TMJ and Orofacial Pain
Temporomandibular disorders (TMD) are a common source of facial, headache and tooth pain. There are two basic types of TMD: muscle generated pain, and jaw joint generated pain. It is quite common to suffer from both types simultaneously. It is important to note that these pain conditions are often incorrectly referred to as “TMJ.” TMJ is the abbreviation used for the temporomandibular joint, also called the jaw joint, and is not a disease condition — it is an anatomic structure.
Temporomandibular Disorders (TMD)
TMD SYMPTOMS include pain or discomfort in or around the ear, jaw joint, and/or muscles of the jaw, face, temples and neck, on one or both sides. The pain may arise suddenly and progress with fluctuating frequency and intensity over months to years. Clicking, popping, grating (crepitus), locking, limited opening or deviating jaw movement, chewing difficulties, and headache are also associated with TMD.
Causes for TMD
TMD rarely has a single cause. It is usually a combination of factors in an individual that eventually overwhelms their body’s ability to adapt. These factors include tooth clenching and grinding (bruxism), head and neck muscle tension, facial muscle overload (from gum chewing or finger nail biting habits, etc.), jaw injuries (trauma), and inflammatory joint disease (arthritis). All of these factors are worsened by a dental malocclusion. When teeth don’t fit correctly, a huge stress is placed on the entire head and neck as extra muscle energy is used to avoid tooth contacts that will damage the crooked and crowded teeth.
However, the body’s inherent mechanism to protect the teeth leads to damage and pain in other structures. Many scientific studies on the general population have shown that signs and symptoms of TMD are significantly lower in orthodontically treated patients than in people who never had braces. Having orthodontic therapy and a correct bite does not eliminate your chance of developing TMD, but it significantly lessens your chance of developing a TMD.
A sound bite, obtained through orthodontia, increases your body’s ability to cope with the insults placed on our head, neck and jaws through everyday life stress and traumas.
Treatment for TMD
Treatment varies depending on the findings of an extensive history and physical examination. For most patients treatment begins with an orthotic device, commonly called a bite splint. A splint is acrylic and covers all the teeth in one jaw while it normalizes the fit of the opposing teeth. This device is custom made by our in-office dental lab, which gives us complete quality control. The splint works to relieve pain and inflammation by allowing the muscles to relax, and eliminating excess muscle pressure in the jaw joint. It is important to note that the boil and bite sports mouthguards will not relieve TMD symptoms and many studies have shown they may worsen your problem. The same is true of devices commonly sold in drug stores.
For some patients, a bite splint, may be the only therapy needed to gain significant relief and return to normal function. For others, additional therapy is required. These adjunctive therapies may include physical therapy and judicial use of medications. There are also some patients with a joint dysfunction who benefit from referral to an oral surgeon, but this determination is made after bite splint therapy has been used for several months.
Do I need braces for my TMD?
This varies for each patient. After successful splint therapy we can determine if orthodontia is in the patient’s best interest to maintain a healthy and pain free function. There are certain types of malocclusion where orthodontics is the primary treatment method, as the patient will not improve due to the aberrant forces of the malocclusion. It must be remembered that a correct, stable bite is always healthier for the mouth, head and neck.
Snoring and Sleep Apnea
What is Sleep Apnea?
Sleep apnea is the condition where a person stops breathing for ten seconds or longer while they are sleeping. As their body senses the drop in oxygen in the blood, it briefly awakens them to breathe. It is sometimes noticed as gasping or choking. This cycle occurs repeatedly throughout the night. The repeated awakenings rob a person of a restful night’s sleep, because they do not maintain deep sleep.
This lack of deep sleep causes many dangerous health problems, including artery disease and high blood pressure. There is also an alarming increase in auto accidents in people with untreated apnea.
How Does Apnea Differ From Snoring?
Snoring is the loud, rasping noise made by the vibration of the soft palate, uvula, tonsils or other soft tissues of the airway during sleep. It is estimated that over 60 million Americans snore.
And, the number of people affected by snoring nearly doubles, since the bed partner’s sleep is also affected. (And sometimes, even family members in other rooms.)
Although snoring was once thought to be a physically harmless condition, recent studies indicate the vibration causes atherosclerotic plaques in the carotid artery (Lee, et al., Sleep. 2008 September 1; 31(9): 1207–1213). This is artery disease which leads to diminished blood flow to the brain, and possible stroke.
Although people with apnea snore, it is the stoppage
of breathing that differentiates snoring from apnea.
How is Sleep Apnea Diagnosed?
Sleep apnea is diagnosed with a sleep study, called a polysomnograph or PSG. The patient will sleep in a sleep center and be monitored for one night.
What Treatment is Available?
Treatment falls into 3 categories.
- Oral Devices: These are retainer-type devices that open the airway by moving the lower jaw forward.
- CPAP (Continuous Positive Air Pressure) Machine: A mask is worn over the nose, or nose and mouth, and delivers air under pressure into the throat and lungs.
- Surgical Intervention: There are many differing interventions, discussed in further detail below.
This is the treatment we provide at our office. The same device is used for both snoring and apnea. It works by moving the lower jaw forward. This opens the airway at the base of the tongue, where the majority of obstructions occur. The device is removable and fits over the teeth like an orthodontic retainer.
If apnea has been diagnosed, a second PSG study is needed to determine if the device is effective. If the patient did not have apnea, but is a snorer, no follow-up sleep study is needed.
CPAP is considered the “gold standard” of apnea treatment. It is almost 100% effective when used. The problem is the bulky equipment that must be worn. A fan/humidifier box sits on the nightstand, connecting to a hose, which then connects to a mask that is worn over the nose or face.
This presents problems for people who travel because it is bulky, and for campers, who do not generally have an electric source. Studies have shown that the compliance rate (the number of people using the device) after one year is about 60%. This means 4 out of 10 people who initially used a CPAP, are untreated for their apnea.
Some of our apnea patients, who have a CPAP, will have us make them an oral device to
have as an alternative for nights when using the CPAP is not practical.
There are various types of surgery that can be helpful with snoring and apnea. The least invasive, used for snoring, is removal of the uvula (the tissue that resembles a punching bag, hanging off the soft palate).
For apnea, other “soft tissue” surgery includes a “PPP” – a pharyngopalatalplasty. This surgery is performed by an ENT and includes the removal of the uvula as well as thinning and removal of excess tissue of the throat at the tonsil and base of the tongue area. The effectiveness of these surgeries is generally about 70%.
The other general class of surgery is orthognathic (jaw) surgery. It is common in patients who have a jaw imbalance to have diminished airway due to the position, shape and relationship of the jaws to each other and to the airway.
In patients who are candidates for orthognathic surgery, there is benefit far beyond treatment of their apnea, as they also get enhanced function and esthetics of their teeth and jaws. These patients require braces for optimal results and we work closely with the oral surgeon.
(See our section Jaw Surgery and Orthodontics for more information.)
What to Expect At Your Snoring/Sleep Apnea Appointment At Our Office
Your apnea evaluation appointment includes taking a history of symptoms, a physical evaluation, and x-rays to determine both the nature of the problem and if an oral appliance would be successful.
If we determine there is a good chance of success with an oral appliance, we can then start the process of fabrication of the device. We will also refer you for a sleep study, if we suspect you have apnea.
If we determine that an oral appliance will not be successful, we will refer you to an appropriate specialist.
As with all of our exams, Dr. Lawrence sets aside time, just for you, to review all of our findings and recommendations. We want you to be fully comfortable with our recommendations and to feel comfortable asking any questions.