managing side effects of oral appliance therapy

MANAGING SIDE EFFECTS OF ORAL APPLIANCE

THERAPY

• Itisimportanttodocumentthepresenceofmuscleorjointtendernessbeforethedeliveryofthedevice.

• Thephysicalexamina:onshouldincludeaevalua:onofjawfunc:on,andapalpa:onexamina:onoftheTMJsandcervicalandmas:catorymuscles.

• Acommoncomplaintofpa:entswithOSAismorningheadache.- However,musclepainandmostpar5cularlymyofascialpain(MFP)arefrequentlyassociatedwithorcauseheadache.

- Acarefulpalpa5onexamina5on,performedaspartoftheini5alexamina5on,helpstodocumentpreexis5ngmusclepainandassociatedheadache.

DOCUMENT

EPIDEMIOLOGYOFTMDSYMPTOMS&BITECHANGEASSOCIATEDWITHMADUSE

• Prevalencees:matebetween10-30%ofpa:entsusingMADdevelopedTMDsymptoms.- ClarkGT,ArandD,ChungE,etal.EffectofanteriormandibularposiAoningonobstrucAvesleepapnea.AmRev

RespirDis1993;147(3):624–9.- ClarkGT,KobayashiH,FreymillerE.Mandibularadvancementandsleepdisor-deredbreathing.CDAJ1996;24(4):

49–61.

• Irreversiblebitechange10%- PeAtFX,PepinJL,BeZegaG,etal.Mandibularadvancementdevices:rateofcontraindicaAonsin100consecuAve

obstrucAvesleepapneapaAents.AmJRespirCritCareMed2002;166(3):274–8.- ClarkGT.Mandibularadvancementdevicesandsleepdisorderedbreathing.SleepMedRev1998;2(3):163–74.

COMMONLYREPORTEDTEMPORARYSIDEEFFECTSFrequency from 6% - 86% of patients

• TMJpain

• MyofascialPain

• ToothPain

• Saliva:on

• TMJointsounds

• DryMouth

• GumIrrita:on

• MorningaLerocclusalchanges

Liu,Y.,Zeng,X.,Fu,M.,Huang,X.,andLowe,A.A.(2000)Effectsofamandibularreposi:oneronobstruc:vesleepapnea.AmJOrthodDentofacialOrthop118,248-256

Lowe,A.A.,Sjoholm,T.T.,Ryan,C.F.,Fleetham,J.A.,Ferguson,K.A.,andRemmers,J.E.(2000)Treatment,airwayandcomplianceeffectsofa:tratableoralappliance.Sleep23,S172-178

Neill,A.,Whyman,R.,Bannan,S.,Jeffrey,O.,andCampbell,A.(2002)Mandibularadvancementsplintimprovesindicesofobstruc:vesleepapnoeaandsnoringbutsideeffectsarecommon.NZMedJ115,289-292

O’Sullivan,R.A.,Hillman,D.R.,Mateljan,R.,Pan:n,C.,andFinucane,K.E.(1995)Mandibularadvancementsplint:anappliancetotreatsnoringandobstruc:vesleepapnea.AmJRespirCritCareMed151,194-198

Pancer,J.,Al-Faifi,S.,Al-Faifi,M.,andHoffstein,V.(1999)Evalua:onofvariablemandibularadvancementappliancefortreatmentofsnoringandsleepapnea.Chest116,1511-1518

Schönhofer,B.,Hochban,W.,Vieregge,H.J.,Brünig,H.,andKöhler,D.(2000)Immediateintraoraladapta:onofmandibularadvancingappliancesofthermoplas:cmaterialforthetreatmentofobstruc:vesleepapnea.Respira:on67,83-88

Liu,Y.,andLowe,A.A.(2000)Factorsrelatedtotheefficacyofanadjustableoralapplianceforthetreatmentofobstruc:vesleepapnea.ChinJDentRes3,15-23

Pan:n,C.C.,Hillman,D.R.,andTennant,M.(1999)Dentalsideeffectsofanoraldevicetotreatsnoringandobstruc:vesleepapnea.Sleep22,237-240

Bondemark,L.,andLindman,R.(2000)Craniomandibularstatusandfunc:oninpa:entswithhabitualsnoringandobstruc:vesleepapnoeaaLernocturnaltreatmentwithamandibularadvancementsplint:a2-yearfollow-up.EurJOrthod22,53-60.

TMJPAIN

TMJPAIN

• Cause- mandibleeccentricity- posteriorcontactheavyonpainfulside- mandibularadvancementbeyondabilityofjointstructures

• Solu5on- correctmidlinewithapplianceasisduringhabitualocclusion- adjustposteriorcontact- setappliancebacktolastcomfortablespot,decreaserateofadvancement,symptoma:ctreatment

TREATMENT-CAPSULITIS

• Pa:entshouldbeinstructedtogoonasoLdiet,- avoidingchewinganyhardfoods,- smallbites,andsteamingvegetables.- deferfromsaladsun5lthepainresolves.

• Pa:entalsoshouldbeinstructedtoreducejawfunc:on:- bynotchewinggum

• Usemoistheatonthejaw2to3:mesperday.

TREATMENT:• Palla:ve1.SoLdiet2.Moistheat10-15minutes2-3:mesaday.3.NSAIDSorSteroids• Physiotherapy(Ultrasoundw/wophonoand/or

iontophoresis,laser,etc.• Re-evaluatein1week• Splinttherapy

CAPSULITUS

RETRODISCITUS

Treatment:a.NSAIDSorsteroidsb.SoLDietc.IceaLerjawac:vityd.SplintTherapy(movecondyleoffretrodiscal:ssue)e.Jointmobiliza:onf.Physiotherapy(ultrasoundw/wophono.and/ionto,lasertx.)

TREATMENTCAPSULITUS

Generic Brand Dosing Guidelines

Acetaminophen Tylenol Start 650 mg QID; increase to 4000-6000 mg/day

Aspirin Aspirin 325-650 mg q 4-6 hours; maximum 4000-6000 mg/day

Diflunisal Dolobid Start 500 mg bid; maximum is 1500 mg/day

Diclofenac sodium Voltaren 25-50mg q 6-8 hours to maximum of 150 mg/day

Ibuprofen Advil, Motrin 300-600 mg tid-qid; maximum is 3200 mg/day

Naproxen Naprosyn, Aleve 250-500 mg bid; maximum is 1025-1375 mg/day

Ketoprofen Orudis 25-50 mg tid-qid; maximum is 300 mg/day

Ketorolac Toradol IM form recommended; 60 mg single dose; 30 mg multiple dosing not to exceed 120 mg/day

Indomethacin Indocin Start 25 mg tid; increase to maximum of 50 mg tid

Sulindac Clinoril 150-200 mg bid; maximum is 400 mg/day

Etodolac Lodine 200-300 mg tid to maximum of 1200 mg/day

Celecoxib Celebrex 100 mg bid to maximum of 400 mg/day

JRS 40

• Reevaluateoralappliance- toseeifitisadvancingthejawtoomuch.

• Determinebalancebetweentheamountofadvancementversustheincreaseinver:cal.

• Increasingthever:calisusuallylessirrita:ngtotheTMJthanadvancingthemandible.

TREATMENT-CAPSULITIS

TMJPAIN

CC:PAININAMONRIGHTMASSETERAREA

CC:PAININAMONRIGHTMASSETERAREA

SOLUTION:CORRECTMIDLINE.

MYOFACIAL PAIN

• Myalgiaisdescribedasadull,aching,andcon5nuouspainassociatedwithmusclefunc:on.

• Confirmedbypalpa:onofthemusclesandlookingforreplica:onofthepaincomplaint.

MASTICATORYMUSCLEDISORDERMYALGIA

•  Physicaltherapy,physicalmedicinetechniques,

• Medica6onmanagementtoop6mizethetreatment.

•  Stretchingthemas6catorymusclesduringtheday.-  stretchthejawbyplacingthetongueonthepalatebehindtheupperfrontteethandstretchingopenasfarastheycanstretchwithoutpullingthetongueoffofthepalate.

-  stretchisheldfor6seconds,repeated6:mes,andtheprocessisrepeated6:mesperday.

-  exercisestretchesthemasseter,medialpterygoid,andtemporalismuscles.

stretching the masticatory muscles during the day. This process should start afterremoval of the MAD and the exercises to reestablish posterior tooth-to-tooth contacts.The patient should be instructed to stretch the jaw by placing the tongue on the palatebehind the upper front teeth and stretching open as far as they can stretch withoutpulling the tongue off of the palate (Fig. 6). The stretch is held for 6 seconds, repeated6 times, and the process is repeated 6 times per day. This exercise stretches themasseter, medial pterygoid, and temporalis muscles. If the muscles are severelytender, the patient should use moist heat for 5 minutes before the stretching exercisesand then ice to cool down the muscles for 5 minutes after the stretching.The patient should also be instructed to assume a jaw rest position during the day.

This practice helps the patient to avoid daytime clenching that can keep the musclestender. The patient is instructed to place the tongue on the palate similar to the jawposition assumed for the stretch in Fig. 6, but the lips are brought together and theteeth kept slightly apart. The patient is also instructed to breathe through the nosein this position. This rest position helps to reduce masseter, medial pterygoid, andtemporalis muscle activity.

ADJUNCTIVE MEDICATIONS

In addition to the medications discussed earlier, other classes of medications can behelpful in mediating the pain. Muscle relaxants can be a helpful addition to treating the

Fig. 6. Stretching exercises. The left image shows the tongue on the palate behind theupper front teeth and the jaw being stretched to the point at which the tongue wouldbe pulled off the palate if the patient opened wider. The right image shows the patientstretching the posterior neck muscles that are often painful in association with the jawmuscles.

Table 2Muscle relaxants

Generic Proprietary Dose

Cyclobenzaprine Flexeril 10 mg at bedtime

Tizanidine Zanaflex 2–4 mg (dosed 3 times a day up to 16 mg)

Baclofen Lioresal 5–10 (dosed 3 times a day up to 80 mg)

Metaxalone Skelaxin 800 mg 3 to 4 times a day

Methocarbamol Robaxin 500–750 mg (1500 mg 4 times a day)

Soma Carisoprodol 250–350 mg 3 times a day. Use for maximum of 2 weeks

TMD Pain and Dental Treatment of OSA 427

stretching the masticatory muscles during the day. This process should start afterremoval of the MAD and the exercises to reestablish posterior tooth-to-tooth contacts.The patient should be instructed to stretch the jaw by placing the tongue on the palatebehind the upper front teeth and stretching open as far as they can stretch withoutpulling the tongue off of the palate (Fig. 6). The stretch is held for 6 seconds, repeated6 times, and the process is repeated 6 times per day. This exercise stretches themasseter, medial pterygoid, and temporalis muscles. If the muscles are severelytender, the patient should use moist heat for 5 minutes before the stretching exercisesand then ice to cool down the muscles for 5 minutes after the stretching.The patient should also be instructed to assume a jaw rest position during the day.

This practice helps the patient to avoid daytime clenching that can keep the musclestender. The patient is instructed to place the tongue on the palate similar to the jawposition assumed for the stretch in Fig. 6, but the lips are brought together and theteeth kept slightly apart. The patient is also instructed to breathe through the nosein this position. This rest position helps to reduce masseter, medial pterygoid, andtemporalis muscle activity.

ADJUNCTIVE MEDICATIONS

In addition to the medications discussed earlier, other classes of medications can behelpful in mediating the pain. Muscle relaxants can be a helpful addition to treating the

Fig. 6. Stretching exercises. The left image shows the tongue on the palate behind theupper front teeth and the jaw being stretched to the point at which the tongue wouldbe pulled off the palate if the patient opened wider. The right image shows the patientstretching the posterior neck muscles that are often painful in association with the jawmuscles.

Table 2Muscle relaxants

Generic Proprietary Dose

Cyclobenzaprine Flexeril 10 mg at bedtime

Tizanidine Zanaflex 2–4 mg (dosed 3 times a day up to 16 mg)

Baclofen Lioresal 5–10 (dosed 3 times a day up to 80 mg)

Metaxalone Skelaxin 800 mg 3 to 4 times a day

Methocarbamol Robaxin 500–750 mg (1500 mg 4 times a day)

Soma Carisoprodol 250–350 mg 3 times a day. Use for maximum of 2 weeks

TMD Pain and Dental Treatment of OSA 427

TREAT-MYOGENOUSPAIN

• Paininelevatormuscles- Moistheatstretches- Musclerelaxantand/orNSAID- Topicalmedica:ons- 10%Ketroprofen&2%cyclobenzaprine

• PaininTMJ- NSAIDSorSteroids- d/cwearingofappliance:llsymptomsresolve

• RefertoPhysicaltherapy

SYMPTOMATICRELIEF

MUSCLE SPASM

ULTRASOUND

ULTRASOUND

MUSCLE SPASM

ELECTRICAL MUSCLE STIMULATION

SPRAY AND STRETCH

TOOTHPAIN

• Cause- wearonstone- distortedimpression

• Solu5on- adjustareaofconcern- remakeapplianceifimpressionwasdistorted

PAINININDIVIDUALTOOTH

PAININANTERIORTEETH

• Cause- clenching- poorposteriorsupport/noposteriorsupport

• Solu5on- addposteriorstopsifnotpresent- adjustanterioraspectofapplianceusing“BULL”rule.

MOBILITYOFANTERIORTEETH

• Cause- retrudingforceoflowerjawonteeth

• Solu5on- adjustanterioraspectofapplianceusing“BULL”rule.

SALIVATION

• Cause- presenceofapplianceinmouth

• Solu5on- towelonorinsidepillowcase- resolvedin1-2weeks

EXCESSSALIVATION

TMJSOUNDS

TMJARTICULARDISORDERS

• Diskderangementsarecommoninthegeneralpopula:on,withprevalencees:matesrangingfrom40%to75%ofthepopula:on.

• Majortraumaalsomaydamagethediskorligaments:- fight,fall,sportsinjury,oralsurgery,ormotorvehicleaccident

• Excessiveparafunc:onalac:vity:- gumchewing,bruxism,bracing,orclenching

• Laxitymayallowthedisktoslipforward,leadingtodiskclicking.

TMJARTICULARDISORDERSCLICKINGJOINTS

Normal ADDw/red.

TMJARTICULARDISORDERSNON-CLICKINGJOINTS

ADDw/outred.Normal

TMJARTICULARDISORDERSCLICKINGJOINTS

• Treatmentofclickingjointsisnotadvocatedunlessseverepainanddysfunc:onareassociatedwiththedisloca:on.

• DeLeeuwR,editor.Orofacialpain;guidelinesforassessment,diagnosis,andmanagement.4thedi:on.HanoverPark(IL):QuintessenceBooks;2008.

• Inpainfulclickingandjointdysfunc:on,considerfabrica:ngananterioradvancementsplintfornightmeandday:meuseun:ljointinflamma:onsubsidesandthejointadaptstothemechanicaldysfunc:on.

• UseofaMADsleepappliancecanprovidethiskindofstabiliza:on.

DRYMOUTH

Cause:• mouthbreathing• lipincompetency• nasalissues

Solu:on:• ar:ficialsaliva• differentappliance• refertoENT

DRY MOUTH

http://www.oracoat.com/pages/xylimelts-directions-for-use

• SpecialDentalOfficePricing:• 50%belowretailprices• Samesize40discsasindrugstores

• PatientSamples:• 4discsinasamplebrochure,40brochuresperbox• Firstsampleboxof8brochures(4discseach)FREE

• ForPricingCall:877-672-6541

DENTALOFFICEPRICING

Xerostomproduct AveragepH

Xerostommouthwash 7.0

Xerostomsalivasubs:tutegel 6.35

Xerostomtoothpaste 7.50

EMAIL FOR SAMPLE

nick.rosemeyer@biocosmetics.es

NASALISSUES

PATENTNASALAIRWAY

• Essential to success with OSA therapy• Independent contributor to Sleep disorders• Affects sleep outcomes

Dixon et al. Criteria to screen for chronic sinonasal diseaseChest 2009;136: 1324-32

NASAL STEROID SPRAYS

Nasal steroid sprays improved the following:1. Congestion2. Daytime sleepiness3. Subjective sleep quality4. Have shown that they can greatly

improve AHI in various studies

POSSIBLENASALOBSTRUCTIONS

• Septaldevia:on• Enlargedturbinates• Sinusi:s• Nasalpolyps• Allergicrhini:s• Enlargedadenoids

NASALAIDS

Mute Nose Clips

GUMIRRITATION

• Cause- rubbingofacrylic

• Solu:on- adjustacrylic

GUMIRRITATION

BITECHANGE

EFFECTSOFMAD-BITECHANGE

• Bitechangeshavebeenreportedinpa:entsusingMADs.

• Commonly,temporaryocclusalchangesareobservedinthemorningwhenthedeviceisremoved,requiringthepa:enttoperformsomeexercisestobringtheposteriorteethbacktogether.

• However,evidenceismoun:ngthatlong-termuseofMADscausespermanentchangesintheocclusalrela:onship.

EFFECTS OF MAD - PLAN

• Pa:entsshouldbegiveninstruc:onsregardingthenecessityofperformingexercisestobringtheposteriorteethbackintocontact.- pa5entsmaynotperformtheexercisesasdirectedandthebitechangescanbecomepermanent.

POSTERIOROPENBITEINAM

• Cause• edemainjointspace• shorteningoflateralpterygoidmuscle• poten:alrecaptureofadislocateddisc

• Solu5on• clenchingonbitetab• chewingbubblegum• bi:ngonleafgauge• leanlowerjawonhand• AMaligner

POSTERIORBITEINAMEdema

Shortening

POSTERIORBITEINAM

BITECHANGE-INITIAL4/18/11

BITECHANGE-11/2/2011-D/C

BITECHANGE-12/12/2011-F/U

BITECHANGE-1/4/2012-F/U

CASE STUDY

• PriorHxoforthodon5cs- Fixedlowerretainer3-3

• Priorhistoryofjointsoundsonopening

• PresentlyledTMJ- earlyopeningclick

• ROM:42mmopening,lateral15+mm,Protrusive5- Overbite5mm,Overjet4mm- deflec:ontorightonopening

CYNTHIA

CYNTHIA-PSG

CYNTHIA-BASELINEPHOTO

CYNTHIA-BASELINEPHOTO

CYNTHIA-IMPORTANTNOTE

Maintain midlines

• Nojointsoundonright

• NOdeflec:ontorightnoted

• PaininrightTMJ1. bi:ngoncowonrollsonright-Pain2. bi:ngontonguebladeonright-NOPain

CYNTHIA-FOLLOWUP1WEEK

CYNTHIA-COMPARISON

• Priorhistoryofjointsoundsonopening

• PresentlyleLTMJ- earlyopeningclick

• ROM:42mmopening,lateral15+mm,Protrusive5- deflec:ontorightonopening

Initial • Nojointsoundonright

• NOdeflecAontorightnoted

• PaininrightTMJ- biAngoncoZonrollsonright-Pain

- biAngontonguebladeonright-NOPain

•

Follow up

CYNTHIA-CLINICALIMPRESSION

• Impression:Disconrightreduced.- confirmbyMRI

• Differen5aldiagnosis:- Rightlateralpterygoidmusclespasm

MELLISA

• PriorHxoforthodon:cs- bicuspidextrac5on

• Bruxer/clencher

• PresentlyRightTMJ- lateopeningclick

• Musclepalpa:on-wnl

• ROM:47mmopening,lateral15+mm,Protrusive7mm- Overbite2mm,Overjet2mm- devia5ontorightonopening

• Mallampatscore:ClassIV

• Tonguelevel:3

• Class1molarrela:onship

• Tongue:- fissured- scalloped

• SoLpalate:- edematous- Grade1tonsils

• Palate:- Valuted- Narrow

• Mandible:- Narrow

MELLISA

MELLISA-INTRAORAL(5/2010)

MELISSAPSG

Overall AHI. 21.6 Supine AHI. 31.4

O2 desaturation Nadir. 77%

REM sleep AHI. 6.4 Non supine AHI. 16.2

Hypnotic Burden. 5.4% or TST

The total arousal index was elevated at 33.2 arousals per hour due to respiratory events, snore arousals and spontaneous

arousals.

MELLISA-APPLIANCE

MELLISA-FOLLOWUP(6/2010)

• RightTMJ- lateopeningclick

• Musclepalpa:on-WNL

• ROM:47mmopening,lateral15+mm,Protrusive7mm- devia:ontorightonopening

• RightTMJ- NOlateopeningclick

• Musclepalpa:on-WNL

• ROM:49mmopening,lateral15+mm,Protrusive8mm- NOdevia:ontorightonopening

Initial (5/2010) Follow up (6/2010)

MELLISA-COMPARISON

Fusion Sleep

Respiration Report

Patient InformationFull NamePatient IDAddressZIP/Postal CodeCityPhone/Mobile

Melissa DanielssonDANME000

Date of BirthHeightWeightBMI

10/22/196262 in138 lb25.2

Age 47

Recording Information

Recording Date 6/27/2010 Bed Time Starts 11:13 PM

Recording Duration 10h 25m 49s Time in BedRecording Time 11:07 PM

10h 12m (612.8m)Bed Time Ends 9:25 AM

Respiration Overview

AHI ODI Snore Index4.9 3.0 0.1%AHI is the number of Apneas and Hypopnea per hour. ODI is the number of oxygen desaturations per hour. Snore Index is the percentage of time spent snoring versus the total time spent in bed.

Respiratory Indices Respiratory CountApnea/Hypopnea Index

Hypopnea IndexApnea Index

4.92.92.0

Apneas

Central/MIxedObstructive

Hypopneas

30141620Snore Index 0.1

5.63.32.30.1

supinetotal28131519

total supine/h/h/h

/h/h/h%%

Longest Apnea 23 23 ss

Longest Hypopnea 36 36 ssAverage Apnea 15 15 ss

Average Hypopnea 24 24 ss

PulseDesaturation Index Average Pulse

Average SpO2

3.0

94.8

40

Desaturation < 90%: 0.1

Saturation3.3

94.6

41

0.1

supinetotal/h

%

bpm/h

%

bpm

Desaturation < 85%: 0.0 0.0/h /h/h /h

Desaturation Count 31 28

SpO2 time < 90%: 5.0 6.0SpO2 time < 85%: 3.2 3.9

% %% %

total supine

Highest Pulse 70 70bpm bpm

Lowest Pulse 35 35bpm bpmLowest SpO2 81.0 81.0% %

Pulse time < 40bpm 41.4 35.7Pulse time > 100bpm 0.0 0.0

% %% %

Average Pulse SD 1.7 1.7bpm bpm

93.3Good100.0Fair

50.6 %% 51.8Paradoxical Index

OtherSupine Time

Activity Time

Non-Supine Time513.9107.8

57.8

Position and Activity82.217.2

9.3

mm

m

%%

%Upright Time 3.3 0.5m %

total supine

91.8 %% 90.3Est. Sleep Efficiency

Oximeter QualityFlow Quality

Invalid Data Time 0 0.0m %

%%

Fair92.4RIP Quality %

Respiration ReportCreated On: 7/2/2010 11:35 AM Page 1 of 3

Melissa Danielsson, DANME000

MELLISA-HSTA

• Impression:Disconrightreduced.- confirmbyMRI

MELISSA-CLINICALIMPRESSION

CPAPBITE

Age: 23BMI: 21.8

CASE

CASE

• Objective findings: • Mild tenderness was elicited upon palpation of the:

• trapezius neck area on the right, • splenius capitis on the right, • buccinator insertion on the left, • temporal tendon on the left, • styloid process on the right, • posterior joint space on the left, • posterior temporalis on the right, • superficial masseter on the right , • deep masseter on the right

• Moderate tenderness was elicited upon palpation of the: • occipital on the right, • posterior joint space on the right, • lateral TMJ capsule on the right

• Severetendernesswaseliciteduponpalpa5onofthe:• stylomandibularligamentontheright.

• Clinicalexamina:onrevealedtheTMjointswithinnormallimits.

• CRANIALNERVESCREENING:withinnormallimits.

• Cervicalrangeofmo:onmeasurementsindicatedpainonextension,painonsidebend(bilateral)andpainonrota:ononbothsides.

• ORALEXAMINATION:• healthyperiodon:um,• missingtooth#1,16,17,32,• 4mmoverbite,a2mmoverjet,• scallopedtongue,tonguelevel3,grade3mallampa:classifica:on,• teethincrossbite:#5,29,• vaultedpalate,• mandibulartori• ClassIdentalrela:onship.

• MANDIBULARRANGEOFMOTIONMEASUREMENTS:• 44mmopeningwithoutpain,• maximumprotrusiveof3mm,• leLlateralexcursionof12mm,rightlateralexcursionof13mm,• normalmandibularmidline,normalmaxillarymidlineandnormal

skeletalmidlines.

• SprayandStretchimprovedmaximumopeningto54mm.

• MYWORKINGDIAGNOSISIScapsuli:softhebilateraltemporomandibularjoint(ICD726.90),bilateralmyalgia(ICD729.1)andcervicalgiaontheright(ICD723.1).

• PLAN:medica:onregimen:Flexeril10mg1tabatnightPRNdisp30tabs.

• Ourgoalistoruleoutasleepdisorderedbreathingproblemthatmaybeacontributoryreasonforhissubjec:vecomplaints.WehaveadvisedhimtoreturntoourofficeaLercomple:onofthediagnos:cprocessanddiscussionoffindingsfromthemedicaldoctorsatFusionSleep.Basedontheoutcomeofresultswewilldetermineatreatmentplanforhim.

CASE

CASE

CASE-HABITUALOCCLUSION

CASE-DAYAFTERAUTOPAPTHERAPY

“‘SLEEPISEASYASLONGASYOUUNDERSTANDTMD’

DR.JAMISONSPENCERDMD