Interviewed by Michael C. DiTolla, DDS, FAGD
Dr. Michael DiTolla: Many of our readers see the term “sleep bruxism” and wonder what this is?
Jeff Wyscarver: The beginning for me with regards to tackling sleep bruxism came when I started talking to a number of dentists and notable pain clinic specialists who had a desire to be able to measure jaw activity while a patient slept. We introduced a device to dentistry that allowed us to measure the airway and the jaw activity while a patient slept, and this struck a chord with many clinicians.
MD: I’m familiar with the types of devices that can be worn for a sleep study, whether it’s performed overnight in a sleep lab or by the patient at home. How does this device differ from a typical sleep study?
JW: The fundamental difference is that our approach is from the dentist’s perspective and not from the sleep lab’s perspective. For example, I’ll describe a sleep study. Many people are surprised to learn that every full polysomnogram (PSG) done in a sleep lab collects jaw electromyography (EMG) data. Because the medical community doesn’t typically tackle bruxism directly, that data is essentially ignored and used for another reason. We learned that the jaw EMG was clearly in dentist’s wheelhouse. Our device detects obstructive sleep apnea, too, but it also tells the dentist what the jaw is doing in relation to the airway. This data is not necessarily collected for the purpose of diagnosing the patient with obstructive sleep apnea (in fact, DDME provides Board-Certified Sleep Physicians for that purpose), but it’s good for a dentist to understand what the airway is doing along with the jaw. I think the primary distinction is that jaw activity is measured on the same time axis as the airway, a bit of useful information for the dentist.
MD: If they’ve always measured EMG data in sleep laboratories, I guess that means they run some of the electrical leads to, say, the face outside of the masseter muscle, for example?
JW: Sleep studies actually measure the chin most often because of that has a unique measurable function during REM sleep. Jaw activity goes down to its lowest level, and the tonic baseline goes back up during non-REM sleep and waking.
MD: Interesting! So they’re actually using the data to determine REM sleep by measuring on the chin, not the masseter. Looking at the incidence of bruxism and obstructive sleep apnea occurring simultaneously, do you see a definite relationship between the two?
JW: In many cases, much more than I imagined, there is a correlation between parafunctional or unusual jaw EMG activity and the presence of obstructive sleep apnea. I’ve been collecting data in conjunction with the dentists that I work with, and it’s unusual not to see some amount of chin EMG activity in the presence of apnea. Getting back to the uniqueness of the jaw musculature, I have learned that the jaw has a direct connection to the arousal response from other muscles in the body. Bruxism in the presence of disordered respirations is closely tied to what we call the “autonomic response,” which is when the body senses something and changes the physiological levels in response. The heart rate goes up, EEG levels change and the jaw participates in the arousal response. There are a variety of theories circling that response, and I think more data needs to be collected.
MD: You mentioned the Bruxism Monitor, which is the name of the device your company distributes. Can you tell me a little bit about how it compares to some of the other devices out there, maybe in terms of size, comfort and what it measures?
JW: When we decided to go into dentistry, we started out by asking, “What is the best sleep device out there?” We went through and evaluated a number of devices. With the selection criteria that we had, we put a premium on ease of use. The reason for that was we knew we were going to go into a non-sleep-trained environment, and we needed to be able to collect good data on someone who has never done a sleep study before.
Another category that we had was cost per test. There were a few devices that passed the ease-of-use category, but were actually quite expensive to use per test. The Bruxism Monitor cost per test was about half that of the remaining devices on our list.
The last selection category we evaluated was clinical yield, which is a term we use to describe how much cost and effort it takes to get effective, usable data. The Bruxism Monitor scores very high marks, with a number of internal design features which give the device a very high clinical yield. That is to say, the data collected can be used to improve the decision the dentist makes. When we passed the devices through the three-phase selection criteria, the Bruxism Monitor won out.
MD: Well it sounds like you did a lot of research, and I certainly agree with the qualities you looked for in a unit. Dentists want operational affordability, and the patient doesn’t want to pay a lot to do the test either. So it sounds like your device measures muscle activity to come up with an idea about the bruxism, and it also measures hypopneas and apneas. Is it also able to record snoring or measure the volume of snoring?
JW: Sure it does. One of the features that improves the functionality of the Bruxism Monitor is that it records the audio of the sleep study. That’s valuable and effective information for two reasons: First, you can play back somebody’s snoring if you have to address patient denial.
The second reason is that when you’re measuring for bruxing, you have to comply with fairly stringent diagnostic criteria set by research done using full PSGs. The
Bruxism monitor combines the audio signal, actually catchings the sound of the teeth clenching, which can be correlated with the EMG burst. To my knowledge, we have the only device on the market that can detect these two at the same time.
MD: What does that sound like?
JW: Well, it’s a low, grinding noise, and it’s actually painful to listen to; If you and I were to sit here and grind our teeth, it would be a fairly silent occurrence. But when you listen to nighttime grinding and you hear the teeth crunching, just imagine how much force it takes to produce that noise.
MD: I guess that could be interpreted to mean that when you’re asleep some of those protective reflexes are down, and you’re able to squeeze together harder than you ever would while you’re awake.
JW: Absolutely. We’re collecting a lot of data in the home, and we’re uncovering some interesting information. If we ask a patient wearing a Bruxism Monitor to grind their teeth as hard as they can, we’ll gain a calibrated measurement in microvolts that records that strongest teeth clench while awake. Then when that patient goes to sleep, it’s not unusual to see a dramatic increase in that patient’s bite force during the night. In fact, I would say that in most people that we’ve measured, their bite force is anywhere from 50 percent to 200 percent higher while they’re asleep than their maximum force when they’re awake. I don’t necessarily have an explanation for this.
MD: So we can measure how loud the snoring is, the apnea-hypopnea index (AHI) and the bruxism. How do you work all three of those factors together? And how do you figure out what type of category the patients belong in?
JW: I’m going to step back just a second and explain my perspective. Coming from a sleep lab in the medical community, we approach medical conditions in a certain way. Now that I work with dentists, I can’t help but impose my medical diagnostic training on this particular problem. We came up with a disposition matrix to manage observed data. The Bruxism Monitor reports snoring in decibels. If the snoring is above a certain amount of decibels for a certain amount of time, you say “yes” to snoring. If the patient has an AHI above normal, you say “yes” to apnea-hypopnea index. If the patient has bruxism, and it crosses the mild-to-moderate level, you say “yes” to that. The disposition matrix gives the dentist a map he or she can use to guide the patient’s therapy.
I’ll give you a couple of examples of how the disposition matrix works. Let’s say that a dentist often treats patients with snoring. The monitor gives data about the possibility that the patient also has obstructive sleep apnea. So if the dentist just wants to treat the patient for snoring but the device indicates obstructive sleep apnea along with snoring, using the matrix means they have to put a check there. Now that dentist has to make a decision. Do they just put in a snore guard, or should they have the patient sent for medical diagnosis? I think most would agree the prudent decision would be to manage the apnea, and in the course of managing the patient’s apnea, the snoring will be managed. It’s not necessarily bad news for the dentist, but it’s an example of using efficient and effective information to make a good, sound clinical decision.
MD: Let’s say that the patient also coincidentally has bruxism, but maybe whatever testing device the dentist used gives no indication of whether the patient is bruxing during these obstructive sleep apnea events. When the doctor simply puts in the sleep apnea device, doesn’t it treat the bruxism in a sense because now there’s something in between the teeth?
JW: That is a perfect example of how our diagnostic system works. After therapy is started with an oral appliance, you titrate the airway by taking two or three measurements during the titration process. You’re going to know whether the patient is breathing well and the status of their bruxism. I can say from personal experience that about half the time, the bruxism does not completely resolve.
MD: Interesting. Everybody seems to agree that continuous positive air pressure therapy (CPAP) is still the gold standard for treating moderate to severe obstructive sleep apnea (OSA). If a physician’s patient goes in for an overnight sleep study do you feel like that treatment completely ignores the bruxism aspect of it?
JW: CPAP is a treatment for a medical condition, and the medical community by and large has handed off any type of issue related to bruxism over to dentistry.
MD: You probably think it’s criminal that we’re not taught about any of this in dental school. Dentists graduate from school and are kind of left to decide if they want to get involved in a field like this. From your perspective, what’s the best way for a dentist to gain some knowledge in this area to get started treating these patients?
JW: I would say the vast majority of dentists who educate themselves in managing patients with apnea get their training after they graduate.
I’ll step back and tell a personal story of how I made the decision to go from medical to dental. When I was running sleep labs, we would have case conferences. I would say that 90 percent of patients that we saw had sleep apnea, and as part of diagnosing sleep apnea, we would have a pulmonologist, a psychologist, a psychiatrist, a neurologist, somebody like myself and the director of the sleep lab all sitting around deciding what to do with a patient that had an AHI of 30. It’s a fairly simple decision, so I was frustrated in medicine as to how difficult we made diagnosing people with obstructive sleep apnea. When I made the move to dentistry, I decided to make this as simple and direct as possible. When you have a relatively healthy patient, and they have complaints of snoring or pauses in breathing, I think that a dentist can be the quarterback at managing that patient.
Now, it’s important to understand that I didn’t say diagnose the patient. I said managing the patient’s process of getting treatment. What I say to dentists is: “Keep it as simple as possible. Make sure you don’t do studies on patients you shouldn’t. Make sure the patients that you identify are good candidates for the therapy that you can offer, and if they’re not, you need to find a place for them.” There is some training involved, there’s picking the right oral appliance, there’s getting good information on the patient that you’re treating; and then from that, you’re able to make some very good decisions and manage the patient’s airway.
I’ll make one other comment about dentists managing healthy patients that have obstructive sleep apnea. In the medical community, we’re very much event-driven. By that I mean that we wait for the patient to have an event to respond to it. We treat the symptoms, and we help them through the event. Dentistry’s model is different. Dentists want to see the patient over and over and over again. One of the things that you learn early when you’re treating patients with OSA is that it’s a chronic condition and requires a lot of follow-up. Follow-up is built into the dental business model. I think that’s one of the reasons that dentists are very well positioned to manage people who are healthy and have apnea complaints.
MD: I like what you said about dentists being able to be the quarterbacks of this process and coordinating the treatment, but leaving the diagnosis to the physicians. If dentists reading this want to get more information on the Bruxism Monitor or the services your company provides, where is the best place for them to go?
JW: We have a website at www.ddmeonline.com, where they can find information on our products and services. They can also e-mail us at email@example.com or contact me on my cell at 951-496-6126.