managing side effects of oral appliance therapy
TRANSCRIPT
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
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
