Page 51 - JSOM Summer 2025

patient experienced significant reduction in DNB, nightmares, and other parafunctional-associated dental behaviors, where it
poor sleep quality, headaches, and frequent awakenings within contributes to improved sleep quality and overall well-being. 25
1 week of device use. The device has provided relief from these
PTSD and TBI symptoms for over 4 years. Sleep medicine literature suggests that polysomnography is
considered the gold standard for documenting sleep disrup-
Case Three tions; however, capturing DNB activity in a laboratory setting
27
A 43-year-old male Special Forces Operator diagnosed with is rare. Therefore, current diagnostic criteria for TSD and
PTSD in 2014 by U.S. Army psychologists after one combat de- DNB are primarily clinical in nature and dependent on obser-
ployment. Prior to treatment, the patient reported nightmares vations and symptoms that are self-reported or provided by a
every night, with multiple nightmares per night on a consis- bed partner prior to treatment. 25–28
tent basis; severe headaches on waking every morning, with
progression to migraines two to three times a week; and poor Symptoms consistent with TSD and DNB occurring in mili-
sleep quality and fatigue during day. Screams and DNB were tary servicemembers are highly prevalent and often associated
2,5
frequently, as reported by the sleep partner. After 4 months, with combat exposure, specifically insomnia in those with
the patient reported nightmares, headaches, migraines, cold sexual trauma (60.8%) compared to those without sexual
sweats, and disruptive nocturnal behavior episodes as com- trauma (51%), with rates of 41% among those deployed to
pletely resolved. The time to fall asleep greatly improved, with combat zones versus 25% in non-combat zones. Other sleep
2,5
sleep duration lasting 6–7 hours per night with an increased behavior disorders, such as TASD and dream enactment be-
quality of sleep and a significant decrease in daytime sleepi- havior (DEB), exhibit similar clinical causes and symptoms as
ness. Social relationships were reported as improved, with an- DNB and TSD, which consist of inciting traumatic experience;
ger issues better controlled and handled. The patient stated he altered dream mentation and enactment; self- or witnessed
was very pleased with the device. reports of DEB with vocalizations, screaming thrashing, or
combative behaviors (e.g., kicking, punching, or abnormal
Case Four motor behaviors); and autonomic hyperarousal characterized
A 54-year-old male senior Special Forces Sergeant, with multi- by tachypnea, tachycardia, and diaphoresis. 2,5,25–29 An import-
ple combat deployments, combat-associated PTSD diagnosed ant distinction between patients with NMD and TASD is the
by VA psychologists and complaints of nightmares up to five presence of DEB, which exhibits excessive muscle activity,
or more times a week. The sleep partner reported that DNB displaying movements, and complex vocal and motor behav-
occurred nightly. Two years prior to returning for treatment, iors during sleep, similar to those seen in rapid eye movement
this patient had used the device and the sleep partner reported (REM) sleep behavior disorder (RBD). 30
that DNB symptoms had completely resolved. Severe bruxing
destroyed the device, and all DNB symptoms returned. The The neurophysiological link between PTSD, anxiety disorders,
patient’s sleep partner insisted the patient return and ob- and the stomatognathic system remains underexplored in sleep
tain another device. A new device was fabricated to the pre- medicine. TMD symptoms affect 15% to 24% of PTSD pa-
31
vious specifications and all symptoms of the DNB resolved tients and up to 31% in certain populations, while 30% may
within a week, according to the sleep partner. The patient re- experience sleep and awake bruxism, distinct from obstructive
ported improved sleep quality and ability to engage in daily sleep apnea (OSA)-related bruxism. 32–34 TMD-related injuries
activities. to the temporomandibular joint, masticatory muscles, and as-
sociated tissues are major contributors to non-dental orofacial
pain, with chronic nocturnal bruxism indicating pathological
Results
31
hyperactivity. Chronic pain from nocturnal bruxing, exacer-
This case series is the first to demonstrate the effectiveness of bated by PTSD and TBI, may disrupt sleep by activating the
23
a removable intraoral neuroprosthesis in attenuating DNB V2-V3 trigeminal nerve biofeedback loop. The observed reso-
and certain sleep disorders in combat PTSD patients. Observa- lution of nightmare-driven DNB may stem from pain reduction
tions from sleep partners revealed complete or near-complete achieved by the dental device, rather than the elimination of
resolution of DNB events in all cases, while patients reported bruxing activity itself.
marked improvements in sleep quality, oral posture, temporo-
mandibular joint conditions, rest, and overall well-being. The Normal bruxing episodes may play a role in inducing and
results suggest that PTSD may be associated with an upreg- maintaining sleep, but PTSD and TBI can upregulate the
ulated stomatognathic system, potentially facilitating night- stomatognathic system, leading to excessive joint and dental
mares and exacerbating DNB. Additionally, the device showed pain that degrades sleep quality and duration. This paradox
impressive durability, with efficacy maintained for periods may be explained by research indicating that bruxing triggers
ranging from 4 to 36 months, even under significant intraoral GABA production, which significantly influences the ascend-
pressures exerted by the bite force during DNB episodes. These ing reticular activating system (ARAS). 32,33 The ARAS receives
findings point to a promising therapeutic approach for manag- glutamate inputs that release noradrenaline, dopamine, and
ing complex PTSD-related sleep disturbances. acetylcholine, driving systemic effects like increased heart rate
and breathing rates, commonly observed in PTSD patients
with sleep bruxism. GABA production, essential for sleep,
35
Discussion
is mediated by the activation of masticatory muscles, which
The mandibular dental splint has a safety track record extend- are innervated by the mesencephalic nucleus and regulated by
35
24
ing a century. It is FDA-cleared for use in stomatognathic the trigeminocervical nucleus. These interconnected systems,
conditions involving the teeth, jaws, masticatory musculature, including the mesencephalic trigeminal nerve’s relationship
and associated parasomnias. It is also effective in attenuat- with the ARAS, highlight the complex neural pathways linking
24
ing sleep-related issues, such as those associated with PTSD bruxism, sleep regulation, and PTSD. 36
Intraoral Neuroprosthesis for PTSD-Associated Nocturnal Behavior Disorder | 49