A recent article in J. Orofacial Pain & Headache, (the Journal of the American Board of Orofacial Pain of which I am a Diplomat) reviewed success rates of treating TMJ problems by Occlusal Adjustment (also called Equilibration of teeth). Occlusal Adjustment was the final treatment after the Dentists initially used a nightguard, then a splint. Neither treatment helped the pain complaints of headache or facial pain. As a final effort to alleviate the symptoms the Dentists decided to equilibrate the teeth because, as the article suggests, “they didn’t know what else to do”. This was reported to have been done despite the dentist’s foreknowledge that equilibration had a low success rate in alleviating TMJ symptoms.
In the American Academy of Sleep Medicine this abstract was included in one of the “most Popular” from last year and it was worth reminding parents of children. The article reviewed the relationship of children, nighttime bruxism (grinding/popping teeth) and preschool behavior problems.
Preschool children who grind their teeth and are withdrawn have lower school performance. This article in the Journal of the American Academy of Sleep Medicine was one of last year’s most popular topics for a good reason.
The study had just over 1500 preschool aged children enrolled. It asked whether the kids snored and then had observations from the parents that indicated the children who snored were more withdrawn, didn’t get involved with other children and had trouble adjusting to preschool. The more days per week these preschool children snored (starting at 1 day – up to 4 days) the observed negative behaviors increased. Interestingly these behaviors started presenting as the front teeth began to grow in (this is when the negative growth and physiologic effects of large tonsils/adenoids become problematic from a TMJ and Dental Sleep medicine specialist).
The article advises that preschool children get 11-13 hours of sleep (which is normal at this age – many parents are surprised at how much sleep kids need), it also mentions stress as a “possible” factor.
Suggestions from both Dental and Medical Sleep Specialists for children as bedtime approaches are universal; have a set bedtime and allow 30 minutes to “wind down”. No electronics of any kind for 30 minutes prior to bed. Interact with your children in a non-stimulating way as they wind down – read to them, etc. In our hectic schedules this can be hard to start, but once it’s established (may take a couple weeks or so of patient but hard work to establish the routine) it gives parents extra time to also wind down after their kids are asleep earlier!
From Dental Sleep Medicine and TMJ perspectives, this article is based on the fails to address the most important reasons early childhood bruxing occurs; large tonsils and adenoids that restrict breathing while kids sleep. This is Sleep Apnea and is directly correlated to behavior problems in children, lower academic performance, and ADD/ADHD-like behavior. These correlations are well documented in the Dental Sleep literature as well as the American Academy of Sleep Medicine journals. Evaluation by a Dentist trained in Dental Sleep Medicine and TMJ/growth for airway obstruction and altered facial development is recommended.
Facial growth is also recognized with infants who are “tongue tied” because they don’t nurse well. Many pediatric dentists are beginning to evaluate this critical anatomic problem – treatment is easy and fast to “free the tongue”. Myofunctional and Speech therapists also recognize this condition.
If your preschool and grade school children have problems going to sleep, staying asleep or snore even once per week they should be evaluated.
Abstract Title: Indirect Effect of Tooth Grinding on Preschool Performance Presentation Date: Tuesday, June 10, 2017. Category: Pediatrics, Abstract ID: 0210, Updated Nov. 6, 2017
Over the past few years, I have seen a growing number of young women and girls with aggressive, degenerative arthritis in their TMJ joints. They didn’t have pain until the damage was late, usually a couple years after clicking started in their joint. Clicking in a TMJ means that the cartilage disc has torn off of the bone and no longer cushions the joint. Arthritis will start soon after. Typically it is wear and tear arthritis, but more recently I’ve seen the aggressive arthritis as mentioned in this study.
The study results align with my experience and more specifically targets juvenile idiopathic arthritis and its underdiagnoses. As the article reports, the TMJ diagnosis is often late because it’s rarely painful in the first 1-2 years.
The two hallmark signs that should prompt an evaluation are limited mouth opening (normal for all ages is the width of 4 fingers between the front teeth – or above 40-44mm open) and clicking in the jaw joint. Either sign should prompt a clinical and radiographic evaluation by an experienced TMJ specialist to assess for early signs of the degenerative joint disease.
The study recommends that to prevent lifelong orofacial complications, early recognition and treatment is important. The signs or symptoms in teenage and early adult females are changes in the bite, TMJ clicking or popping and/or pain in the TMJ area. Young girls seem to be more likely to have this condition, but males are also affected.
A clinical exam of the TMJ along with our high resolution, low dose i-cat 3-D imaging can show the early signs of degernative joint disease and clinical limitations that are associated with it. Decompressing the TMJ with orthotics is one of the most important interventions to arrest the disease. Additionally we would refer for JIA (juvenile idiopathic arthritis) testing in the event other joints might be at risk.
Sleep is essential for our bodies to rest and repair and it’s the only time our brain gets a chance to rest, regenerate, and clean up the memories and inputs from the day. During sleep, there are distinct stages of sleep that help the brain rest and recover, and other stages allow the muscles and joints to decompress and repair daily damage.
When sleep is disrupted by not breathing well (sleep apnea, snoring, etc.) the specific stages of restful and restorative sleep are also disrupted. Over time, the brain gets overloaded with toxins, excess information that hasn’t been properly stored, etc.
In one study from 2007, depression was cited to affect 20% of the adult population. At that time, the statistics also showed about 20% of adults also has Obstructive Sleep Apnea (or OSA).
The prevalence of both has dramatically risen in recent years and may also reflect the inter-relationship between proper sleep and mental health. The amount of sleep disruptions, severity of being tired during the day, correlated with levels of depression.
The repeated oxygen deprivation during sleep apnea and sometimes chronic low oxygen in snorers leads to changes in brain chemistry that may lead to neurocognitive changes. Serotonin reuptake inhibitors, the mainstay of treatment for depression, may have a slight negative effect on the airway dilator muscles that are responsible for keeping the airway open while we sleep.
If someone is developing a sleep breathing disorder (due to anatomy, aging, weight gain, etc.) is it possible that SSRI’s can contribute to development or worsening of a sleep breathing disorder. New medications are always being looked at in treatment of depression.
Repeated oxygen starvation also causes significant inflammation throughout the cardiovascular system and in the brain. Inflammation chemicals called cytokines also play a role in depression.
Symptoms of depression also overlap with symptoms of sleep breathing disorders including OSA (obstructive sleep apnea) such as fatigue, feeling tired, poor motivation. Patients with OSA also report difficulty concentrating, remembering information, being irritable, loss of enjoyment for life, etc.
Snoring is one sign of a potential Sleep Breathing Disorder. Dentists trained in TMJ and Sleep Disorders can recognize the damage to the mouth, teeth, airway and TMJ and help the physician get a proper evaluation for a sleep disorder. TMJ damage from clenching and grinding of the teeth is also a well-established symptom of a sleep breathing problem. In up to 70% of patients with TMJ problems, we find a co-existent sleep disorder and vice versa. This is especially true in teenagers and younger children.
If you or someone you know has problems sleeping, with depression or anxiety that isn’t responding with medical intervention, an evaluation for TMJ and the related signs of a sleep breathing disorder would be an important step to take.
 Advance for Managers of respiratory Care, October 2007. Subramanian, S., MD, DABSM, FCCP
Over the years I’ve seen a few patients whose TMJ symptoms started while scuba diving. Some had been diving for a longer time, while other patients it occurred on their first open water dive.
A recent article  surveyed divers regarding dental pain and reported barodontalgia (tooth ache from ambient pressure change) in 42% of divers, Pain from holding the regulator too tight in 24% and TMJ pain in 22%. I would suggest that the pain from holding too tight might refer to TMJ muscle or joint referred pain. It didn’t differentiate that pain. It also reported 22% specific pain in the TMJ. Potentially the 2 categories would suggest that TMJ or TMJ muscle pain occurs around 50% of the time in scuba divers of all levels.
Clenching tight on a mouthpiece can induce a lot of sustained pressure in the TMJ. No joint is designed for long term loading. If someone clenches while diving for an hour or so, it will compress most of the lubricating fluid from the TMJ disc (this is called exhaustion of weeping lubrication).
This creates areas on the disc that stick to the bony socket and upon moving the jaw, the disc itself can tear or it can tear the ligaments. This will typically cause a sharp pain and then feel like the joint is swollen. If the disc ligaments are damaged, the TMJ disc can slip and begin to click or the jaw may lock and not be able to move well.
If your bite feels off after scuba diving, it can be from a muscle cramp. The best thing is to let the jaw slowly re-align over 20-30 minutes. Don’t try to bite hard to get the teeth to touch. Avoid any heavy chewing until the bite returns to normal. Attempting to clench and get your teeth to touch could damage the joint irreversibly.
If the bite doesn’t get back to normal, have your TMJ evaluated by someone specializing in TMJ disorders to determine the nature of the problem and give you options to correct it. Adjusting the bite (occlusion) wouldn’t be the first line of treatment, but might be considered later.
 Dental Abstracts; Nov-Dec 2017, V62: Dental Pain When Diving
TMJ (Temporal Mandibular Joint) is a term that describes all problems in and around the TMJ. With TMJ disorders, there are problems in the joint itself (this is almost 100% of the primary problem) that cause muscles to cramp, spasm or hurt. It also shifts the alignment of the lower jaw (mandible) due to a shift inside the joint. This often makes your bite feel uneven.
Managing the muscle pain with drugs, physical therapy, injections, etc. is helpful with providing comfort but it won’t fix damage in the joint, typically. Likewise, adjusting the fit of the teeth (equilibration) will not fix what happened inside the joint and often can lead to further pressure in the joint, causing more damage. It will, however, provide some muscle relief because it has restored balance between the occlusion and the damaged joint.
80% or more of patients presenting for TMJ problems have arthritis, dislocated/damaged discs and joint pain. Recent improvements in imaging and other biomedical technology helps in diagnosis and providing therapeutic strategies to improve joint function and alignment as a primary goal; since most symptoms arise from the sudden shift in the joint from a slipped disc or other microtrauma.
I treat the joint back to health first (as much as is possible), then assess whether any change in the occlusion (bite) is indicated to support the joint. Myofascial and physical therapy treatments facilitate joint rehabilitation only when oral orthotics are being used.
A majority of dentists understand that the most important etiologic factor in TMJ arthritis and damage is excess loading of the joint (clenching, grinding or an underlying misalignment from uneven growth of the jaws) that slowly causes damage to the cartilage disc, ligaments and bone.
Using 3D cone beam imaging, I can measure joint space narrowing or loss and proper alignment of the joint in the socket. This guides treatment strategy by focusing on the most important factor first, which is the joint. Damage to the cartilage leads to and precedes joint space narrowing and eventual arthritic damage. Early detection and correction is our goal.
Statistics relating to the incidence of TMJ Disorders (TMJD) and Sleep Apnea are often quoted around 70%.
In my specialty practice, I see above 50% of people presenting with TMJ problems also have undiagnosed sleep-breathing problems (Sleep Apnea, UARS, Fatigue).
One of the many reasons these conditions are linked is the fact that an obstruction of the airway during sleep often triggers an episode of clenching or grinding in an effort to stiffen (open) the airway. This is done while asleep, so it is usually discovered at a dental appointment when you are told your teeth “look like you have been clenching or grinding”.
Long term clenching and grinding slowly damages the TMJ cartilage disc and triggers arthritis in the TMJ. Dental nightguards do not stop clenching or grinding, nor do they necessarily protect the TMJ joint. They are designed to protect the teeth only.
An article this week describes link between Rheumatoid Arthritis (of the TMJ) and Sleep Apnea. Those of us who treat TMJD intuitively know this and it’s encouraging when research appears that supports our clinical observations.
When the TMJ (jaw joint) has either a disc that dislocates (any clicking in the TMJ means the cartilage has been torn off the bone) or develops the arthritis that follows disc displacement – it causes the entire jaw to move slightly up and back. This is because the jaw joints lose their support and stability. As the lower jaw slides backwards, it sometimes shows up as a change in your bite (occlusion). Often feeling like a back tooth or teeth are sore, hit harder than the rest of the teeth, or your front teeth no longer fit together when trying to bite into something.
Rheumatoid arthritis is a genetic condition where the body attacks and destroys cartilage and bone in various joints. The pain caused can disturb sleep, often triggering clenching. If the TMJ joint is involved, it causes the jaw to slowly collapse backwards over time. The support of the airway is decreased as the muscles under the chin fall back, often narrowing the airway during sleep.
The article also relates arthritis in the upper neck to have an effect on the size of the airway, contributing to a loss of airway support at night.
If you find your sleep becoming less refreshing, if you are told that you are grinding/clenching your teeth, have neck pain or popping/noise in the jaw joints, it should be evaluated by a Dentist specializing in TMJ and Sleep Breathing Disorders. I work with a network of medical professionals to help evaluate complex conditions and get to the source of problems.
Let’s take a moment to be reminded at how amazing it is that our body has been made to care of itself.
Someday, instead of having to give a blood sample during your physical exam, the doctor might just ask you for a saliva sample. Saliva is an amazing fluid. Besides helping us moisten and digest food, saliva is able to speed healing and fight bacteria, fungi and viruses. Saliva is chemically almost identical to the clear part of your blood. It even has, in lesser concentrations, the infectious organisms found in your blood.
Let’s say, for example that you suddenly find yourself in a stressful situation. The level of the hormone cortisol will increase in your blood in response to the stress. Within 20 minutes, that increase will be evident in your saliva. This means that someday saliva tests may replace blood samples. In the United States, saliva tests have been approved to diagnose AIDS, illegal drugs, periodontal disease, alcohol and premature labor. If the hormone estriol rises in a woman’s blood before 36 weeks of gestation, doctors know that the woman may go into labor prematurely. Saliva testing is also used to check hormone levels in women who are having a difficult time conceiving a child. Other countries have approved a saliva test for hepatitis B.
Judy Foreman, The spitting image gains credibility, Star Tribune, September 12, 1999, p.E3, Image: Salivary glands. Courtesy of Bruce Blaus. (CC BY 3.0)
Many offices utilize panorex images to check for 3rd molars, abscesses, and as a general screening. There are advantages and disadvantages of panorex images compared to an FMX series.
Panorex images allow a broad, general dental screening. With some training, they can also detect TMJ pathology, upper cervical spine problems (neck problems) and sinus pathology.
Having looked at hundreds of CBCT images, plain film tomography of TMJ’s, and MRI’s; I’m able to detect questionable areas on panoramic images suggesting further investigation. Let’s look at some of the most common findings warranting further evaluation.
Antegonial Notching: This is often seen in clenchers, bruxers, and TMJ patients. The masseter muscle (cheek) attaches to the lower jaw along the length of the lower jaw (except at the gonial angle of the mandible, hence the name antegonial meaning before, or ahead of the gonial angle.
If you see AGN (antegonial notching), it is suggestive of sustained (long term) masseter muscle tension. This is typically from clenching, bruxing or a dislocated TMJ disc on that side of the mandible.
In younger patients, it is often associated with airway-distorted growth of the facial skeleton. A video animation of growth and development can be viewed on the video below0. Intra-oral findings on the dentition will be bicuspid drop-off and is often associated to Antegonial Notching.
Antegonial Notching suggests clenching, TMJ problems (dislocated disc most commonly). It may also be the sign that the facial growth was distorted by early childhood breathing problems (allergies, large tonsils).
The right side here has a more notched area of bone reaction suggesting different muscle forces on that side.
A later topic, but evident here is the moderate osteoarthritis in the patients left condyle (arrow points to it). The flat area and “point” are diagnostic of advanced joint problems.
Mild antegonial notching with “irregular or bumpy” gonial angles. The top arrows at the TMJ point to the TMJ’s. Additional imaging showed moderate osteoarthritis in the left TMJ and advanced degenerative disease in the right TMJ condyle (difficult to see here).
How do you address sightings of these anatomic irregularities? These findings prompt me to point it out to the patient and list some of the common things that contribute to it and why (as mentioned above). Often, patients will reveal symptoms such as “yes my jaw sometimes hurts” or “yes, I wake up with a sore jaw”, “my neck hurts in the morning”, “my jaw gets stuck sometimes”, etc.
Measuring the jaw Range of Motion is a good way to provide feedback to patients. Clicking, popping or limited movement of the TMJ’s indicates disease. Painful muscles (to examination/palpation) indicate the damage is more than the body can tolerate and treatment might be suggested.
A variety of occlusal problems can also be seen with AGN such as anterior tooth wear, abfractions, canine cusp tip wear, etc.
Bicuspid Drop Off:
This finding is most often associated with distorted facial growth from airway problems in the first 10 years of growth. Allergies, enlarged tonsils and adenoids, etc. This can be seen on a panorex image, but is also quite easily seen intraorally. Patients with significant bicuspid drop off will often have lower incisal wear, upper anterior incisal edge wear and scalloped tongues. Children typically have “tense tongues” or a heightened gag reflex with distortions such as this. There can be “functional problems” associated with uneven jaw growth such as TMJ disorders, parafunction, headaches, and sleep breathing problems. The potential for TMJ problems and Sleep Breathing Disorders (sleep apnea, snoring) is what you should think of when you see a deep overbite (which is what the bicuspid drop-off contributes to). ROM (range of motion), palpate for clicking/popping or other TMJ sounds or pain.
The center black line shows the incisal edges of the lower anterior 6 teeth. You can see the molar and premolar teeth haven’t erupted as far (the “bicuspid drop off”). In panorex images that have an anterior bite tab for patients, this “drop off” to the bicuspid and molar cusps is more easily seen. The (lower) gray arrow points to the early antegonial notching on the patients left side. The upper left gray arrow shows the TMJ abnormally positioned in the fossa. This teenage girl has been in TMJ treatment for a couple years as we manage joint growth, position. She is now in orthodontics.
Panoramic or clinical findings of Antegonial Notching and Bicuspid Drop-Off (both are clinical findings too) should prompt some additional questions and perhaps screening for TMJ disorders or Sleep Apnea.
Recently, I attended the American Academy of Craniofacial Pain’s annual Sleep Disordered Breathing Conference. At these events, friends and colleagues always provide new tips and insights. We are privileged to have the opportunity to hear from esteemed Physicians and Dentists on varying topics ranging from TMJ, chronic pain, Sleep disorders and pediatric breathing problems.
Dr.Lustig, a professor from the University of California, was especially interesting at this past conference. He is a Pediatric Neuroendocrinologist who spoke about the epidemic of liver failure, insulin resistance, and childhood diabetes in children, as well as adults, from added sugars (especially fructose) and the damage it does to our bodies. We had the pleasure of an in-depth 2+ hour talk that changed my knowledge about the sugar epidemic. I would like share a seven minute message about the addictive nature of sugar. You can find more on you tube if you wish to become more educated on this topic.
Dr. Mark J. Barnes holds multiple prestigious accolades including:
Diplomate, American Board of Craniofacial Dental Sleep Medicine
Fellowship, American Academy of Craniofacial Pain
Mastership, International College of Craniomandibular Orthopedics