Dental Sleep Medicine: A Clinical Guide

Description

This book is designed to enable dentists to understand various aspects of dental sleep medicine, and to recognize the signs and symptoms of sleep disorders in their patients. It discusses potential negative impact of a sleep disorder on oral and systemic health, and shows how to collaborate with others in order to implement appropriate patient management. The first part of the book concentrated on the scientific background of sleep medicine in connection to dentistry covering the physiology of sleep, classifications of sleep disorders, their diagnosis as well as medical and dental comorbidities. The second part of the book is dedicated to clinical applications like CPAP therapy, oral appliance therapy, surgical procedures and adjunct therapies. Last, the future of dental sleep medicine is discussed. Each chapter is written by specialized researchers and clinicians in the field making the book a useful guide for dental clinicians all around the world. Foreword Preface Contents Part I: Science/Research 1: Metascience in Dentistry and Medicine 1.1 Introduction 1.2 Metascience 1.3 Defining the Bibliome 1.3.1 Stating the Question 1.3.2 The Analytic Framework 1.4 Capturing the Best Available Evidence 1.4.1 The Level of the Evidence 1.4.2 The Quality of the Evidence 1.5 Analysis 1.5.1 Acceptable Sampling 1.5.2 Overarching Statistical Significance 1.5.3 Clinical Relevance 1.6 Reporting and Dissemination 1.6.1 Dissemination for Clinicians and Researchers 1.6.2 Dissemination for Patients and Caregivers 1.7 Biases and Fallacies in Clinical Decision-Making 1.7.1 Cognitive Biases 1.7.2 Fallacies 1.8 Implications for TMJ and Airway Disorders in Dental Sleep Medicine 1.8.1 Obstructive Sleep Apnea 1.8.2 Obstructive Sleep Apnea and Cognitive Decline 1.8.3 Obstructive Sleep Apnea in Children and Young Adults 1.9 Conclusion References 2: Physiology of Sleep and Diagnosis: Basic Information for Dentists 2.1 Introduction 2.2 Generation and Maintenance of Sleep and Wakefulness 2.3 Basic Mechanisms Coordinating and Governing Sleep and Wakefulness 2.3.1 Autonomic Nervous System Balance During Sleep 2.3.2 Homeostatic and Circadian Regulation of Sleep 2.3.3 Interplay Between S and C Processes 2.4 Effect of Sleep on Organ Systems 2.4.1 Cardiovascular System 2.4.2 Respiratory System 2.4.3 Renal System 2.4.4 Gastrointestinal System 2.4.5 Thermoregulation 2.5 Selected Clinical Sleep Disorders 2.5.1 Obstructive Sleep Apnea (OSA) 2.5.2 Obstructive Sleep Apnea-Related Hormonal Dysregulation 2.5.3 Growth Hormone Secretion in Obstructive Sleep Apnea 2.6 Neurotransmitters for Wakefulness 2.6.1 Histamine 2.6.2 Acetylcholine 2.6.3 Dopamine 2.6.4 Glutamate 2.6.5 Serotonin and Norepinephrine 2.6.6 Hypocretins 2.7 Neurotransmitters for Sleep 2.7.1 Gamma-Aminobutyric Acid 2.7.2 Adenosine 2.8 Hormone Control of Sleep 2.8.1 Melatonin 2.8.2 Ghrelin and Leptin 2.8.3 Follicle-Stimulating Hormone and Luteinizing Hormone 2.8.4 Thyroid-Stimulating Hormone 2.8.5 Cortisol 2.9 Diagnostic Process 2.9.1 Diagnosis 2.9.2 Objective Testing 2.9.3 Polysomnography 2.9.3.1 Electroencephalography (EEG) 2.9.3.2 Electrooculography (EOG) 2.9.3.3 Chin Electromyography (EMG) 2.9.3.4 Masseter EMG 2.9.3.5 Leg EMG 2.9.3.6 Electrocardiogram (ECG) 2.9.3.7 Respiratory Parameters 2.9.3.8 Blood Oxygenation (Oxygen Saturation: SpO2) 2.9.3.9 Capnography 2.9.4 Sleep Stages 2.9.4.1 Stage Wake 2.9.4.2 Non-REM Sleep 2.9.4.3 REM Sleep 2.9.5 Sleep Cycles 2.9.6 Home Sleep Apnea Testing (HSAT) 2.10 Technical Aspects of Polysomnography 2.10.1 Machine Calibration 2.10.2 Biocalibration 2.11 Understanding Findings of a Polysomnography Report 2.11.1 Definitions of PSG Report 2.11.1.1 Total Recording Time 2.11.1.2 Sleep Latency 2.11.1.3 Total Sleep Time 2.11.1.4 Sleep Fragmentation 2.11.1.5 Sleep Efficiency 2.11.1.6 WASO and WASF 2.11.1.7 Rapid Eye Movement Latency 2.12 Stages of Sleep 2.12.1 Non-rapid Eye Movement Sleep 2.12.2 Rapid Eye Movement Sleep 2.12.3 Practice Implications 2.12.4 Insomnia 2.12.5 Parasomnias 2.12.6 Confusional Arousals 2.12.7 Sleepwalking (Somnambulism) 2.12.8 Sleep-Related Eating Disorders 2.12.9 Sleep Terrors (“Pavor Nocturnus” Incubus) 2.13 Basics of Sleep Hygiene 2.14 Sleep-Related Medications and Their Effect on Sleep 2.14.1 Benzodiazepines and Barbiturates 2.14.2 Gamma-Hydroxybutyrate (GHB) 2.14.3 Neuroleptics 2.14.4 Dopamine 2.14.5 Adrenergic Drugs 2.14.6 Recreational Drugs 2.14.7 Antidepressants 2.14.8 Antihistamines 2.14.9 Melatonin 2.14.10 Modafinil References Untitled 3: Current Classification of Sleep Disorders 3.1 Introduction 3.2 Insomnia 3.2.1 Chronic Insomnia Disorder 3.2.2 Short-Term Insomnia Disorder 3.2.3 Insomnia in Children 3.2.4 Other Insomnia Disorder 3.2.5 Isolated Symptoms and Normal Variants 3.3 Sleep-Related Breathing Disorders 3.3.1 Obstructive Sleep Apnea Syndromes 3.3.2 Central Sleep Apnea Syndrome 3.3.2.1 CSA with Cheyne-Stokes Breathing 3.3.2.2 CSA Due to a Medical Disorder Without Cheyne-Stokes Breathing 3.3.2.3 CSA Due to High-Altitude Periodic Breathing 3.3.2.4 CSA Due to a Medication or Substance 3.3.2.5 Primary CSA 3.3.2.6 Treatment-Emergent Central Sleep Apnea 3.3.2.7 Primary Central Sleep Apnea of Infancy 3.3.2.8 Primary Central Sleep Apnea of Prematurity 3.3.3 Sleep-Related Hypoventilation Disorders 3.3.4 Obesity Hypoventilation Syndrome 3.3.5 Congenital Central Alveolar Hypoventilation Syndrome 3.3.6 Other Sleep-Related Hypoventilation Disorders 3.3.6.1 Late-Onset Central Hypoventilation with Hypothalamic Dysfunction 3.3.6.2 Idiopathic Central Alveolar Hypoventilation 3.3.6.3 Sleep-Related Hypoventilation Due to a Medication or Substance 3.3.6.4 Sleep-Related Hypoventilation Due to a Medical Disorder 3.3.7 Sleep-Related Hypoxemia Disorder (SRHD) 3.3.8 Isolated Symptoms and Normal Variants 3.3.8.1 Snoring 3.3.8.2 Catathrenia 3.4 Central Disorders of Hypersomnolence 3.4.1 Narcolepsy Type 1 3.4.2 Narcolepsy Type 2 3.4.3 Idiopathic Hypersomnia 3.4.4 Kleine-Levin Syndrome 3.4.5 Hypersomnia Due to a Medical Disorder 3.4.6 Hypersomnia Due to a Medication or Substance 3.4.7 Hypersomnia Associated with a Psychiatric Disorder 3.4.8 Insufficient Sleep Syndrome 3.5 Circadian Rhythm Sleep-Wake Disorders 3.5.1 Delayed Sleep-Wake Phase Disorder 3.5.2 Advanced Sleep-Wake Phase Disorder 3.5.3 Irregular Sleep-Wake Rhythm Disorder 3.5.4 Non-24-h Sleep-Wake Rhythm Disorder 3.5.5 Shift Work Disorder 3.5.6 Jet Lag Disorder 3.5.7 Circadian Sleep-Wake Disorder Not Otherwise Specified 3.6 Parasomnias 3.6.1 NREM-Related Parasomnias 3.6.1.1 Disorders of Arousal Confusional Arousals Sleepwalking Sleep Terrors 3.6.1.2 Sleep-Related Eating Disorder 3.6.2 REM-Related Parasomnias 3.6.2.1 REM Sleep Behavior Disorder 3.6.2.2 Recurrent Isolated Sleep Paralysis 3.6.2.3 Nightmare Disorder 3.6.3 Other Parasomnias 3.6.3.1 Exploding Head Syndrome 3.6.3.2 Sleep-Related Hallucinations 3.6.3.3 Sleep Enuresis 3.6.3.4 Parasomnia Due to a Medical Disorder 3.6.3.5 Parasomnia Due to a Medication or Substance 3.6.3.6 Parasomnia, Unspecified 3.6.3.7 Isolated Symptoms and Normal Variants Sleep Talking 3.7 Sleep-Related Movement Disorders 3.7.1 Restless Leg Syndrome 3.7.2 Periodic Limb Movement Disorder 3.7.3 Sleep-Related Leg Cramps 3.7.4 Sleep-Related Bruxism 3.7.5 Sleep-Related Rhythmic Movement Disorder 3.7.6 Benign Sleep Myoclonus of Infancy 3.7.7 Propriospinal Myoclonus at Sleep Onset 3.7.8 Sleep-Related Movement Disorder Due to a Medical Disorder 3.7.9 Sleep-Related Movement Disorder Due to a Medication or Substance 3.7.10 Sleep-Related Movement Disorder, Unspecified 3.7.11 Isolated Symptoms and Normal Variants 3.7.11.1 Excessive Fragmentary Myoclonus 3.7.11.2 Hypnagogic Foot Tremor and Alternating Leg Muscle Activation 3.7.11.3 Sleep Starts (Hypnic Jerks) References 4: Cone Beam Computerized Tomographic Imaging for Sleep Disorders 4.1 Introduction 4.2 Radiographic Anatomy and Clinical Correlation 4.2.1 Sinonasal Complex 4.2.1.1 Nasal Cavity Nasal Valves Nasal Cavity Nasal Septum Nasal Turbinates 4.2.1.2 Paranasal Sinuses 4.2.2 Nasopharynx 4.2.3 Oropharynx 4.2.3.1 Soft Tissues Soft Palate Tonsils Tongue 4.2.3.2 Hard Tissues Jaws, TMJs, and Hyoid Bone Cervical Spine 4.3 Conclusion References 5: Medical Comorbidities of Obstructive Sleep Apnea 5.1 Introduction 5.2 Risk Factors for OSA 5.2.1 Genetics 5.2.2 Gender 5.2.3 Nasal Obstruction 5.2.4 Developmental or Congenital Narrow Airways 5.2.5 Smoking 5.2.6 Medications/Alcohol 5.3 Signs and Symptoms of OSA 5.3.1 Excessive Daytime Sleepiness 5.3.2 Snoring 5.3.3 Nocturnal Sweating 5.3.4 Nocturia 5.3.5 Decreased in Sex Hormones 5.4 Comorbidities 5.4.1 Obesity 5.4.2 Hypertension 5.4.3 Insomnia 5.4.4 Diabetes 5.4.5 Asthma 5.4.6 Gastroesophageal Reflux Disorder 5.4.7 Irritable Bowel Syndrome 5.4.8 Cardiovascular System 5.4.9 Trigeminal Cardiac Reflex 5.4.10 Arrhythmias 5.4.11 Stroke 5.4.12 Renal Failure 5.4.13 Metabolic Syndrome 5.4.13.1 Adiponectin 5.4.13.2 Leptin 5.4.13.3 Ghrelin 5.4.14 Chronic Pain 5.4.15 Sleep Apnea Headache 5.4.16 Mood Disorders 5.4.17 Alzheimer’s Disease References 6: Dental Comorbidities and Risk Factors of Sleep-Disordered Breathing 6.1 Introduction 6.2 Causes of OSA 6.3 Orofacial Risk Factors 6.3.1 Obesity 6.3.2 Narrow Airway Passages 6.3.3 Nasal Congestion/Obstruction 6.3.4 Mouth Breathing 6.3.5 Large Tongue 6.3.6 Tongue Scalloping 6.4 Bruxism and Related Conditions 6.5 Dental Clinical Signs of Bruxism 6.5.1 Attrition 6.5.2 Abfraction 6.5.3 Tori and Buccal Exostosis 6.5.4 Loss of Vertical Dimension 6.5.5 Soft Palate and Elongated Uvula 6.5.6 Tonsils 6.6 Malocclusion 6.7 Bicuspid Extractions and Maxillary Expansion 6.8 Temporomandibular Disorders and OSA 6.9 Headaches References Untitled 7: Sleep Diagnosis: Polysomnography and Home Sleep Apnea Testing 7.1 Introduction 7.2 Polysomnography: In-Lab Testing 7.3 Home Sleep Apnea Testing 7.4 Pros and Cons for In-Lab PSG Testing and HSAT 7.5 Most Private Health Insurance Companies Will Follow the Same CMS Criteria References Part II: Clinical 8: Examination for Dental Sleep Medicine 8.1 Introduction 8.2 Medical History 8.3 Dental History 8.4 Screening 8.5 Radiographic Evaluation 8.6 Nasal Evaluation 8.7 Evaluation of the Temporomandibular Joint 8.7.1 Joint Sounds 8.7.2 Jaw Movement 8.8 Muscle Examination 8.9 Intraoral Examination 8.9.1 Tongue Assessment 8.9.2 Tonsil Assessment 8.9.3 Tori 8.9.4 Nasal Evaluation 8.9.5 Airway Evaluation 8.9.6 Dentition References 9: Beneficial Effects of Continuous Positive Airway Pressure Therapy 9.1 Introduction 9.2 CPAP Therapy 9.2.1 Metabolic Syndrome 9.2.2 Alzheimer Disease 9.2.3 Seizures References 10: Dental Sleep Appliance Therapy for the Treatment of Obstructive Sleep Apnea 10.1 Introduction 10.2 History and Evolution of Dental Sleep Appliance Therapy 10.3 Definition of Dental Sleep Appliance 10.3.1 Mechanism of Action of DSA 10.3.2 Predictors of Success 10.3.3 Dental Sleep Appliance Design and Effects 10.4 Types of Oral Appliances 10.4.1 Over the Counter 10.4.2 Temporary Sleep Appliances 10.4.3 Tongue Retainer Device 10.4.4 Dental Sleep Appliances 10.5 Combination Therapies 10.6 Record Taking 10.6.1 Impression and Scanning 10.6.2 Bite Registration Techniques 10.6.2.1 George Gauge 10.6.2.2 Pro Gauge 10.6.2.3 SOMGauge 10.6.2.4 Andra Gauge 10.6.2.5 Airway Metrics 10.6.2.6 Pharyngometer 10.6.2.7 Phonetic Bite 10.7 Managing Side Effects Associated with DSA Therapy 10.7.1 Short-Term Side Effects and Management 10.7.1.1 Tooth Sensitivity 10.7.1.2 Temporomandibular Joint Dysfunction or Pain 10.7.1.3 Myalgia/Myofascial Pain 10.7.1.4 Joint Sounds 10.7.1.5 Salivation and Drooling 10.7.1.6 Tongue, Soft Tissue, and Gingival Irritation 10.7.1.7 Dry Mouth 10.7.1.8 Bite Instability 10.7.1.9 Interproximal Gaps 10.7.2 Long-Term Side Effects and Management 10.7.2.1 Bite Changes 10.7.2.2 Bite Exercises/Morning Repositioners 10.8 Long-Term Follow-Up 10.9 Adherence 10.10 Health Outcomes References Untitled 11: Surgical Approaches to Treatment of Obstructive Sleep Apnea 11.1 Introduction 11.2 Surgical Treatment of Obstructive Sleep Apnea 11.3 Nasal Surgery 11.4 Palatal Surgery 11.5 Base of the Tongue and Hypopharyngeal Surgery 11.6 Transoral Robotic Surgery 11.7 Skeletal Surgery 11.8 Hypoglossal Nerve Stimulation References 12: Adjunctive Therapies for Dental Sleep Appliances 12.1 Introduction 12.2 Positional Therapies 12.2.1 Positional Obstructive Sleep Apnea: Prevalence and Definitions 12.2.2 Mechanisms of Action of Positional Therapies 12.2.3 Efficacy of Positional Therapy 12.2.4 Compliance with Positional Therapy 12.2.5 New Generation Design Modifications 12.2.6 Combinations of Positional and Dental Sleep Appliance Therapy 12.2.7 Efficacy of Combination Dental Sleep Appliance and Positional Therapy 12.2.7.1 Active Devices 12.2.7.2 Passive Devices 12.2.8 Modifying the Dental Sleep Appliance to Counteract Positional Apnea 12.2.8.1 Practice Points 12.3 Positive Airway Pressure as an Adjunct Therapy for Dental Sleep Appliances 12.3.1 Continuous Positive Airway Pressure 12.3.2 Expiratory Positive Airway Pressure 12.3.2.1 Definition 12.3.2.2 The Rationale for EPAP Therapy 12.3.2.3 Mechanisms of Action of Expiratory Positive Pressure Devices 12.3.2.4 Efficacy and Compliance with nEPAP Therapy 12.3.2.5 Efficacy and Compliance of oEPAP Therapy Practice Points 12.4 Adjunct Therapy for Anatomical Compromise in Dental Sleep Appliance Therapy 12.4.1 Surgery as an Adjunct Therapy 12.4.2 Drug-Induced Sleep Endoscopy for Assessment of Airway Collapse and Prediction of Treatment Outcomes in Dental Sleep Appliance Therapy 12.4.3 Improving Compromised Nasal Airway Anatomy 12.4.3.1 Behavioral Modifications 12.4.3.2 Intranasal Medications 12.4.3.3 Nasal Dilators 12.4.3.4 Nasal Surgery 12.5 Improving the Compromised Oropharyngeal Anatomy 12.5.1 Soft Palate 12.5.2 Tongue 12.6 Obesity 12.6.1 Dietary Interventions 12.6.2 Bariatric Surgery 12.6.2.1 Practice Points 12.7 Adjunctive Therapies for Sleep Quality During Dental Sleep Appliance Therapy 12.7.1 Insomnia 12.7.1.1 Comorbidity of Insomnia and Obstructive Sleep Apnea Cognitive Behavioral Therapy for Insomnia Sleep Restriction Therapy Stimulus Control Therapy Sleep Hygiene Psychoactive Substances Caffeine Alcohol Nicotine Relaxation Therapy Exercise Pharmacological Agents 12.8 Circadian Rhythm Disorders 12.8.1 Chronotherapy 12.8.2 Bright Light Therapy 12.8.3 Melatonin 12.8.3.1 Practice Points References 13: Oropharyngeal Development Through Dental Orthopedics and Orthodontics 13.1 Why Do We Have a Problem? 13.2 Facial Changes from Lifestyle Changes of Agriculture and Industrialization 13.3 Example of Face Falling Back with Growth 13.4 What Is Commonly Recommended for OSA in the Orthodontic Literature? 13.5 What Should Be the Focus of Orthodontics in Treating the Airway? 13.6 Orthodontics Traditional Focus on the Anteroposterior Plane of Space 13.7 Tools to Evaluate Jaw Position to Optimize Facial Balance/Airway 13.8 Retraction Reducing the Airway 13.9 Practical Application of Treatment to Optimize Facial Balance and Airway Size in Varying Ages and Situations 13.10 Treatment in the Primary Dentition 13.11 Treatment in the Early Mixed Dentition 13.12 Treatment in the Permanent Dentition 13.13 Missing Lateral Incisor Teeth in Adolescents 13.14 Adult Class II Nonsurgical Correction 13.15 Adding Extra Bicuspid Teeth 13.16 Reopening Extraction Spaces 13.17 Class II Camouflage Treatment 13.18 Surgical Correction of OSA with Double-Jaw Advancement Surgery 13.19 Palliative Solutions 13.20 Alternatives to Palliative Treatment 13.21 Dentistry: The Gateway to the Airway References 14: Pediatric Obstructive Sleep Medicine 14.1 Introduction 14.2 Etiology/Prevalence 14.3 Distinction Between OSA and the Upper Airway Resistance Syndrome 14.4 Sleep Testing 14.5 Obesity 14.6 Genetics? Could Obstructive Sleep Apnea be Syndromic? 14.7 Consequences of Pediatric OSA 14.8 Cognition and Behavior 14.9 Growth Failure 14.10 Nocturnal Enuresis 14.11 Sleep Bruxism 14.12 Gastroesophageal Reflux 14.13 Snoring 14.14 Screening Questionnaires and Clinical Assessment 14.15 Physical Examination 14.16 Sleep Assessment Tools 14.17 Ankyloglossia and Airway 14.18 Oral Restrictive Complex 14.19 Orofacial Myofunctional Disorders and Therapy 14.20 Sleep Team Collaboration 14.21 Role of the Dentist References 15: Orofacial Myofunctional Therapy for Sleep-Related Breathing Disorders 15.1 Introduction 15.2 Orofacial Myofunctional Disorders 15.3 Sample of Exercises 15.3.1 Soft Palate, Uvula, and Lateral Walls of Pharynx 15.3.2 Lateral Pharyngeal Walls 15.3.3 Tongue: Elevation and Strengthening 15.3.4 Tongue: Depression of the Posterior Tongue 15.3.5 Lip: For Lip Seal and Strengthening 15.3.6 Facial Exercises 15.4 Stomatognathic Functions 15.4.1 Breathing 15.4.2 Swallowing and Chewing References 16: Dental Sleep Medicine Case Studies 16.1 Introduction 16.2 Case Studies 16.2.1 Case Study #1: Severe Apnea Treated with DSA, Positional Therapy, and Nasal Aids 16.2.1.1 Background 16.2.1.2 Clinical Exam 16.2.1.3 Radiographic Exam 16.2.1.4 Treatment Recommendations 16.2.1.5 Treatment 16.2.1.6 Treatment Summary 16.2.1.7 What We Learned 16.2.2 Case Study #2: Severe Apnea Treated with a Dental Sleep Appliance 16.2.2.1 Background 16.2.2.2 Clinical Exam 16.2.2.3 Radiological Exam 16.2.2.4 Treatment Recommendations 16.2.2.5 Treatment 16.2.2.6 Treatment Summary 16.2.2.7 What We Learned 16.2.3 Case Study #3: Noncompliant CPAP Patient with Moderate Sleep Apnea Treated Successfully with an EMA DSA 16.2.3.1 Background 16.2.3.2 Clinical Exam 16.2.3.3 Radiological Exam 16.2.3.4 Treatment Recommendation 16.2.3.5 Treatment 16.2.3.6 Summary of Treatment 16.2.3.7 What We Learned 16.2.4 Case Study #4: Severe Noncompliant CPAP Patient with TMD Treated Successfully with a DSA 16.2.4.1 Background 16.2.4.2 Clinical Exam 16.2.4.3 Radiological Exam 16.2.4.4 Treatment Recommendations 16.2.4.5 Treatment 16.2.4.6 Summary of Results 16.2.4.7 What We Learned 16.2.4.8 What to Do 16.2.5 Case Study #5: A Patient that Developed a Significant Bite Change During DSA Treatment But Needed Further Advancement to Treat the Apnea Along with Positional Therapy 16.2.5.1 Background 16.2.5.2 Clinical Exam 16.2.5.3 Radiological Exam 16.2.5.4 Treatment 16.2.5.5 Summary of Results 16.2.5.6 What We Learned 16.2.6 Case Study #6: Moderate Apnea with Severe Oxygen Desaturations Treated with DSA and Positional Therapy 16.2.6.1 Background 16.2.6.2 Clinical Exam 16.2.6.3 Radiological Exam 16.2.6.4 Treatment Recommendations 16.2.6.5 Treatment 16.2.6.6 Summary of the PSG Tests Before and During the Oral Dilator 16.2.6.7 Treatment Summary 16.2.6.8 What We Learned 16.2.7 Case Study #7: Moderate Sleep Apnea with Excessive Daytime Sleepiness Treated with DSA and Nasal Components 16.2.7.1 Background 16.2.7.2 Clinical Exam 16.2.7.3 Treatment Recommendation 16.2.7.4 Treatment 16.2.7.5 Efficacy Sleep Study 16.2.7.6 Treatment Recommendations 16.2.7.7 What to Learn 16.2.8 Case Study #8: Moderate Sleep Apnea Treated with DSA and Recommendation of Supplemental Oxygen 16.2.8.1 Background 16.2.8.2 Clinical Exam 16.2.8.3 Treatment Recommendation 16.2.8.4 Treatment 16.2.8.5 Efficacy PSG Sleep Study 16.2.8.6 Treatment Recommendations 16.2.8.7 What to Learn 16.2.9 Case Study #9: Noncompliant CPAP Patient with Moderate OSA and TMD Present Treated with DSA, Nasal Surgery, and Supplemental Oxygen 16.2.9.1 Background 16.2.9.2 Clinical Exam 16.2.9.3 Treatment Recommendation 16.2.9.4 Treatment 16.2.9.5 Efficacy PSG Sleep Study 16.2.9.6 Treatment Recommendations 16.2.9.7 Follow-Up to Efficacy 16.2.9.8 What to Learn 16.3 Synopsis References