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This position paper, as developed by a Task Force of the American Academy of Craniofacial Pain on Mandibular Advancement Oral Appliance Therapy for Snoring and Obstructive Sleep Apnea, contains recommendations for dentists engaged in the management of patients with snoring and obstructive sleep apnea utilizing mandibular advancement oral appliances. The recommendations are supported by current scientific evidence, published standards and guidelines, and expert panel consensus. Snoring and obstructive sleep apnea (OSA) affects millions of people. Oral appliance therapy (OAT) is recognized as an effective therapy for many with primary snoring and mild to moderate OSA, as well as those with more severe OSA who cannot tolerate positive airway pressure (PAP) therapies. Dentists are playing a much larger role in the screening and management of patients with snoring and OSA as part of a multi-disciplinary team. It is also recognized that OAT has the potential to cause untoward side effects, including temporomandibular joint (TMJ) pain and dysfunction. The present paper highlights the need for dentists who manage patients using mandibular advancement OAT to be competent in the assessment, diagnosis and management of temporomandibular disorders (TMDs) and craniofacial pain disorders. The authors of this article are all clinically engaged in the management of patients with snoring and OSA, and reached consensus based on their review of the current evidence, published guidelines and clinical experience. It is the opinion of the authors that dentists experienced and knowledgeable in the assessment, diagnosis and management of TMD and craniofacial pain applying this knowledge to the management of patients with snoring and OSA using OAT will provide their patients with the best prognosis and most successful treatment outcomes.

Dr. Charles Greene's article, "Managing the Care of Patients with TMDs A New Guideline for Care," and the American Association for Dental Research's (AADR) 2010 Policy Statement on Temporomandibular Disorders, published in the Journal of the American Dental Association (JADA) September 2010, are reviewed in detail. The concept that all temporomandibular disorders (TMDs) should be lumped into one policy statement for care is inappropriate. TMDs are a collection of disorders that are treated differently, and the concept that TMDs must only be managed within a biopsychosocial model of care is inappropriate. TMDs are usually a musculoskeletal orthopedic disorder, as defined by the AADR. TMD orthopedic care that is peer-reviewed and evidence-based is available and appropriate for some TMDs. Organized dentistry, including the American Dental Association, and mainstream texts on TMDs, support the use of orthopedics in the treatment of some TMDs. TMDs are not psychological or social disorders. Informed consent requires that alternative care is discussed with patients. Standard of care is a legal concept that is usually decided by a court of law and not decided by a policy statement, position paper, guidelines or parameters of care handed down by professional organizations. The 2010 AADR Policy Statement on TMD is not the standard of care in the United States. Whether a patient needs care for a TMD is not decided by a diagnostic test, but by whether the patient has significant pain, dysfunction and/or a negative change in quality of life from a TMD and they want care. Some TMDs need timely invasive and irreversible care.

Forty-eight (48) consecutive patients seeking treatment in a referral based practice for complex chronic painful temporomandibular joint (TMJ) disease were enrolled in a prospective study to assess specific symptom relief from anterior repositioning appliance (ARA) therapy and the relationship between specific symptom relief and the status of the TMJ disk. Each patient was assessed on 86 symptoms based upon whether each symptom was present before treatment and absent, better, unchanged or worse after Maximum Medical Improvement (MMI). The most common symptom was occipital cephalalgia (94%). The least common symptom was pain and burning of tongue (8%). A profile of a temporomandibular disorder (TMD) patient was developed. The typical TMD patient has cephalalgia, mainly in the occipital, temporal and frontal region, pain upon chewing food, pain upon opening and closing the mouth, TMJ pain, pain in the back of the neck and difficulty chewing food. Before treatment, patients with bilateral displaced disks had more symptoms than those with unilateral displaced disks and the opposite side normal. After MMI, the maximum benefit (percent of pretreatment symptoms relieved) was found in patients with normal or recaptured disks. The minimum occurred in patients whose disks did not recapture with therapy. ARA therapy improved or eliminated symptoms in all patients in the study.

Most patients do not require magnetic resonance imaging (MRI) of the temporomandibular joint (TMJ) to make the diagnosis of acute disc dislocation without reduction. The patient will typically repo...