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
Symptoms in and around the ear are very common in patients with TMJ disorders.
Tinnitus (ringing or buzzing in the ear), dizziness, earache, and vertigo are all common symptoms of a TMJ problem. If you suffer from any of these symptoms and your physician does not find a cause in the ears, it’s likely that you have a TMJ problem.
In one study, 81%-100% of these symptoms resolved when conservative treatment for TMJ was provided after their physician had a negative ear exam.
Why does TMJ affect the ear?
The inner ear is located behind the TMJ socket in your skull. If you TMJ is not centered in the socket (almost all TMJ problems begin with this structural problem); as the TMJ damage progresses, it can put pressure on the bony ear structures and cause pain, altered hearing or tinnitus, and sometimes vertigo. If moving the jaw seems to clear a stuffy ear or change the symptoms, you should have a TMJ evaluation.
Tinnitus, ringing, buzzing or sometimes stuffiness in the ear can typically be caused by muscle spasms in the TMJ muscles associated around the ear. A clicking jaw or TMJ that has a “displaced disc” that limits movement causes various muscles around the TMJ and neck to become tense. This triggers tension in the small muscles inside the ear and can cause tinnitus-like symptoms (hissing, buzzing, or stuffy ear) as well as dizziness.
Referred pain to the ear can be caused by a dislocated TMJ disc, chronic clenching (which compresses and irritates the ear structures), along with muscle spasms of the TMJ and ear.
Vertigo, dizziness, and ear pain can also co-exist with a TMJ/neck imbalance that causes the sternocleidomastoid muscle (large muscle on the side of the neck) to eventually develop areas of spasm and pain that are felt around the ear.
If you develop pain or any of these problems of the ear and your physician doesn’t find cause, it’s likely that it is a significant TMJ problem that has progressed to the point of needing treatment. General dentists are not trained to recognize symptoms of a TMJ problem affecting the ear. Find a Dentist that specializes in treating TMJ problems (not occlusal or bite problems) and schedule an evaluation. In this study it suggested that 80%-100% of the time it could be a TMJ disorder.
Overall, about about 1/4th of Coloradans aren’t getting as much sleep as recommended for optimal health.
Our bodies require a certain amount of time in sleep to allow all of the “stages” of sleep to occur. Insufficient sleep deprives the brain, cardiovascular, and musculoskeletal system enough time to repair the microdamage that happens during our waking time.
Alcohol helps to fall asleep faster, but it deprives the body of REM sleep (Rapid Eye Movement). REM sleep allows the brain to “file” what was learned or processed during the day and consolidate what was learned. One drink before bed doesn’t seem to have a measurable effect according to experts, but more than 2 drinks will affect memory, restorative sleep, and will affect your performance the following day.
One night probably won’t have an effect, but if you’re drinking every night before bed, the cumulative effects of “sleep loss” will affect your performance, memory, and increase that risk of other problems associated with low sleep times (see chart).
Patients want alternatives to their CPAP for travel, business, camping or just to have a choice when they get tired of their CPAP later in the night. Having 2 methods of managing Sleep Breathing Disorders that can be interchanged (or 100% compliance with either method) is being shown to have similar long term outcomes as studies have had more years to gather data.
If you aren’t using CPAP all the time, consider adding an Oral Appliance as an alternative therapy.
Identifying sleep disorders in pediatric patients requires more observation than questions, as with adults.
The #1 factor affecting sleep in kids is enlarged tonsils and adenoids. Decreased oxygenation because of the airway restriction upregulates the sympathetic nervous system (fights or flight part of our nervous system) and children react as if they are fidgety, distracted, ADD/ADHD-like behaviors, such as emotional outbreaks or over-reaction to stimuli. They may have trouble focusing or concentrating. These behaviors can likely be identified in younger patients (up to middle school).
Large Tonsils in 17 Y/O and Long Swollen Uvula
If they have large tonsils, a tongue that seem too big, narrow arches; all are signs of airway restriction. Just because you can’t see the tonsils, doesn’t rule out enlarged adenoids (tonsil tissue at the back of the nasal airway). These children will typically have dark rings under their eyes and mouth breathe.
Children or teens that present with worn or chipped teeth from grinding have a high likelihood of sleep disordered breathing. Bruxism is a known marker for a sleep disorder in children. As in adults (but more pronounced in kids), clenching/bruxing is thought to be a reaction to a collapsing airway as inspiration begins. Stress is not a valid explanation in the orthopedic TMJD and sleep literature for parafunction, although there are rare exceptions.
This patient was referred to me for TMJ popping and pain and headaches; after imaging her airway she was referred to have her tonsils and adenoids out, which stopped the clenching (that had damaged her TMJ’s), as a result slept better, was no longer fatigued, no longer had to nap after school, and her behavior “calmed down”. Her TMJ’s rehabilitated with orthotics as she slept better.
Children with SDB (Sleep Disordered Breathing) can have painful jaw muscles and headaches, but won’t typically report it. Push on the masseter & temporal muscles and press over the jaw joints. Pain is an indication of parafunction, as is clicking/popping.
Narrow maxillary arches is another sign identifying mouth breathing. Children who mouth breathe have maxillary arches that have a high palatal vault, are more “V” shaped than horseshoe-shaped and have less spacing between primary teeth. Bicuspid depression indicates a chronic mouth breathing condition.
Tongue “Too Large” and Overlays Posterior Teeth and Narrow Arch
Reports of children being difficult to put to bed at night and who resist getting up in the morning are another suggestion of improper sleep.
Bed wetting can be a sign that deeper sleep stages aren’t being achieved. Deep sleep, the bladder is inhibited from filling. Patients who don’t spend enough time in restorative sleep stages have to go to the bathroom a couple times per night. Children may wet the bed unknowingly.
We must keep examining patient’s mouths, throats, and teeth from a sleep/parafunction connection. TMJ clicking and pain is also a sign that they are clenching or grinding at night and has a strong correlation to sleep disordered breathing. TMJ problems especially popping and clicking doesn’t “go away” and is sometimes secondary to the sleep disordered breathing problems.
I am available to consult on any of these issues, and help make referrals for tonsil/adenoid removal with clinical and 3D airway measurement of the tonsils and adenoids.
Why is it that getting our teenagers up and going is sometimes such a battle?
We nag them to get up, they want to sleep longer
We’re in a hurry- they can’t seem to get out of bed
They stay up too late…
Actually, it’s not totally their fault. As kids enter teenage years their circadian rhythm, as well as the rest of their physiology, begins to change. All parents know that for sure! Teens are known for staying up late and sleeping in. During teenage years, melatonin’s release (the sleep hormone) is delayed. Teenagers start getting sleepy (melatonin release) around 11pm and need more time to fall asleep. 8-10 hours of sleep is ideal for teens according to the American Academy of Sleep Medicine. They need to sleep until around 7:30 AM.
There is a growing pressure on school systems to change school start times based on research in the sleep literature. It’s being met with resistance because of our work schedules, after school programs/sports and parent’s time schedules. It’s a clash between physiology and a society that has, for decades been on a schedule that seems to have trended earlier over the decades.
According to an article in this month’s American Academy of Sleep Medicine journal:
Short sleep in adolescents is associated with poor school performance, obesity, metabolic dysfunction and cardiovascular morbidity, increased depressive symptoms, suicidal ideation, risk-taking behaviors, athletic injuries, and increased motor vehicle accident risk.9–17 Increased motor vehicle accident risk is particularly concerning because young, novice drivers have a higher crash risk when sleep deprived, and motor vehicle crashes account for 35% of all deaths and 73% of deaths from unintentional injury in teenagers.18–20
Importantly, a delay in school start time has beneficial impacts on teenage students. Studies show that implementation of later school start times for adolescents is associated with longer total sleep time, reduced daytime sleepiness, increased engagement in classroom activities, and reduced first-hour tardiness and absences.7,21–23 Delayed school start times also are associated with reduced depressive symptoms and irritability.21,22 Reaction time improves, and crash rates decline by 16.5%, following a school start time delay of 60 minutes.12,13 Extension of sleep time also facilitates behavioral weight loss interventions in adolescents.24.
There isn’t an easy solution to this clash between physiology and society’s needs. But recognizing it can take some of the stress off families. Let the kids schedule relax on the weekends for sleep, talk to them about “sleepy driving” and remaining alert. Perhaps a nap after school would help some of them. If they seem overly tired, they should be screened by a qualified Dentist in sleep/breathing disorders for airway obstructions and altered craniofacial growth that may be a contributing factor.
Citation: Watson NF, Martin JL, Wise MS, Carden KA, Kirsch DB, Kristo DA, Malhotra RK, Olson EJ, Ramar K, Rosen IM, Rowley JA, Weaver TE, Chervin RD. Delaying middle school and high school start times promotes student health and performance: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2017;13(4):623–625.
Every time you have an apnea (a total block of air for 10 seconds) or hypopnea (partial breathing block) the “fight or flight” reflex is triggered.
With each event, the heart rate and blood pressure increase. It’s the same feeling you get when you’re scared suddenly; a little sweating, hard to catch your breath, and your heart pounds for a few seconds.
Apneic’ s have this sympathetic response many times per hour, all night long. The body begins to be in a constant state of alert.
With Sleep apnea, the body is chronically low on oxygen. Oxygen is needed to produce nitric oxide in our sinus’ and blood. Nitric oxide is a potent vasodilator- it relaxes the blood vessels and decreases the work of our heart. In sleep apnea the blood vessels chronically tighten and don’t get to relax and repair. The higher blood pressure causes damage to the inside of the artery. This contributes to plaque and more narrowing. As the arteries get narrower it places a higher burden on the heart which leads to heart attacks, strokes, and chronic high pressure.
Walking through the airport I saw a cover of Consumer Reports regarding how to sleep better.
It reviewed all types of mattresses, pillows, sleep positions, etc. suggesting that this is the primary cause of poor sleep. Not most likely.
While discomfort in your neck, back, or hips can disturb your sleep, the PRIMARY cause of sleep issues in America today is BREATHING. You’re not breathing well. Sleep Apnea, Upper Airway Resistance, Reactive Airway conditions are the most likely culprits robbing you of restful, restorative sleep.
If you have neck, back, shoulder or spinal disease or pain, the pressure and position you sleep in can cause progressive pressure on discs and nerves as you sleep. As you enter deeper stages of sleep your joints may become “irritated” enough to cause a signal to the brain to move or change positions to lessen the pressure. If it happens often enough you will feel that you’re not sleeping well. These are the conditions that pillows and mattresses can improve.
Most sleep disturbances in adults result from Obstructive Sleep Apnea, Snoring, or other conditions involving airway collapse during sleep. If you snore, there’s a near 70% chance that you have Sleep Apnea or that your oxygen is dropping to levels that increase risk of stroke or heart attacks. That is the first consideration to rule out.
Narrowing of the throat (such as with snoring, gasping, jerking) is a reaction to significant drops in the oxygen in your blood and brain. The brain reacts by sending a “flight or fight-like” surge of adrenaline to jerk or twitch us awake and take a breath (but not awake enough to remember) This can happen many time per hour and rob our body of sleep it needs to be mentally sharp.
Another stage of sleep causes all body muscles to be “paralyzed” and completely relaxed. This is believed to be so that our joints, vertebral discs, and cartilage discs, ligaments can have time to repair and heal from the day’s jarring. The oxygen drops associated with Sleep Apnea episodes (snorts, snoring, gasps) are micro-arousals (mentioned above) that re-engage the muscles and interrupt the joint repair periods of sleep. This can lead to joint discomfort, muscle aches and pains, etc. in the morning. Especially if we already have some “wear and tear” on our joints from sports or activities.
If you suffer from poor sleep, achy tired joints in the neck, back or TMJ in the morning, make sure to have your Physician or a Dental Sleep Specialist evaluate you for potential Sleep breathing problems, in addition to finding comfort with pillows and mattresses.
Our website has a convenient, private self-assessment that you can take and have instant feedback as to risk factors for a Sleep breathing disorder. TMJ problems are also associated almost 70% of the time to a sleep disorder. Clenching and bruxing are also activities triggered by breathing interruptions that eventually damage the joints and discs, in addition to our teeth.
I work with local Sleep Specialists and Physicians to help determine whether patients with TMJ pain, neck pain, or other symptoms should be screened for a sleep disorder.