Ketoprofen, and you have to use a compound pharmacy to make this, 10% Ketoprofen, 2% Cyclobenzaprine, which is Flexeril, but again, it's being applied topically, so it doesn't have that much systemic absorption and effect. And also, they can add 5% Lidocaine, again, that's just for pain. My suggestion would be, when you're using those medications, to have them do the Lidocaine in a separate tube rather than mixing it into the medium that they mix the Ketoprofen and the Cyclobenzaprine because it costs a lot more to mix all three together. It's easier just to get the 5% Lidocaine separately. And they would apply it, just again, on the musculature, usually BID, twice a day. And that's what I would use also before I jump the gun and start decreasing the vertical. And one last thing that I have a patient do, again, I like to go down the natural route, so I have the patients go behind the pharmacy counter and ask for a product called Magnesium Citrate, which is a liquid version. If they drink the whole bottle, they have to be really close to the restroom because it's a laxative. And when the pharmacist dispenses it for them, it's not a prescription. They're going to look at them funny. But the patient would be instructed to take a tablespoon of liquid Magnesium Citrate at bedtime to just relax their muscles so that the patient, if nothing else, is not clenching against the appliance or, at the same time, just to relieve those muscles that are starting to get sore. Yes? The correct amount of? Vertical? OK. So when I finish, I'm going to talk about, in a case study, about vertical. So if you're asking me, what do I start with with vertical, everybody has different ideas on that. And your range can go from probably 4 millimeter, as minimal as you can get, up to 12 millimeter. But I'll discuss that more when I do the case study, is just how I determine vertical, if that would be OK. All right? The question was, do you take off the anterior deprogrammer and go back to the posterior pad contact? That's even. I don't. What I do, though, is, because it's a very muscle relaxing effect ongoing, and even though it might be transient, as long as I have posterior support to the TM joints, there's really no reason that you have to have that acrylic in the meantime. And you're only putting enough of a bead to disclude the posterior pads that were originally on the appliance. If you leave the amount that you had on in the back to get contact in the distal most portion of the distal second molars, if you had contact all the way through, and just either relieved or build up a little acrylic in the front, that's all you really need to do. And once they disclude those posterior pads, do you follow me? Once they disclude those posterior pads, there's no need that you have to replace that. But on the distal most portion of the second molar of the tooth. So what you're doing is you're relaxing the muscles that would be contracting if the first molar, the main clenching molar, and the bicuspids, which again contract the temporalis muscle, you're basically preventing those muscles from contracting by discluding their contact against the pads. That's the concept of anterior deprogramming, is to make sure that the elevator muscles are not contracting. So as it applies to appliance, you don't want the posterior pads to be in contact if the patient starts to develop some soreness and you're trying to troubleshoot as to what the issue might be. So one way to relax the muscles is to take away the contact in that middle section of the posterior pad all the way up to, if you have contact all the way through and no opening in the front, all the way up to the central incisors or the four incisors and just leave a little contact on the distal most part of the distal of the second molar, just to have some TMJ support. Okay, so how do we treat then some TM joint pain that shows up maybe as a transient side effect? So first of all, what we wanna know is it typically happens because the condyles have a relationship with, a different relationship with the retrodiscal pad that's behind it, which is the blood vessels and nerves that sit in the TM joint. It may have a different relationship with the disc that it typically saddles, the disc typically saddles the condyle. So there may be a change the way the condyle disc relationship is. And also there may be a change in the way the condyle is attached to the ligaments that are the elastin and the collagen ligaments that hold it in place in the joint space. So that's what you have to determine is when you're starting to have TM joint pain relative to the position of the condyle, what is the source of the issue? So it may be that you're rapidly advancing your appliance to the point, as I mentioned during the first lecture, that you can do larger increments of advancement or your rate of advancement may be too fast and it's starting to either strain the ligaments or move the condyle too fast in the joint space. Or in the end, again, if you look at my bottom reason why people have issues, instead of having too much vertical, you may have too little vertical. In between that, outside of too rapid advancement and too much incremental advancement, you may have uneven advancement. So this is why it's important that you always have to check the position of the appliance of the patient if you're having the patient do the adjustments on the appliance when you leave them after their first insert visit. You might have a discrepancy in the midline. So again, Dr. Adame mentioned about when you take your bite registration, you wanna make sure that their habitual bite that they close into normally is lined up properly when you take your bite registration. If you don't, when you make the appliance, then the upper and lower trays are not going to line up and you're gonna cause some TM joint strain toward one side or the other. And again, I'm a believer in having TM joint support, so there has to be some type of contact in the back of the appliance to support the TM joints. And then again, if you're doing a very thorough workup on the patient clinically, then you wanna make sure that there's no intracapsular issues that you missed from lagging on what would typically be an ideal TMJ exam or TMD exam in your first workup. So you have to make sure that you've covered all those bases before you put the appliance in place. If you look at just some basic anatomy of the TM joints to understand a little bit more what I'm talking about, so that's your condyle sitting in the joint space. It sits in the glenoid fossa. It has a disc on top of it, but it also has collagen and elastin ligaments connected to it that connect it to the ear canal, connected to other parts of the fossa. And whether it be the, this is also the lateral pterygoid. Again, it's just between the condyle and the coronoid process, which is in front of it there. So you have to understand the anatomy of the joint so that when you're making an appliance, and you can do this just by looking at your panoramic X-ray. You don't need anything over and above that. I have another X-ray though to show you because this is what I mean by having not enough vertical. So when you have an X-ray, and again, you can do this with your Panorex, you wanna look at the height of the eminence relative to the position of the condyle. You wanna look at the slope of the eminence relative to the condyle. And what the point of it would be is if you don't have a significant slope, and you have too much height, and you have inadequate vertical, then when you start to move the condyle forward, then you might eventually impinge the disc depending on where it sits normally when you do your workup on a patient. You might start to impinge the disc more medial to the head of the condyle instead of having it naturally as it saddles on top of the condyle, or you might start to posteriorly dislocate the condyle back into the retrodiscal tissue and start to cause some pain. So for that reason, you may start to have discomfort when the patient starts to advance the appliance because you don't have enough vertical. So you have to look at that when you look at your panoramic x-ray to make sure the anatomy predisposes to have minimal vertical over a little bit extra vertical to be able to clear the condyle from the height of the eminence or an eminence that doesn't have much slope to it there. So when we're trying to improve an individual that has some TM joint pain, some of the things we look at, so here's the thing that's a key. When people call in and say, I'm having this soreness in my jaw joint, the idea is not to stop the wear of the appliance if the patient is having benefit to the appliance. So before again, you jump the gun and stop have the patient using the appliance, you wanna find out that if they are having improvement with their snoring and they feel like they're getting a better quality, deeper sleep, they may have some REM catch up and start to have a lot of vivid dreaming, then try to treat the situation with the medication first. So it could be over-the-counter medication like taking some maybe for three, four, five, up to seven days, some over-the-counter ibuprofen or Tylenol on a regular basis. What we also use again is that same cream that has the ketoprofen and the cyclobenzaprine in it and the lidocaine applied to the joint space. If it's a real exacerbation, again, before we jump the gun and do anything more drastic, we'll have them use a Medrol dose pack, just a prescription Medrol dose pack right from the get go and see if it makes their symptoms go away because a lot of times it's just a transient flare up in their TM joint from just the movement of the condyle forward. So you don't have to jump the gun, hurry up and have them stop using the appliance or do anything different. Now, on the other end of it, one other thing that you can do is have them return the appliance back to the advancement position before they had their symptom. And usually it's just the turn right before they start to have the flare up. So if you advanced them 20 turns on a certain appliance and when they say I got to the 20th turn and I was on the 18th turn, I didn't have an issue, have them back up to the 18th turn and then when the symptoms resolve, and if the symptoms resolve, then you can have them start to move forward again with their advancement, but do it so in a fashion where it's smaller increments with more of a period of time between increments and see if that continues to allow them to advance without having any recurrence of symptoms. Then we talked about if the bilateral advancement on the mechanisms or just the advancement in general, if it's an appliance that has a bilateral advancement mechanism, when they adjust the appliance on both sides, you'd be surprised when they're doing it on their own and we have our patients do their own advancements. We give them a schedule, we tell them how much and when to advance their appliance, but you have to check and make sure that they're advancing their appliance evenly on both sides. If they're not and they have uneven advancement, of course they're gonna have the possibility of having joint strain in their TM joints. So when they come in and they, again, you're looking for the source of the problem, check the advancement, have one of your assistants check the advancement or you check it yourself to make sure that they have advanced evenly. If they haven't, then you send them back to the correct advancement position that's even and then again see if their TM joint symptoms go away. And then as we mentioned with the dental midline, if the dental midline does not line up, if you take out the appliance, have them bite down, see what their habitual bite is and see that their dental midline, their deviation might be two millimeters to the left or two millimeters to right of having the central incisors on the top and bottom perfectly line up. If that is the case but you took a bite registration where you lined up the central incisors on the top and bottom that it looked like they lined up perfectly but that's not their natural habitual bite, then when the appliance is made it's gonna be made two millimeters to the right or two millimeters to the left and again it's gonna cause some TM joint strain. So make sure that you're lining them up when you take your bite registration with a habitual bite that is what is normal for them. If that's not the case, unfortunately you'd have to take a new bite registration and send your appliance back and have them take it apart and realign the appliance to fit your new bite registration at the correct midline. So I did mention about using the increase in vertical. So you have to keep that in mind as again your last resort if you've covered all these other potential sources for a problem and everything else checks out, you've used medication just again on a short term basis to see if it clears up their symptom and then they still seem to complain that when they advance the appliance they have some discomfort, then you have to consider you may want to again refer to your panoramic x-ray and look at the position of the condyle against the distal slope of the eminence. So another thing that you'll do which I'll cover later is if a patient has a click when you do an initial workup on their TMD, it's not again something that's a panic but that can be an indication for you that the initial position of their disc in their condyle disc relationship is not where it should be and then when you start to advance the appliance, again what does the click mean when they open? The click means when they open that their disc is receding back on top of the head of the condyle where it should be. So when you start to move the condyle forward with advancement with minimal vertical, that disc may be pinned initially and then when you start to move the condyle forward with a little bit of opening, then you may be starting to pin the disc against the distal slope of the eminence and cause some pain or on the other end of it cause the condyle to be pushed posteriorly into the retrodiscal bundle of nerves and blood vessels and cause some discomfort. So if we look at some of the other maybe less common symptoms, tinnitus, again ear ringing, that primarily involves what we call the malleo-mandibular ligament or Pinto's ligament and that is connection of the ligament on the condyle to the malleus bone in the ear. This is pretty cut and dry. If they start to develop ear ringing, you really have no choice but to stop using the advancement. It's coming from too rapid or too excessive advancement so you have to discontinue use of the appliance and see if the ear ringing goes away. If the ear ringing goes away, then you can start to use the appliance again, again not discouraging the patient that this is gonna be something that's gonna persist but have them start to advance the appliance again in smaller increments over a longer period of time and see if you can get past having the tinnitus reoccur. Tooth mobility. So there's a couple things that you have to, again as I go back to that same workup, you wanna make sure that you've done a good periodontal exam just like you've done a good TMD exam and the most important thing about tooth mobility is to make sure you identify during that first periodontal exam as part of your dental workup with the patient that they don't have any preexisting mobility. So beyond that, if they do not, then it may be caused that they're having tooth mobility because of the forces applied by the appliance. So we know, especially with say a hinge appliance, that a hinge appliance puts a lot of force against the incisor teeth. We know from the literature that there can be a inclination of the central incisors on the maxillary arch and a protrusion or proclination of the lower incisors on the lower arch and a lot of that happens with a hinge appliance because of the pull effect of that appliance. So that may be causing movement to the teeth that wasn't there before. Also, let's see here. And also, what you might see is when the patient is not following your instructions, which you specifically outline in their informed consent that they have to do, and in our case, as I explained, we have them do jaw muscle exercises as a precursor to using an aligner, an appropriate aligner. If they're not doing those things and the bite's not resetting, then what you might notice over time is as they start to bite down and their bite hasn't been reset, they might start to develop what we call some occlusal trauma. So we all know what that is. You may have a premature contact on a tooth that previously didn't have a premature contact because that tooth hasn't settled back into the habitual bite that they should be returning to if they're doing their exercises and using their aligners. So they might start to have a mobility develop on that tooth that they really shouldn't. Going the wrong way. Okay, so in order to, again, get past that, if we had determined that, oops, we forgot to do a good periodontal exam and there was some existing mobility in a tooth, then we may have to consider disbanding treatment with the appliance because we feel that we missed something in that initial exam that's causing a lot of tooth mobility because it just doesn't happen overnight when you're using an appliance if you notice generalized mobility or there's generalized mobility through a lot of the teeth. Again, you may have to switch an appliance out and every once in a while we may do that where we find if a patient's using a hinge design and they're starting to get some movement in their anterior, the single-rooted anterior incisors, we may have to consider right from the get-go disbanding using that appliance and maybe going to a different appliance. If you have just a patient coming in and say, my two central incisors on the maxillary arch start to feel like they're loose ever since I've been wearing this appliance, it may be, and if you again remember some of the ideal things that appliance has to have as part of that effect of appliances, one of them is the ability to adjust the appliance, you may be having just some excessive force on the teeth that you have to just adjust the acrylic off of those teeth that are causing some initial mobility because they're just too tightly adapted against the appliance. And then finally, again, as I mentioned, you have to encourage them to do what you tell them to do as you have outlined in the informed consent as they have signed and you have witnessed that they have to do what you tell them in terms of jaw muscle exercises and using a morning aligner to reset their bite so they don't have the chance of having occlusal trauma. So another thing that we might experience over time are open contacts, and again, this can be reversible if you catch it soon enough. So when you do your initial workup, I don't know how well that was covered initially, I might've missed that, but when you're doing your initial workup on a patient, you must floss through every contact around the mouth, upper and lower arch to document if there's any open contacts pre-appliance. Then as you're seeing patients on follow-up, you tell them if you start to notice any areas where you're catching more food between your teeth than you did initially, I need to know about that, or when you do your follow-ups on patients, six months and on an annual basis after that, if you start to notice that there's open contacts, then as soon as you can catch it, you want to be able to identify what is causing the issue. So it may be that, again, as you remember, the effective appliance has to cover all the teeth. You have to cover all the teeth, including the most distal part of the distal teeth that are in the upper and lower arch. So if that isn't the case, then you may have some separation between the teeth that are covered and are being moved by the appliance, or at least with force against the appliance and those that are not covered. Then there's clasps that are placed, ball clasps between the teeth to retain the appliance. So you may have to consider that it's the placement of the clasp. And also, when the patients do clinch on the appliance, they start to wear either the acrylic or the soft liner, and you can start to develop space between the acrylic or the soft liner and the teeth, which gives them room for the teeth to move and separate and cause the open contacts. So what do we do as management if we can identify what the issue is? So first of all, if we didn't cover the entire appliance, all the teeth with the acrylic material of our, or whatever the material may be of our appliance, then we may have to jump ship using that appliance or have that appliance reconstructed to cover all the teeth, for one. Secondly, if we have offending clasps, so most of the clasps are retained from the buccal and proximal areas, we may wanna get a buffalo knife and start bending those clasps out where there's an open contact to prevent that as the patient is closing down, again, if they have posterior pads and closing down so that clasp is not pushing between those two teeth where it is in the interproximal area that's separating the teeth. So we start to bend the clasps out in those areas and see if that'll allow those teeth to drift back together. We also want to possibly adjust the contact on the posterior pads in the area where the clasps are engaged between the teeth. So if you have, say, between number 29 and 30, an open contact that develops that wasn't there pre-appliance, if you've already bent the clip away, it doesn't seem like it's changing anything, you can actually take the contact off of the opposing pad so if the patient is clenching, they're not putting force against that clip, even though you've bent it away, or even if you don't bend it away in that area, and again, see if those teeth may, again, drift back together. And, of course, one other thing that you can do in the end is to have the patient, again, follow your instructions using the repositioner every morning and doing the exercises that you mentioned to make sure that they're not the reason that you're having these open contacts because you're getting functional forces put on the teeth that are related to having the bite not be set back into its habitual position. One other thing that you want to look out for is when the patient is clenching over time, especially on follow-up, you may notice if you put an impression tray over teeth, and you know how much play you have before you put impression material in the teeth, you know how much play there is between the teeth and the impression material, how much space, if you put an appliance in place and they're grinding and clenching on it over time, and you start to get that tray and you can actually move it, then you know that there is space between the acrylic or the soft liner and the tray. And if they're starting to develop movement in the teeth, the teeth aren't contacting like they used to, or there's a lot of open contacts, then it's really time that you're going to have to replace that tray, kind of fill that in. You may not be able to reverse the open contacts at that point, but you certainly don't want it to get any worse. And that happens probably more with soft liners than it does with hard acrylic liners because the soft material has a tendency to wear more than the hard acrylic. So clenching, bruxing, a little bit different than what I mentioned before. So initially, when you put something over somebody's teeth, the first thing that their brain's going to say is we've got this foreign body over top of our upper and lower teeth. I think we're going to clench down on it just for the sake of it because it's a nice clenching surface. So that might happen initially when you first put the appliance in place. And again, that'll pass. Another thing, again, the brain recognizes just as if you had a premature contact with a tooth and the brain recognizes that and it starts gnawing on that premature contact to get it to go away. It's the same thing with your pads. If your pads are uneven, say you have just contact on the molars of a left side posterior pad and nothing else touches and you haven't checked those pads, then just naturally you start to clench against that to try to wear down that high spot on the pad. And that makes the patient clench and the patient is aware of it. And then finally, you have to identify is there some other reason that the patient is clenching and it's not related to the pads and it's not related to the fact that it's just a foreign object because it's past that point. And it may be the fact that the patient is taking certain stimulants or medications, I'll talk about that when we finish up here, that is causing them to clench as a side effect of using that medication or that stimulant. So what do we do? So again, if the patient is clenching relative to the fact that the pads are uneven, we want to make sure we adjust the contacts bilaterally and from front to back so that that is not a stimulus for the patient to clench their teeth. If they're clenching and they can't seem to get away from clenching their appliance and it's ongoing, then again, we can eliminate all the contact on the pad as we mentioned before, the anterior deprogrammer concept. Again, just leaving a little bit of contact in the most posterior part of the pads and just eliminate everything in the middle. And the reason you're doing that is because the anterior deprogrammer concept is that it reduces the intensity of the clench, maybe to the point that the patient doesn't recognize that they're clenching anymore. So when you put an anterior deprogrammer on her, nothing's gonna stop someone from clenching their teeth, absolutely nothing. I do TMD treatment, nothing stops the patient from clenching their teeth unless you inject their muscles with Botox because it's gonna weaken the muscle and doesn't have enough strength to clench. They're still gonna try to clench, but there's no intensity to it. So you're not gonna stop them from clenching, you're trying to deter it to the point where they don't recognize that they're doing it anymore. So if you eliminate all the contacts from the central incisors, if you had contact all the way through the top and bottom trays, only back to the point of the second molars, eliminate everything in between, then the intensity of the clench by the anterior deprogrammer concept may decrease it to the point that they don't recognize it. And so this is another unique thing that you can continue to do. If they say they're clenching their teeth, we know by the literature it says if you advance the appliance 50% of the maximum horizontal range of motion, the patient will decrease the frequency of them clenching. If you advance it 75%, they'll further decrease the frequency of their clenching. Again, maybe to the point where they don't recognize that they're doing anymore. So it may be that continued anterior advancement may help them stop to continue the clench or Brux habit. Again, one of the things that I mentioned as to the source of it may be that they're using some stimulants or meds. I'm gonna talk about that at the end so I won't make a comment on that now. One of the reasons that, one of the sources of clenching a lot of times is the patients are in the supine position. So we know that if a patient lays in a non-supine position that they decrease their clenching. So it may be a suggestion to them that if they can position themselves non-supine, it may decrease also the fact that they are clenching or Bruxing. And if we know that the patient is a lateral Bruxer, not just an anterior clencher, and our appliance hasn't allowed for that, and we kind of missed that when we did our dental exam and saw that there were wear spots on the cuspids, we may have to change the design of the appliance to allow them to go ahead and laterally Brux. Occlusive bite changes. So again, these can be short-term, but we know in the literature it says that long-term use of an appliance can cause changes to the way the teeth come together. We can document this from our initial examination, we can document this from taking a bite registration with models that we have as backup, but this can happen and this certainly happens due to forces, as I mentioned in the first lecture, that are applied to the teeth from the different designs of the appliances. And again, trying to minimize this as much as possible. You're talking about doing aggressive jaw muscle exercises and the realignment with a morning aligner, or you can all together, you tell the patient this is inherent as we discussed in the informed consent. With the use of an appliance, you can discontinue use of the appliance so nothing changes any more so, or you can use a different design of the appliance because even though they've had some changes, with certain designs you're gonna get less force on the teeth, especially in areas where you've noticed that the bite has changed, or they can go to second phase treatment and do some orthodontics to put their bite back into what they felt was their original habitual occlusion. So let's talk a little bit now about some of the less common side effects that you may see, and again, this is no reason, even though it sounds drastic, for you to abandon SHIP or for the patient to abandon SHIP using the appliance, you just have to understand why it might happen and what you can do in order to counteract the effect that has happened. So you may have what develops over time, and we all experience this here and there, a unilateral posterior open bite, usually in the molar area, and this can happen for two reasons. One, either the lateral pterygoid muscle goes into spasm, and on the side that it goes into spasm, it'll separate the molars, or you may have a disc, God forbid, but you may have a disc where you've actually done a favor to the patient that has relocated that was originally dislocated, and again, by our initial examination, we may be able to identify that the patient does have a dislocated disc, and from moving the mandible down and forward, we may have created enough joint space for that disc to relocate, and all of a sudden, their molars don't separate because now they have something between their condyle and their fossa that they didn't have before. So if it's related to a lateral pterygoid spasm, then we can do a couple different things, some real aggressive lateral pterygoid exercises. Again, I'll go over them right at the end. We can use a device called a Aqualizer. An Aqualizer is something that we can use to release or relax a muscle spasm. It's basically a fluid-filled, you can call it a device that fits over top of the teeth, and when they bite on it, it's almost like a waterbed for the teeth. It will balance the occlusion to the point where it can relax all the musculature in the face. It's kind of like the poor man's version of doing neuromuscular dentistry, but it does give you a instant more relaxation or a release of a muscle and spasm if the patient uses it and uses it consistently in the way you've described. And usually, you only have to use it for a day to get an effect that you're looking for. Or again, you can employ a short-term muscle relaxer. It can be a prescription, but again, it's short-term, just within a day or two to see if it might release that tight lateral pterygoid muscle spasm. Or if you really want to not get involved but you're a little bit in panic because their bite has opened unilaterally, you can refer to a PT and have them do their therapy to relax the lateral pterygoid and change the posterior open bite. If you have a recaptured disc, then the patient has two options. One is they can move their appliance back to the position, and typically what'll happen is the disc will dislocate again. Or you can tell them, I've actually done you a favor. I've relocated your disc on top of help making you breathe better, and you just have to understand that I've done something for the long-term better for your TM joint, but I've caused an open bite in your back teeth. So you have to weigh what the benefit is to you of progressing forward with your oral appliance therapy, knowing that your TM joint has been restored to better health or abandoning treatment to the point where your disc will dislocate again and their molars will touch, and then they wouldn't use their appliance any further. A bilateral posterior open bite, that sounds really bad, but it can happen, and it does happen. And again, it can be short-term if it's identified early enough, or it can be long-term if we don't see the patient for a period of time, and they don't let us know about it in the meantime. And again, when we're moving muscles forward, we're moving muscles that are tight and shortened in order to maintain the mandible forward, so that can cause some significantly tight muscles to the point that if we don't loosen up those muscles and use our aligner to move that jaw back, then we can have literally the mandible move forward to the point that the posterior teeth, and particularly the molars on both sides don't touch, but it can go as far forward as the bicuspids. Again, certain appliances, particularly the hinge type, put a lot of pressure against those incisors and can tip them, the upper one's inward, the outer one's outward, and change the overbite to the point that the back teeth will not touch any further because the front teeth now are touching in a different overbite relationship. And then, as I mentioned in the first lecture, you can have a fluid buildup in the TM joint because if you're using an appliance that's very static in the way it holds the jaw forward, and there's no circulation of synovial fluid in the TM joint, then you can get a buildup of fluid in the joint, and when you try to reseat the condyles in the morning, there's that fluid in the joint and you can't quite seat the condyles, so the mandible stays a little bit more forward and you can't close your teeth back into their habitual bite. To manage this, again, what we do, especially if we feel it's related to musculature and they haven't been using their exercises, then we start to employ some more exercises to relax more so the posterior temporalis muscle and the posterior digastric muscle, which are two muscles that are used to retrude the mandible, so we give them some more specific exercises beyond the ones we normally give them for the masseter and for the pterygoid muscles, and they're simple exercises, but it helps retrude those muscles that are tight to try to bring the lower jaw back, and it seems to work pretty well. Another thing you can do is if you have the models of your teeth, that you save the models, you can actually make a new aligner because they can't get back into the aligner that they had, or if their aligner had distorted, you can actually get their models, make a new aligner just by articulating the cast, and you can either gradually, kind of like using Invisalign, gradually have them use an aligner that you slowly have them bring their bite back with the different aligners that you make in different positions of how you articulate the cast to the point where they can slowly move their jaw back into position, which was their original habitual bite, so we've tried things like that, too, when that happens, and you can have some success with that, too. And then, again, trying to have the patient use their exercises and their repositioner not just in the morning when they take their appliance out but in the evening before they put it in place, but also they can use it more frequently and they can use their aligner longer during the course of the day. To me, the best time for them to use their aligner and do their exercises is you like to have a period of time between the use of the two, but when they get into the shower in the morning and they have some nice warm heat on their face and they do some stretching exercises and then they wait a few minutes and put the aligner in place, that's probably the best environment for having warm, moist teeth and those tight muscles and then putting the aligner in and trying to seat the condyles back into their normal bite. One other thing that you can do is to do what we call levering. You can get a tongue blade and put a tongue blade between the lingual of their central incisors and the facial of their lower incisors and typically as they're levering, trying to push the tongue blade backwards to bring the lower jaw forward, which they can't do because it's connected to the skull, but it helps them lever the lower jaw back and trying to seat the condyles that way. So that's another attempt or else, again, if you don't want to have to give the patient instructions on your own, you can refer to PT. And finally, talking about a TM joint lock, again, not something that you have to just feel that you've done a disservice to the patient, but occasionally you'll have a situation where you might see that the disc in the patient's jaw joint will dislocate because the condyle repositions itself different in the fossa or it might be related to the disc that dislocates because you have a lateral pterygoid spasm. So if your patient calls up and says, my jaw is locked after I use the appliance, when I wake up in the morning, what can I do? The first thing that they can do is to take their lower jaw, open it slightly, move it as far forward as they can, move it to the left, move it to the right, and probably nine times out of 10, they'll unlock their jaw. That's a quick and easy way to have them re-unlock their locked joint that they didn't have prior to using their appliance that night. Another thing you can do is have them get a couple Popsicle sticks and on the area where they're locked, if they're locked on the left side or locked on the right side, just put a couple Popsicle sticks on the most distal molars, usually the second molars, have them bite as hard as they can at about a two or three thickness of Popsicle sticks or tongue blades and squeeze as hard as they can. They're basically trying to torque the jaw and open up the joint space to allow that disc to have freedom to be able to unlock itself. We talked about the lack of vertical when we make an appliance and we unknowingly have a minimum vertical distance in our bite registration. And again, one thing that can happen if you have a patient that had a click in their TM joint when you did their initial workup and then you start to move them forward and you're only opening them slightly if their disc was dislocated initially. So again, if they're opening up their bite during the course of putting an appliance in and or even when you do the workup on them and when they open up their bite and they have a little click in their jaw joint early opening, so that means that their disc is dislocated more forward of where it should be and soon as they start to open initially, their disc is slipping back on top of the head of the condyle. So when you put an appliance in place and they start to move down and forward but only with certain vertical, it doesn't give that disc enough room to clear to reposition itself and that click won't return because the disc won't relocate back to where it should come from. So you're literally pushing the condyle against the disc and locking the disc forward and that's causing a joint lock. So again, that would be an indication where when you've done everything else and nothing is unlocking it, that you may want to consider quickly increasing the vertical of the appliance to give them more room to, again, because of the height of the eminence or the lack of slope of the eminence to give them more room for the disc to free itself. And again, you can use the Aqualizer to relax or release a tight lateral pterygoid that can pull the jaw to a position where it can actually lock the disc.

oral appliance

adverse events

excessive salivation

muscle soreness

TM joint concerns

xerostomia

tinnitus

tooth mobility

open contacts