Although a discussion of movement disorders of sleep is not the focus of this article, as previously stated, 26% of TMD patient will likely have two sleep disorders1 so it was not surprising for LY to report these subjective complaints. The recommended protocol for managing RLS requires assessment of serum ferritin levels which we determined were normal (>50 ng/mL), hence, she was prescribed ropinirole, a dopamine agonist, which completely eliminated this “movement problem” and certainly contributed to the success of her treatment.
The Clinical Assessment
High tongue posture (Malampatti IV), crenations on the lateral borders (enlarged tongue), the tongue are coated due to mouth breathing. I asked LV if she awakened with a dry mouth to which she responded, “Yes, because I cannot breathe well through my nose”. It should also be mentioned that some time after LY’s initial assessment that her PCP determined that she had developed hypertension and was given a prescription for hydrochlorthiazide. Over time, it was determined that the hydrochlorthiazide improved her HTN but insufficiently; consequently Tenormin was also prescribed concurrently with good results.
LY’s high upper airway (HUA). The CM assesses patency and adequacy of size of the nasal valves. The internal nasal valve area is the narrowest portion of the nasal airway, thus assessment of this region is valuable. LY showed significant nasal valve collapsibility so we elected to perform AR The nasal valve area when assessed with AR was shown to be very reliable in estimation of nasal airway volume at the level of the nasal valve.
Acoustic Rhinometry Assessment Of High Upper Airway (HUA)
Extraoral Examination This view from the side shows a retruded underdeveloped mandible. Neck: cricomental space In addition to retrognathia LV also displays a reduced cricomental space, i.e. the area and volume of space in front of the neck and below the jaw often seen in the OSA subject. Evidence shows that a cricomental space of <1.5cm is a risk factor for OSA.6
Malampatti Grade: Risk factor for SRBD A high Mallampati score is well accepted as a risk factor for obstructive sleep apnea especially if it is associated with nasal obstruction. The association of a high Mallampati score and nasal obstruction warrants the attention of the sleep specialist.14-16
Nasal airway assessment: Cottle Maneuver & Acoustic Rhinometry (AR)
Intraoral Examination
The intraoral examination revealed dental arches, which had previously been treated with extraction orthodontics. Mandibular range of motion was relatively normal; there were noticeable wear facets on many of the teeth consistent with her history of sleep bruxism. PAGE
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LY had informed us that she often awakened in the morning with a dry mouth; she thought that it might have something to do with her inability to breathe through her nose. The literature is in agreement as we noted above. Furthermore, in the non-obese patient, nasal airway function may be a significant component of SRBD.17 Acoustic rhinometry (AR) may be a useful screening tool in the evaluation and treatment of the SRBD patient. We performed a Cottle Maneuver (CM) for our initial clinical assessment of
The Cottle Maneuver as a simple screening tool had proven productive. The Rhinometric exam seen above revealed significant obstruction at all levels of the high upper airway on both the right and left sides. We provided a decongestant for the LY after the first AR test and waited 5 minutes until retesting.
Radiographic Assessment: right and left TM joints, lateral views Cone Beam Computerized Tomograms (CBCT) images of TM joints: lateral view The right mandibular condyle displays regressive changes; the left mandibular condyle shows evidence of degenerative changes; both condyles are retruded excessively in the fossa. This is consistent with LYs history.