The Many Questions of TMJ (and OSA)

Studies, recommendations, allies and liabilities all play a part in creating the information available when trying to get answers to the many questions surrounding TMJ. Some studies are designed to follow a single-symptom, linear progression protocols, which means the study is not able to follow a new symptom even if the change is of problem progression. Therefore, the self-help suggestions should be used for no more than a week before consulting a Board Certified TMJ/Dental Sleep Medicine Dentist. The common recommendation through most dental websites including the ADA and TMJ Association are no longer supported by research, despite their claims. There is a detailed reason why they say “research supports TMJ as a self-limiting condition” and that “it resolves without treatment”. They advise “not to do anything but self-help and medications, counseling, rest; because it is a self-limiting disorder” [1].  (read below)

As a Board-Certified Specialist in both Dental Sleep Medicine and Orofacial Pain[2], early diagnosis and appropriate, orthopedically-based diagnostic evaluations and interventions are recommended. Because bruxing is a response to problems within the TMJ and/or a response to Sleep Apnea in almost all cases, self-help is not advised for more than 2 weeks. Of course, clenching and bruxing can be a response to pain or musculoskeletal problems elsewhere in the body.

If symptoms don’t resolve, seek a consult with a Board-Certified Dentist in Orofacial Pain, and TMJ/Dental Sleep Medicine. This does NOT include Dentists trained in “Occlusal Adjustment philosophies”, which is being shown to be an outdated and inaccurate modality as research has evolved in the past decade.

Dentistry still teaches that bruxism is primarily a middle-aged, female reaction to stress as many physicians, dentists, and some online searches suggest. There is very little support of this outside of “occlusal-related modalities” of treatment which follows.

Literature reports bruxism is more common in middle age for both men and women. It is suggested to have different etiologies. The current diagnostic triage for assessment of the underlying trigger for bruxism suggests sleep disordered breathing. Men are more likely become overweight in middle age and may not make time for exercise due to careers that are demanding travel, late meetings, etc. Weight gain, especially in the neck and abdomen is a risk factor in Sleep Disordered Breathing. Fat deposits are significant throughout the tongue.

In women, the decrease in hormones (perimenopause- estrogens especially, that are airway-protective) decrease, leading to increased collapsibility. Women typically present with symptoms of fatigue, poor sleep, etc; but not snoring. This is the “hallmark” of UARS (Upper Airway Resistance Syndrome), a sleep -breathing disorder almost universally in perimenopausal women.

A large neck circumference is an important predictor of OSA in men and women. A circumference greater than 17” in men and greater than 16” in women is a significant predictor of OSA.

Why are sleep-breathing disorders such an important disorder to rule out? It’s likely the #1 reason for Clenching and grinding (parafunction). The collapse of the oropharyngeal airway triggers a neurologic alarm, which awakens you slightly and triggers a momentary “clench”, which rapidly re-opens the airway. Studies have shown up to a 70% predictability of a sleep breathing disorder with a report of clenching.

Bruxing is typically associated with clenching. Although there aren’t studies to support it definitively, there is proof that it is associated with the damage to the TMJ from clenching as well as a misalignment of the jaw joints (which exists in 91% or adults in a study in the 1980’s). The bruxing component may be an attempt to move the displaced jaw joints as they are damaged by repeated clenching and the associated muscle tension. Damage to the disc elicits significant muscle co-contraction and further joint misalignment.

Stress can lead to increased muscle tension, increased heart rate and blood pressure, etc. None of these physiologic parameters are controllable when we are sleeping properly. If you’re asleep, you’re asleep. Clenching and bruxing occur in lighter stages of sleep- which is the strong association with a sleep-breathing disorder. They also cannot be controlled unless you aren’t asleep.

“Jaw misalignment” must be clarified as a “TMJ joint misalignment”.  Condylar Position (jaw joint) in the fossa has no relationship to how our bite appears. The bite determines how the joints align and can only be assessed by a 3D image and using acceptable joint space analysis that is well documented in literature. This is the primary disconnect within Dentistry today; Dentists blindly believe that well-aligned occlusion correlates to proper joint alignment. In over 90% of all adults, this is not the case.

Typically, the severity of the jaw joint misalignment in its socket (pathologic position from early childhood growth that positions the joint backward/up in the socket, such as in dental occlusal adjustment protocols that “manually manipulate the jaw/joint up & back”. The only method to assess this is careful “joint space measurement” using 3D cone beam imaging with published references of joint space. Clinical measurement of jaw mobility is also a valuable and necessary examination tool. Although equilibration of the bite can reduce symptoms, it follows the wandering nature of symptoms that are related to the anatomy and external factors and physiologic adaptability.

Acceptable therapies should objectively and subjectively focus on the following parameters:

  1. Objective improvement of all TMJ joint spaces to normal, or as close as possible.
  2. Improvement of all 4 measurements of TMJ mobility.
  3. Relief of head and neck muscle pain, co-treat if necessary, with other providers.
  4. Assess for sleep apnea and other breathing disorders.
  5. Use removable and reversible Orthotic Appliances. These do NOT place the jaw in a backwards position in the fossa that causes the back teeth touch harder or require equilibration or occlusal adjustment over several visits.
  6. Proper restoration of joint space positions the jaw slightly forward, typically resulting in the back teeth not touching. This is a positive sign that the joint space is restored.

 

 

[1] All studies by these organizations follow single-symptom, linear progression protocols. For instance, if a TMJ is clicking and it “stops” after a period of time, the study ends with the conclusion that “clicking is a self-limiting symptom that resolves with self-help therapy”. True, because the “disc” that partially dislocates will eventually “completely dislocate” and no longer click. At that point the TMJ is rubbing bone on bone. Other symptoms may then appear such as muscle pain, joint pain on the other side, headaches, uneven bite, etc….

Since those “signs and symptoms aren’t in the original study”, they cannot be reported or followed.

The reason the clicking stops is because it’s now “completely dislocated”, which changes the progression of the problem.

The study can’t follow a “new” symptom as the TMJ problem progresses. They recommend taking various medications including muscle relaxers, anti-anxiety meds, sleep aids, etc. The TMJ Association is allied with pharmaceutical companies. The American Dental Association cannot take a stance due to potential “liability claims” should “TMJ” be associated with any type of “dental bite” procedure or “occlusion”…….

[2] American Academy of Orofacial Pain

Board Certified, American Board of Craniofacial Dental Sleep Medicine

Board Certified, American Board of Craniofacial Pain.

Mastership, Int’l College of Cranio-Mandibular Orthopedics

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