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A quick question, a clinical scenario, a voice note between patients, a photo for educational discussion. The answer leads with the point, then the criteria and the limits of the evidence. Write sources and the published studies behind it arrive with their links.
52M, snores loudly, his wife says he stops breathing at night. wakes up tired with headaches and dozes off in meetings. he wants a mouth guard for the snoring. do i make one or does he need cpap?
He needs a sleep study before any appliance. Loud snoring with witnessed pauses, unrefreshing sleep, morning headaches and daytime sleepiness point to obstructive sleep apnea (OSA), and an anti-snoring device can silence the snoring while the apneas go on.
At the chair: score STOP-Bang (3 or more raises the risk) and Epworth (above 10 means excessive sleepiness), then refer him in writing to a sleep physician.
How the study grades it: the apnea-hypopnea index (AHI) counts the times breathing stops or falls per hour of sleep.
- 5 to 15: mild
- 15 to 30: moderate
- 30 or more: severe
The lowest oxygen saturation and his sleepiness weigh in too.
What follows: in mild to moderate OSA a mandibular advancement device works about as well as CPAP on sleepiness and blood pressure; in severe OSA with marked sleepiness or desaturation, CPAP comes first, and the device is the option if he cannot tolerate it.
Next step: send me the report (AHI, lowest saturation, Epworth) and we can see together whether a mandibular advancement device fits him and how to make it.
sources
Published references behind the last answer:
- Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017. doi.org/10.5664/jcsm.6506
- Ramar K, Dort LC, Katz SG, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015. doi.org/10.5664/jcsm.4858
- Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008. doi.org/10.1097/ALN.0b013e31816d83e4
patient in the chair, 28F, her jaw clicks when she opens and sometimes when she closes. no pain right now. what is it and what should i check?
Most likely a disc displacement with reduction (DDwR). With the mouth closed, the articular disc sits in front of the condyle; on opening, the condyle slides back under it, and that recapture is the click. A second, softer click on closing is the disc slipping forward again.
Check today:
- Palpate over the lateral pole of each joint while she opens, closes and moves sideways and forwards: which side, at what opening, and whether it repeats.
- Measure pain-free and maximum opening and watch the path: a deviation that returns to the midline after the click fits DDwR.
- Ask if the jaw has ever locked, even briefly, and if chewing or yawning hurts.
- Palpate the masseter, temporalis and the joint for familiar pain.
- Ask her to open from a forward position: if the click disappears, the disc stays in place there.
Next step: do these tests and send me the results. A painless click with no locking usually needs only monitoring; if it hurts or catches, we can work out together whether an anterior repositioning splint is the right option and the steps to make it.
sources
Published references behind the last answer:
- Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for clinical and research applications. J Oral Facial Pain Headache. 2014. doi.org/10.11607/jop.1151
- Maracci LM, Savegnago GDO, Antoniazzi RP, et al. Influence of examiner calibration on clinical and MRI diagnosis of temporomandibular joint disc displacement: a systematic review and meta-analysis. Dentomaxillofac Radiol. 2024. doi.org/10.1093/dmfr/twae027
- Manfredini D, Favero L, Federzoni E, Cocilovo F, Guarda-Nardini L. Kinesiographic recordings of jaw movements are not accurate to detect magnetic resonance-diagnosed TMJ effusion and disk displacement. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012. doi.org/10.1016/j.oooo.2012.04.016
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Write sources after any answer and you receive the published studies behind it, with DOI or PubMed links, so you can read the original before you decide.
Sleep and breathing, the other half of the job.
Every night guard, splint and orthodontic plan touches the airway. The same contact answers the sleep questions that reach a general practice, with the same grounding.
Mandible retruded
Mandible advanced- Screening at the chair. Snoring, witnessed pauses, STOP-Bang and Epworth: what each score means, and what it does not.
- Referral and the way back. When to send a patient for a sleep study, and the dentist's place once the report arrives.
- Mandibular advancement devices. Who they suit, CPAP or MAD, titration, and the bite changes to watch.
- Safety first. Drowsy driving, sedatives in a patient who snores, and children who snore and grind.
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