Legacies of Drs. Gordon Zink and

B.A. TePoorten

Mark S. Cantieri, DO, FAAO

J. Gordon Zink, DO, FAAO

The Garbage man, The fluid freak, The lymphomaniac. A vain/vein man.

Bernard A. TePoorten, DO, FAAO

DMU-COM Fellows

Most recognized works

• Piriformis Syndrome (TePoorten)

• Common Compensatory Pattern (Zink)

• Respiratory Circulatory Model (Zink)

Piriformis Syndrome: Why is it tight?

• Posture, chronic muscle shortening.

• Weakness.

• Joint instability of the hip capsule or the

sacroiliac joint.

Zink: Common Compensatory Pattern , i.e

Torsional Strain Patterns.

Common areas of strain:

Occipital-Cervical Junction

Cervico-Thoracic Junction

Thoraco-Lumbar Junction

Lumbo-Sacral Junction

Common Compensatory Pattern

• Occiput posterior on the right.

• C2NRLSR

• T1FRSR (Thoracic inlet)

• Elevated left first rib

• Depressed right first rib

• T10 to L2, NRLSR (Thoracolumbar transition

area)

Common Compensatory Pattern

• L5NRRSL

• Left on left forward sacral torsion

• Anterior right and posterior left innominates

• Cephalad left and caudal right innominates

• Longer right arm

• Longer left leg

Respiratory Circulatory Model

• Consistent with A.T. Still’s Rule of the artery

is supreme .

• Normalization of arterial blood flow is

dependent upon unrestricted venous and

lymphatic drainage.

• Unimpaired diaphragmatic movement results

in normalized venous and lymphatic drainage

by the creation of pressure gradients .

Supine Respiration - Types

• Costal

• Mixed

• Diaphragmatic, Eupnea

• Other signs of abnormal respiration: Nasal

flaring, mouth breathing, keratotic ridges of

the inner cheeks, scalloped tongue, septal

deviation, teeth crowding, coated tongue,

grinding, abnormal nasal exam.

Respiration - Depth

• Supine patient observation.

• Costal. Wallet maneuver.

• Abdominal movement?

• To umbilicus?

• To pubes?

Zink quotes:-

-Pain is the cry of the tissues for oxygen.

-External respiration determines internal respiration.

-All spinal curves straighten with inspiration.

Benefits of Nasal Breathing

• Warms to 36° C

• Humidifies to 95% relative humidity

• Cleans inhaled air

• Stimulates the release of nitrous oxide. This is a potent antimicrobial, antioxidant and smooth muscle relaxant.

• Nasal mucosa contains IgA

• Normal development of the palette and dentition.

SDB Infants and Children

Funct Orthod. 2001 Fall;18(3):24-7.

Breastfeeding is early functional jaw orthopedics (an introduction).

Page DC1.

Author information

Abstract

Breastfeeding places beneficial orthopedic forces on the jaws, similar to the forces of Functional

Jaw Orthopedics--the newest form of orthodontics. To date most breastfeeding benefits have

been attributed to the content of mother's milk. The true orthopedic benefits of breastfeeding,

suckling, deserve more definitive attention and research. Breastfeeding is early preventive

Functional Jaw Orthopedics because breastfeeding forces impact the jaws during a very rapid

period of infant jaw growth. Breast suckling aids proper development of the jaws which form

the gateway to the human airway. Bottle, pacifier and digit sucking deform jaws and airways.

Forward forces of suckling clearly oppose the backward forces of sucking. Dentists who

understand the positive impact of forward orthopedic forces on the jaws should support and

advocate exclusive breastfeeding for about 6 months.

• All children should be screened for snoring.

Per American Academy of Pediatrics

guidelines.

• Those with snoring should have an in lab

sleep study.

• T&A’s. 75% redeveloped SDB within 3 years

of surgery.

Altered respiratory pattern, such as breathing through the mouth rather than the

nose, could change the posture of the head, jaw, [teeth,] and tongue”. These

manifestations include, but are not limited to the following:

• Mouth breathing (day and night)

• Forward head posture

• Tongue scalloping

• Coated tongue

• Bruxism (clenching and/or grinding of the teeth)

• Deficient midface

• Deficient mandible

• Narrow or collapsed dental arches

• Vaulted palate

• Enlarged tonsils and/or adenoids

• Tubes in the ears

• Fatigue

• Snoring

• Low-resting tongue posture

• Dental malocclusions (tooth crowding, overjets, overbites, open bites, and

crossbites)

• A recurrence of sleep apnea within one year post T&A.

Myofunctional Therapy

• The study and treatment of oral and facial muscles as they relate to speech, dentition, chewing/bolus collection, swallowing, and overall mental and physical health.

• The tongue will be trained to function like a natural retainer that minimizes aggressive orthodontic work. We have heard it said that people’s teeth shift because they did not diligently wear their retainers for the recommended amount of time. Yet, Myofunctional Therapy trains the tongue to rest high in the roof of one’s mouth, which will naturally help prevent potential relapse of orthodontic cases. We should seek to answer the question of why teeth became crooked in the first place.

Detrimental Effects of Oral Breathing

• Increased rate of upper and lower airway

infections.

• Significant postural changes to open a

compromised airway. Over time these

changes lead to various MSK pain issues.

• Sleep disordered breathing (SDB).

• Abnormal jaw, maxillary and oral

development.

Postural changes due to mouth breathing

41

41

41

Clawing of Toes

Transverse Metatarsal Ligaments

Metatarsal Taping

Detrimental Effects of Oral Breathing

• Increased rate of upper and lower airway

infections.

• Abnormal jaw, maxillary and oral

development.

• Significant postural changes to open a

compromised airway. Over time these changes

lead to various MSK pain issues.

• Sleep disordered breathing (SDB).

Sleep Disordered Breathing

• Sleep-disordered breathing is a chronic disorder caused by repeated upper-airway collapse during sleep, resulting in recurrent nocturnal asphyxia, fragmented sleep, major fluctuations in blood pressure, and increased sympathetic nervous system activity.

• Furthermore, patients with untreated sleep-disordered breathing are at increased risk of hypertension, stroke, metabolic syndrome,, heart failure, diabetes, car accidents, anxiety and depression.

Lancet Respir Med. Author manuscript; available in PMC 2015 Oct 1.

Published in final edited form as:

Lancet Respir Med. 2015 Apr; 3(4): 310–318.

Published online 2015 Feb 12. doi: 10.1016/S2213-2600(15)00043-0

PMCID: PMC4404207

NIHMSID: NIHMS664840

Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study

R Heinzer, S Vat, P Marques-Vidal, H Marti-Soler, D Andries, N Tobback, V Mooser, M Preisig, A

Malhotra, G Waeber, P Vollenweider, M Tafti,* and J Haba-Rubio*

Author information ► Copyright and License information ►

The publisher's final edited version of this article is available at Lancet Respir Med

See other articles in PMC that cite the published article.

Go to:

Summary

Background

Sleep-disordered breathing is associated with major morbidity and mortality. However, its

prevalence has mainly been selectively studied in populations at risk for sleep-disordered

breathing or cardiovascular diseases. Taking into account improvements in recording

techniques and new criteria used to define respiratory events, we aimed to assess the

prevalence of sleep-disordered breathing and associated clinical features in a large population-

based sample.

Methods

Between Sept 1, 2009, and June 30, 2013, we did a population-based study (HypnoLaus) in

Lausanne, Switzerland. We invited a cohort of 3043 consecutive participants of the

CoLaus/PsyCoLaus study to take part. Polysomnography data from 2121 people were included in

––

Findings

The median apnoea-hypopnoea index was 6·9 events per h (IQR 2·7–14·1) in women and 14·9

per h (7·2–27·1) in men. The prevalence of moderate-to-severe sleep-disordered breathing

(≥15 events per h) was 23·4% (95% CI 20·9–26·0) in women and 49·7% (46·6–52·8) in men.

After multivariable adjustment, the upper quartile for the apnoea-hypopnoea index (>20·6

events per h) was associated independently with the presence of hypertension (odds ratio 1·60,

95% CI 1·14–2·26; p=0·0292 for trend across severity quartiles), diabetes (2·00, 1·05–3·99;

p=0·0467), metabolic syndrome (2·80, 1·86–4·29; p<0·0001), and depression (1·92, 1·01–3·64;

p=0·0292).

Interpretation

The high prevalence of sleep-disordered breathing recorded in our population-based sample

might be attributable to the increased sensitivity of current recording techniques and scoring

criteria. These results suggest that sleep-disordered breathing is highly prevalent, with

important public health outcomes, and that the definition of the disorder should be revised.

Pharmacotherapeutic Failure in a Large Cohort of

Patients With Insomnia Presenting to a Sleep

Medicine Center and Laboratory: Subjective

Pretest Predictions and Objective Diagnoses

Barry Krakow, MD'Correspondence information about the

author MD Barry KrakowEmail the author MD Barry Krakow,

Victor A. Ulibarri, BS, Natalia D. McIver, BS

Mayo Clinic Proceedings, Volume 89, Issue 12

Published online: September 15, 2014

DOI: http://dx.doi.org/10.1016/j.mayocp.2014.04.032

SDB

• Out of 1200 insomniacs 900 were using Rx

sleep aids and failing pharmacotherapy. 91%

of these had a physical condition causing the

insomnia, OSA.

• In insomniacs 100% reported that there was

no breathing disorder associated with their

awakening while 90% showed sleep

disordered breathing in a sleep lab.

Reliable signs of SDB

1. Dry mouth

#2 Morning Headaches

• Obstructive sleep breathing (OSA) or SDB

leads to a build up of CO2. This will cause

vasodilation of the cerebral arteries and the

sensation of headache or a band around the

head.

#3 Nocturia

• Obstruction of the upper airway leads to

increased intrathoracic negative airway

pressure.

• This causes increased venous pressure causing

an increased flow of blood into the right

atrium. The right atrium distends and

experiences a false fluid overload.

• This results in the release of atrial natriuretic

peptide (ANP) the body’s natural diuretic.

Positive airway pressure (PAP) treatment ends

the nocturia.

Patient Chief Complaints

• Can’t sleep.

• Can’t fall asleep

• Can’t stay asleep

SDB Reality

• Snoring, choking, gasping, struggling for breath and cessation of breathing are all denied by the patient but present on their sleep study.

• Zolpidem, Lunesta, trazadone don’t treat sleep apnea, and in fact worsen the patient’s symptoms.

• If a patient fails these meds they need a sleep study.

Other clues to SDB

• Sleep questionnaire's: STOP BANG, Epworth Sleepiness Scale, Berlin and G.A.S.P. (BEARS for children)

• Physical examination of the head clues: Scalloped tongue, tori, coated tongue, forward angle of the upper and lower incisors, gapping of the bite laterally, keratotic ridges of the inner cheeks, septal deviation, mouth breathing, TMJ pain; pterygoid, temporalis and masseter pain, stylomandibular ligament pain and occipital pain.

Other Causes of TMD

Causes of clenching:

• Obstructive airway issues

• Chronic pain that is recognized and

unrecognized by the patient and the

physician.

• Generalized inflammation, often dietary in

origin.

• Elhers Danlos Syndrome

Motor Nerve Reflex Testing

(MNRT)

• Autonomic reflex testing to identify primary structural issue causing postural instability.

• It is a triage system that gives one a starting point for the treatment of complex pain cases.

• Used on every patient in Sleep Therapy Centre’s in order to make proper referral for treatment of a patient’s pain disorder.

• Allows the DDS/DO/MD to speak the same language.

TMJ & Sleep Therapy Centre

• Centre Directory tmjtherapycentre.com

• American Board of Craniofacial Pain (ABCP Diplomats) abcp-us.org

s

A primer on the first level of evaluation in the

practical application of neuropostural

evaluations (P.A.N.E. process). By John L. Beck,

MD Volume 8, Issue #9 Neurodevelopmental

Basis for Chronic Regional Pain Syndrome

Published on Practical Pain Management

(http://www.practicalpainmanagement.com)

Dan D.

• Initial evaluation 01/20/2014

• CC: LBP and right knee pain for 6 years

• ROS: Snoring, daytime sleepiness and fatigue, awakens gasping for breath, dry mouth qam, and restless sleep

• Tx: Prolotherapy on 5 occasions through 6/24 for LS and SI sprains.

• Patient’s pain is better but feels like results from treatment have plateaued.

• Wife is complaining of his snoring. Prior orthodontics, uvalectomy, sinus surgery and T&A. Referral to Dr. Klauer 6/24 as well as for a lumbar MRI

Lumbar MRI 07/14/2014

• CC: Central and right-sided LBP

• Right L5-S1 disc protrusion 1.8 x 0.8 cm (large)

abutting the right S1 nerve root.

• Moderate bilateral foraminal stenosis.

Dr. Klauer’s Treatment 07/28/2014

• Toe spacer between 1st-2nd digits of the right

foot!

• Oral appliance to address TMJ inflammation.

• Referral to ENT/Sleep certified physician.

Dan D.

• 7/29 LB and RLE pain. Rx: Medrol Dosepack

and LowDye taping.

• 8/14 Pain is better 75% better. Took widget

out 1 week later.

• 9/19 Worse. Resumed widget . Did well

thereafter and would tape or use toe spacer

when physically active.

Adult Care Goals

• Recognize pain and somatic dysfunction may only

be symptoms, look for the primary cause.

• Add knowledge of multiple treatment modalities

to your toolbox: Multiple OMT techniques,

regenerative medicine and exercise instruction.

• Collaborate: PT, myofunctional therapists, ENT

with sleep medicine certification, DDS with sleep

and TMJ expertise, orthodontists, speech and

myofunctional therapists, orthopods,

neurosurgeons and et al. It takes a team.

Mind, Body, Spirit

Post Treatment