TMJ\Sleep Clinical Decision Matrix based on Objective Evidence
Introduction: There are a number of decisions many clinicians make with regard to patients with craniofacial pain and sleep related issues that could be enhanced and\or supported by objectively measuring the jaw EMG musculature. It is widely understood these issues are sometimes related and at other times are not related. To further complicate sometimes sleep and jaw-EMG problems exist as two separate issues or one is masked by the other.
For example, a 48yo male patient, BMI 33, is in your office complaining of jaw pain, regular headaches, damaged teeth, and jaw clicking and excessive daytime sleepiness (EDS).
- Are the headaches from hypoxemia or bruxism?
- Is the EDS from chronic pain or OSA?
- Does a relationship exist between apneas and teeth grinding?
We propose to measure these types of patients with an HST which includes jaw EMG monitoring to objectively measure the status of these complex complaints. However because there is not a large body of evidence on these types of patients we would like to propose the following:
The purpose of this document is to standardize criteria of bruxism\Jaw EMG activity for data collected in the home environment using typical HST equipment and associated software.
Monitoring jaw EMG during sleep can provide critical insight into a patient’s condition as it relates to TMJ, jaw pain and sleep complaints. Moreover, progress can be measured during the therapeutic process over time to correlate with patient feedback.
Measuring the jaw muscle while the patient is awake many times does not measure the problem but rather measures the patient’s ability to respond to a verbal command to use the jaw muscle. The issue as it relates to TMJ is largely an involuntary muscle problem. Moreover, much of the activity which causes tooth damage and TMJ symptoms occur while the patient is asleep or sub-consciously. For these reasons, it makes sense to measure the issue during sleep.
Another reason to standardize scoring of jaw EMG activity is to categorize the physiological environment in which these jaw EMG events occur. For example, some EMG events occur in apparent isolation, no obvious trigger or observed association, while other jaw EMG events appear to be caused by other events occurring in relative close temporal proximity. Many of us are tempted to associate a causal effect. With enough observed and standardized data, we believe good data can be used to make more effective clinical decisions.
Previous work in this area by Gilles Lavigne and others have yielded basic event types
Phasic, Tonic and Mixed which have gained acceptance but is not typically measured, even in the attended sleep lab environment. The reasons for this are outside the scope of this document but I call upon the leadership in dental sleep medicine and craniofacial pain to come together and coalesce around the idea that collecting this data can be routine and of immense benefit to treat patients with some combination of these disorders.
Sample events described by Giles Lavigne et. Al. top-Phasic, middle-Tonic, bottom -Mixed
In addition to Phasic, Tonic and Mixed events we propose another criteria for categorizing jaw EMG activity which takes into account the overall physiological environment in which these events occur.
In order to achieve a more complete physiological environment more data needs to be collected and we collect the following parameters:
- Heart Rate,
- Pleth waveform,
- 2 channels of respiratory effort (RIP) ribcage and abdomen,
- Body position,
- Audio recording (snoring and tooth clicking),
- Pressure nasal\oral flow
- Actigraphy – predicts movement associated with arousal-wakefulness
- 2 channel amplifier – user defined (ExG)
It is important to remember the average patient with limited instruction can successfully collect this data. Technically speaking this type of data was only available in the sleep labs which in of itself presented a barrier to the majority of clinicians treating patient with craniofacial pain and\or TMJ issues. HST technology has advanced sufficiently to allow for both the jaw EMG and HST parameters to be collected. These advancements will contribute to the success of dentist practicing sleep medicine and craniofacial pain clinics as the Sleep\TMJ link can now be monitored by a specialist on patients using HST technology.
Glossary of Jaw EMG Activity
ISOLATED GROUP – No observed proceeding event
ASSOCIATED GROUP – The Jaw EMG event occurred during any type of respiratory event or within 5 seconds after a respiratory event. Often times occur with other types of EMG activity associated with a respiratory event.
Summary: The purpose of this document is to develop clinical decision support (CDS) matrix based on objective evidence from a fairly large body of evidence. The CDS recommendations will be born from experts reviewing the type of data contained in this document collected in the home environment using controlled data collection techniques.
Jeffory Wyscarver, RPSGT
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