Posted by Craig on March 27, 2002 at 15:43:12:

In Reply to: Bruxism posted by Paul on March 23, 2002 at 19:44:14:

The NPSG seems to have revealed three major abnormalities:
1. mild OSAs
2. PLMs with a mildly increased PLMAI
3. Bruxisms that appear to initiate arousals

I have the advantage of seeing Dr. Hull's comment. I do agree that the significance of the PLMs may be underestimate when calculating the PLMAI from a single night. Unfortunately, the usage of a dopaminergic agent may worsen her "nightmares."

I would approach her by treating all three disorders at once:

1. OSA: Although her OSAs is mild, it is known that symptoms do not always follow the degree of the AHI. I would be inclined to treat the OSAs initially.

Since the patient is already accustomed to using a dental device to protect her teeth from bruxism, I would probably refer her to a dentish for a dental prosthetic for MILD OSAs. (This is also in combination with the concern that a 40 year old female with a questionable history of fibromyalgia would probably not be compliant with CPAP even on a trial basis.)

2. PLMs: I would discuss with her primary MD, the concern of "fibromyalgia." I would favor discontinuing the SSRI that may worsen PLMs.

I would probably give the patient a low dose benzodiazepine after the fitting of the dental prosthetic. As stated above, I would be concerned that a dopaminergic agent may worsen the nightmares. Also, the combination of bruxism, nightmares and a question of fibromyalgias do make me concerned that there might be a degree of somatized stress with this patient that a benzodiazepine may treat. (Also, if she is complaining to you of this now, she is an accountant who is in the middle of tax season.)

Homework I would want to do:

1. Was there a significant sleep stage or positional dependence for the OSAs? (For instance, was the total RDI 15, but the REM RDI 50 and the recurrent REM arousals is why she recalls nightmares)

2. Ask the patient about other medications (especially caffeine containing compounds or diet pills) and alcohol usage (Abstaining from alcohol may mean that her OSAs is worse at home, answer questions about her nightmares, and maybe "alcohol withdrawal" is why we saw these dramatic bruxisms?

3. I also would give her a sleep log? (Remember, accountant during tax season with a lot of bruxism...is she under a lot of stress and spending irregular hours at the office?)

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• Re: Bruxism Paul 18:48 3/30/02 (0)

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