Page 50 - JSOM Summer 2025

sleep disorder (TSD) and DNB is characterized by the uncon- conducted by a Veterans Affairs (VA) psychologist, and were
scious motor activity of the patient during sleep. 14,15 This activ- observed having episodes of frequent DNBs by their sleep
ity interferes with the patient’s ability to obtain quality sleep, partners. DNB events were defined as noticeable symptoms,
results in daytime fatigue, and also presents a clear and present including screaming, thrashing, combative behavior, and ac-
danger to the sleep partner. 15 cidental trauma to the sleep partner. A physical assessment
was completed for masticatory muscle trigger points, exces-
Numerous publications have discussed the prevalence, symp- sive dental wear, temporomandibular joint pain, and nocturnal
toms, and effects of PTSD and PTSD / traumatic brain injury headaches. An intraoral neuroprosthesis device was individu-
16
(TBI) on mission readiness in Big Army units, but there is ally fabricated, a constructed soft mandibular splint from ther-
scant documentation on how these conditions affect the be- moplastic material as described in Moeller et al., and Giddon
havior of smaller Special Operations Units. In the most elite et al. (Figure 1). 20–22 The sleep partners of the participants were
units of the United States Armed Forces, recent findings sug- educated on combative activity and the changes they should
gest a “unique constellation” of symptoms first defined by see. They were then asked to record their observations and
17
Frueh et al. in 2020 as operator syndrome. Operator syn- provide subjective data at the point where they observed a de-
drome is characterized by a common structured pattern and an crease in DNB events.
accumulation of neural responses from chronic stress, which
lead to specific healthproblems. 17,18 These findings further un-
derscore the need for additional clinical research and compre-
hensive, intensive immersion programs to address the unique
needs of this community.

The interconnectedness of the symptomatology in operator syn- FIGURE 1 Neuromodulating
drome closely maps standard PTSD and PTSD/TBI symptoms, intraoral neuroprosthesis used in
including sleep disturbances; headaches; chronic sleep depriva- the cases.
tion and poor quality of sleep; mental health mood disorders,
such as depression, suicide, and anger; cardiovascular disease;
type 2 diabetes disturbances; hypervigilance; hallucinations;
immune system dysfunction; dysfunctional social interactions;
DNB, bruxing; and temporomandibular disorders. 8,9,17,18

Functional magnetic resonance imaging (fMRI) has demon- WIRB Copernicus Group (WCG) IRB Affairs Department
strated the activity of the orbitofrontal cortex following the reviewed the study under the Common Rule and applicable
19
insertion of an oral device. This type of neural pathway acti- guidance and determined that the study was exempt with a
vation with an oral device is especially important in improving waiver of consent under 45 CFR § 46.104(d)(4). Study partic-
the cognitive processes in decision-making and emotions. In ipants were not involved in the design, conduct, interpretation
2013, Moeller et al. were the first to report the potential effi- or translation of current findings. Consents were previously
cacy of a mandibular splint as an intraoral neuroprosthesis to obtained, and no harm or injury was reported.
attenuate parasomnias in pilot study of 30 combat veterans and
civilians affected by PTSD. 20,21 Furthermore, Giddon et al. sug- Case One
gested that PTSD-associated nightmares, sleep disruptions, and A 45-year-old male Special Forces Operator who had served
nocturnal headaches could be significantly attenuated with a two military combat tours, reported nightmares four to five
mandibular device, such as an intraoral neuroprosthesis. The times a week, difficulty initiating sleep (fear of nightmares),
22
neuromodulation from the intraoral device affects the trigemi- short, interrupted episodes of sleep, non-restful DNB, and daily
nal cervical nucleus by working on the masticatory muscles and headaches on waking. After four months of treatment, night-
Golgi tendon sensors. This interaction modulates afferent and mares and sleep disturbances resolved, sleep duration increased
efferent neural pathways, helping to regulate and reduce dis- by 3 hours per night, and night awakenings and episodes of
ruptive nocturnal behaviors by stabilizing neuromuscular ac- diaphoresis were reported as completely resolved. Additionally,
tivity and improving the coordination of airway and behavioral the amount of time to initiate sleep significantly decreased, and
control during sleep. The fabrication of these devices requires no events of DNB were reported by the bed partner. The patient
23
a clinically titrated level of occlusal material that is greater then reported experiencing improved attitude, reduced awareness
that of a standard dental splint. This results in a constant neu- of anger, and improved ability to focus. He described the use of
romodulatory effect, further impacting the autonomic nervous the intraoral neuroprosthesis as “life changing.”
system response and nasal breathing during sleep. 23
Case Two
In a first-of-its-kind study, we describe the use of an existing A 64-year-old male Special Forces Senior Non-Commissioned
intraoral neuroprosthesis to attenuate the symptom frequency Officer, diagnosed with combat-associated PTSD in 2003 by
of the accepted definition of DNB in four patients with com- civilian psychologists and having served multiple (greater than
bat-associated PTSD and associated nightmares, headaches, six) combat deployments and sustained two documented sig-
and sleep disruptions as observed by the bed partner. nificant TBIs. Nightmares occurred three to five times a week
and were associated with poor sleep quality and duration as
well as awakenings. The patient experienced routine difficulty
Methods
initiating and sustaining restful sleep. The patient’s sleep part-
The four patients in this case series met the inclusion criteria ner, a healthcare professional, documented years of chronic
with a diagnosisof long-standing combat PTSD, a diagnosis DNB with gross body movements and vocalizations. This

48 | JSOM Volume 25, Edition 2 / Summer 2025