All posts by kpecoraro

Why can’t I get to sleep?

In an article from the American Sleep Association they recommend some of the basics to start with such as avoiding caffeine for several hours before bedtime. They report that brainwave patterns during can continue to show effects of a double espresso coffee 16 hours after it was consumed! In the same study, the measurable level of caffeine spit showed the caffeine to be gone.

Caffeine is reported to be the most widely consumed psychoactive drug in the world. It’s followed by tea, pop, and energy drinks.

If you are having problems with insomnia, try to stop all caffeine by lunch-time for a couple weeks and see if your insomnia improves. Caffeine can also act by arousing you out of deeper sleep which may be noticed as you not feeling rested despite having slept for 7 or more hours without consciously waking up.

Besides caffeine, sleep breathing disorders (snoring, sleep apnea, Upper Airway Resistance) also affect sleep quality and depth. It can also leave you feeling unrested in the morning on a consistent basis. UARS is especially prevalent in pre-menopause and menopause. Hormones are protective against airway collapse and as they decrease, sleep breathing disorders tend to show up.

Typically sleep apnea is reported by bedpartners as loud snoring, pauses in breathing – sometimes with a gasp, jerks while sleeping, lack of dreaming, among other signs and symptoms. Women with UARS rarely snore or aren’t aware of waking throughout the night; they just feel unrested.

Atrial Fibrillation (A-Fib, an abnormal heart rhythm) is associated with sleep apnea due to the interruptions in oxygen that irritate the heart muscle/blood flow. Drug resistant hypertension (high blood pressure) is also associated with sleep breathing disorders, especially in a single drug is ineffective at controlling your hypertension.

There is no identifiable reason or genetic link for sleep that can be found. Our bodies decay daily and our creator made a complex biochemical self-reboot mechanism to refresh our brains, bodies, and every system needed for being awake in every creature. It’s fascinating to learn about the small details of what sleep does and, the differences between men and women in some aspects of sleep.

If you’re having trouble with sleep, ask your physician about a sleep study, or see a sleep specialist. Dentists such as myself who are credentialed in Dental Sleep medicine work closely with physicians to get people screened and treated for their sleep disorders. Oral Appliance Therapy (OAT) is an effective and easy option for the treatment of Sleep Apnea at any level of severity as well as some other sleep breathing disorders for those who don’t want to use CPAP.

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Can A Panorex Dental X-ray Detect TMJ Problems?

Yes and no.

TMJ problems such as slipped discs (clicking or popping noises) or complete disc dislocation (can’t open your mouth very far) doesn’t always show up on radiographs until the condition has been going on for a few weeks, months or even years.

Clicking, popping or locking of a jaw joint happens when the cartilage disc or cushion has been torn off the bone. The noise is the cartilage disc getting pushed around in the joint.

Knees and spinal discs can make noise and still be in place. The noises in other joints are typically caused by compression of air that is in the cartilage in other body joints. The TMJ is the only joint with a disc that is fibrocartilage, unlike the rest of the body. It shouldn’t and doesn’t click or pop in normal movements. Any consistent noises in your TMJ indicate significant, permanent damage.

When the disc is out of place, the bones in the TMJ may rub together. Over time this causes arthritis, changes in the joint position (that cause your bite to feel uneven). The muscles around the jaw and neck also tighten, as a protective reflex. The reflex adds more pressure to the damaged TMJ and accelerates the arthritic damage.

TMJ’s can have varying degrees of arthritic damage that may not be seen on standard dental panoramic radiographs. [1] Experienced TMJ specialists can detect TMJ problems on standard panoramic imaging however, cone beam imaging is considered “standard of care” for TMJ diagnosis and treatment, sometimes in conjunction with MRI (if surgery is being considered).

Clinical measurement of TMJ mobility, palpation of the joints both lateral and posterior can provide a high degree of accuracy for disc displacement but not arthritic changes or misalignment.

Virtually all non-traumatic TMJ pathology stems from an unequal growth of the upper and lower jaws, typically influenced to the negative by enlarged tonsils, adenoids, short lingual frenum, and the associated Myofunctional problems that develop because of all of these factors.

Medical doctors aren’t familiar with the subtle signs of altered growth, pre-clinical TMJ compression, etc., and rarely recommend screening by a TMJ specialist until obvious symptoms or signs are present.

If your jaw joints make noise, don’t move well or lock, or if you feel a shift in your bite, you likely have a TMJ problem developing. It may take time to become obvious, but the damage is progressive and never “fixes itself”.

Early intervention offers the best opportunity for a more stable rehabilitation.

[1] Diagnostic accuracy of panoramic radiography & MRI… AGD General Dentistry, July/Aug 2018. Kaimal, et al.

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Accutane, Bruxing and TMJ

Recently, a patient presented with “clicking” that has progressed to having a locked left jaw in the morning.  They can “unlock” it easily at this point. The clicking symptoms started when they were taking Accutane for acne and the clicking seemed to resolve when Accutane was discontinued.

Did Accutane have anything to do with this?

Yes and no.  Accutane side effect profile shows that very few people who take Accutane “brux” or “grind their teeth” after 6 months of taking it (.4% of sample of 30,000 who reported it).  Bruxing seems to subside for a few months and then re-appears after another 6 months of use, but at much lower rates.  Bruxing significantly increases the pressure in the TMJ and if there is an underlying misalignment or subtle problem, it could “push it over the edge” to become symptomatic. It would have anyway…the increased pressure just hastened it’s onset.

Women report bruxing almost 3X as often as males.

The #1 reason that TMJ problems develop (regardless of bruxing) is due to the jaw joints (condyles) being “out of center in the sockets”.  This is a growth/imbalance between the upper and lower jaws that can only be seen with a 3d radiograph.  Up to 90 % of people have some “misalignment” of their TMJ, but not all develop signs (clicking, locking, limited opening or sideways movement, bite change) or symptoms (jaw pain, headaches, clenching or grinding teeth).

Many factors trigger the TMJ symptoms to appear and, once they start they don’t “go away” on their own, despite what you read and are told…the symptoms just change.

If your TMJ starts clicking, if your bite changes or feels uneven, your ability to open changes, etc…You have a TMJ problem.

It won’t “go away” on its own. The symptoms do change as the damage progresses, depending on what structures are being affected.  The sooner you can be evaluated by a credentialed dentist the better outcome you will have.  Adjusting the bite, “Equilibrating the Teeth” or using an NTI appliance or anterior bite appliance to “get the jaw in the right place” may temporarily decrease symptoms but will accelerate the orthopedic damage in your jaw.  They are the wrong devices for any type of TMJ condition and should only be used a week or so.

FDA Reports, Who have Bruxism with Accutane.

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How It’s All Linked: The Facts

Let’s face it; what we all want is to spend quality time with those we love. We value health and happiness, experiencing life’s adventures, and snuggling in warm and cozy on a winter’s day. But the truth is most families experience health issues, questions arise and the unknown keeps us from living our lives the way we want to.

Following are answers to common questions about links between sleep, TMJ, oral breakdown and other serious health concerns.

Sleep apnea is responsible for a wide variety of medical problems, which may seem confusing to dentists and patients alike. It is far more common in children that thought to be, especially in the US where tonsil’s and adenoids aren’t removed when enlarged in children. This is partly due to insurance constraints and very low reimbursement to providers for the small, but possible risk of severe post- surgical infection/complication.

Enlarged adenoid and/or tonsils affect facial growth and increase the likelihood of future TMJ problems as well as adult sleep apnea.

About 6 million adults are diagnosed with obstructive Sleep Apnea (OSA) and the estimate is that 23.5 million adults remain undiagnosed or treated. This places a large burden on the healthcare system because untreated OSA is shown to be a factor in developing TMJ problems, Diabetes, Heart attacks, Strokes, High blood Pressure, and Periodontal Disease (Gum Disease).

It’s reported that Sleep Apnea has been found to have been present in 60%-80% of post cerebral vascular [1] events.  Irregular heartbeats are also seen in untreated Sleep Apnea patients and can be the source of a nighttime heart attack.

Untreated sleep apnea can also contribute to attention deficits in all ages groups, memory problems, multi-tasking, among other executive functions.

Symptoms of sleep apnea vary by gender and age. Toddlers and grade school children often have difficulty falling asleep and waking in the morning. They are often restless sleepers, moving around the bed, kicking the wall, etc. Younger children with sleep breathing disorders often resist going to bed, sometimes causing a stressful nighttime routine.

Men typically present with snoring, pauses in breathing while asleep (reported by others), and clenching/grinding the teeth.

Women more often complain of difficulty falling asleep or staying asleep. This will worsen with hormonal changes in mid-life. The perimenopausal years significantly increases the onset of sleep apnea in women due to the airway “protective” effect of hormones. Hormone replacement can lessen the severity of sleep breathing problems, but can’t eliminate it.

Nighttime Reflux or GERD has a strong association with Sleep Apnea. Each time the airway closes, the attempt to breathe causes acid to push into the esophagus, causing irritation and also eroding the enamel, which Dentists can recognize. Clenching and bruxing is associated with sleep apnea (as mentioned earlier). Both cause the neck muscles to tense and represent a rapid way for the brain to “stiffen or open” a closed airway from sleep apnea.

For more information or an evaluation with an expert, please schedule an appointment.

[1] J Stroke Cerebrovas Dis., 2017;26,1745

General reference also from Cristina Casa-Levine, RDH, edD, Decisions in dentistry, Nov. 2018

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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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Dehydration, Nighttime Urination, Bedwetting and How It Relates to Obstructive Sleep Apnea

Dehydrated? Get more sleep….Tired? Drink more water….it’s all connected.

This article reviews what we already know about proper sleep time and quality: if your sleep is disrupted it affects our entire body chemistry. Kidney function is also impacted by Sleep Apnea and other sleep breathing problems.

Proper length and depth of sleep is known to affect judgment, executive functioning, attention, mood, as well as a significantly affect our heart health, blood pressure, and increases risk for type 2 diabetes.

It’s been known for decades that children who bed-wet and adults who need to urinate 2-3 times at night likely have Sleep Apnea or one of a couple sleep-breathing problems.

Rosinger & colleagues analyzed 2 large database studies from China, looking at over 20,000 healthy young adults. Sleeping (16-59% more likely) less than 6 hours was correlated with dehydration by symptoms (thirsty) and measuring urine concentration and amount.

What’s the relationship?

Disturbed or shortened sleep disrupts the release of vasopressin, a hormone released at night when sleep quality and duration is normal. This hormone is released later in the sleep cycle in greater quantities and with increasing frequency the longer you sleep. WHY???? Without vasopressin, our kidneys would continue to “fill” throughout the night, causing us to wake up and urinate 2-3 times over a normal 8-hour sleep period. Vasopressin is released throughout the lateral stages of sleep and, with increasing release later in the sleep cycle. This makes sense…if you’re sleeping a “normal” 8 hours and entering all the stages of sleep such as REM and Stage lll, the body releases Vasopressin in those deeper sleep stages to slow the kidneys from filling up and causing you to wake up, go to the bathroom and, have to go back through the sleep stages…it’s disruptive to the body/brain repair sequence as we sleep.

Children with enlarged adenoids and tonsils can’t breathe well in deep sleep, so the body makes them restless and deprives their brain of REM sleep…all the while allowing their kidneys to fill. The result: bedwetting.

Adults who snore, have sleep apnea or women with sleep anxiety or frequent waking also don’t release as much Vasopressin, causing us to wake 2-3 times to urinate. Typically the 1st waking is just after midnight…

By morning, the body has dehydrated itself by the continued water loss and can cause long term dehydration symptoms such as muscle weakness, headaches, fatigue (similar symptoms as sleep apnea contribute to)…

Amazing how our physiology is so intricately designed!

Sleep Deprivation May Cause Dehydration

Published Wednesday 7 November 2018,  

Medical News Today

By Ana Sandoiu

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The Impact of Cell Usage on College Kids

Research shows that use of electronics pre-bedtime can affect sleep. A recent study of college students’ use of Cell Phones after “lights out” was shown to definitively contribute to sleep disturbances and mental distress.

This was a large, significant group of almost 4,400 college students self-reporting cell phone use and specifically, use in bed after “lights out”. The pre-post testing took place over 8 months and measured many variables. Excessive cell phone use was defined as 4 hours per day or above.

To most of us, this does not seem excessive, but it was considered excessive in this research. Excessive cell phone use was positively associated with sleep disturbances and mental distress scores at follow up (8 months…a great long-term study).

They also looked at the results when the students stopped using the phones after lights out, the symptoms declined back towards baseline measures of normal sleep and distress…that’s good news!

84% of students (college) used their phones every day (4+ hours) and compared it to adolescents (junior high) excessive use (2+ hours/day).

The study also compared the effects of Melatonin secretion (great study) when the cell phone was used pre-bedtime VS after “lights out”.  Melatonin is a hormone that is secreted as the sun goes down and helps “ready” the body for sleep. Use of the cell phone pre-bedtime decreased the initial amount of melatonin secretion, but it “caught up” over the night….it was delayed and slowed…which would disturb sleep onset and perhaps initial quality of sleep. After lights out there were EEG changes and delayed melatonin secretion.

Of interest, they also commented on texting VS talking. If conversations are emotional, thoughtful, or considerable they contribute to insomnia because of the release of emotional hormones. Text doesn’t require the sender or receiver to be ready for the communication, and a response may be well after the sender’s “purpose” has been forgotten. That could re-engage or excite hormonal release. Texting is far more common than talking for “convenience” and (my opinion) doesn’t require as much emotional engagement with all topics.

Overall, this was interesting in that Text messaging after “lights out” had a negative and statistical effect on sleep quality, duration, anxiety, insomnia.

Take Away: put the phones in another room pre-bedtime and leave them there until morning. Your brain will thank you for it!!

Sleep Research Society. The associations of long term mobile phone use with sleep disturbances and mental distress in technical college students: prospective cohort study. Published in SLEEP, zsy213

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The TMJ Treatment Debate Debunked

If you search for advice with TMJ problems, some sites suggest simple self-care is all you should do. And they say it’s a “self-limiting muscle tension problem” that will resolve.

Decades ago that might have been believed. With improved imaging technology, there is understanding of the progressive damage to the TMJ (one study showed nearly 90% of adults have a misaligned TMJ) that is asymptomatic or episodically painful or showing signs of irreversible damage, such as clicking or limited opening.

Damage to the cartilage disk inside the jaw joint begins years before signs or symptoms and is easily recognized with 3D cone beam imaging and good clinical skills. If found, it can be monitored for damage or treated before irreversible damage has occurred, if patients choose to.

A few “TMJ Advice” sites are very adamant in “not doing anything that will change the bite (or occlusion)” for a TMJ disorder. Here is the dilemma. The study mentioned earlier showed (by MRI on about 100 adults seeking braces) that most had displaced discs in one of their jaw joints.

The TMJ joint is misaligned in most of us as we grow, due to functional habits, genetics and environmental growth interferences (allergies). If your teeth aren’t ideally aligned (without braces) then YOU are one of the 90%. You may or may not develop pain, but you will have intermittent damage to the joints as the years go by. Unequal growth of the upper and lower jaws is the instigating factor.

Unequal size of the upper and lower jaw is seen as crowded or crooked teeth (even mild). Bruxing and clenching of teeth is also a symptom of this misalignment (as well as other things – stress is only a minor contributor). Over time, the cartilage, bone, or muscles may develop symptoms as damage progresses. Over several years, it becomes an obvious problem. If you can’t fit your 4 fingers between your open mouth (like a salute) you have TMJ problems, regardless of pain, at any age. Three fingers width is typically chronic degenerative disease that may have burned out and is often without acute pain. It does flare up easily with dental care.

One of the common “warnings” is to “not change the bite” if you have TMJ. Since an underlying cause of TMJ IS the imbalance of the jaws/teeth/joint, it is also the solution, if you understand current orthopedic approaches to treatment. Let’s look at options:

  1. Do nothing. Because you have been told it is “self-limiting”. As the joints/cartilage degrade or become arthritic, the lower jaw will begin to shift and cause either a noticeable bite changes or, result in bruxing, broken molar teeth, painful teeth, etc. This is the early phase. More advance damage can cause the front teeth not to touch when biting, or contribute to more teeth breaking, etc. This is a pathologic result of TMJ damage and represents a bite change. Some are dramatic. So, doing nothing WILL result in a bite change. The TMJ Association is vocal with this approach. They advocate self-help, counseling for chronic pain, and a multitude of pharmaceuticals to suppress bone damage, muscle tension, anxiety and stress, depression, etc. They are also strong advocates of psychological counseling. Their board (last time I looked) has PhD’s from pharmaceutical and psychology backgrounds. A couple dentists have received grants from them and focus on the “psychosocial” approach with some doing tooth grinding as their method of treatment (…that changes the bite… what they say NOT to do). For some cases this is appropriate but based on studies, it should be less than 10% of sufferers).
  2. Adjust the “bite” or equilibration of the teeth. Sometimes it is a minor 1-2 tooth re-shaping (due to the underlying bigger problem mentioned above) or to try and relieve muscle symptoms or joint clicking (a dislocated disc). Grinding down the teeth (and using a “bite plate” in between sessions to “relax the muscles”) is, essentially allowing the joint to degrade and grind the enamel off the teeth until the joint is so badly damaged it stops degrading or “burns out”. Often at this point the recommendation is to “crown all the teeth” because the enamel has been ground off and the teeth are flattened. The “restoration” is to restore the grooves on the teeth. What happens if the joints start degrading again? A new round of grinding the crowns and later replacing them again. I don’t support this approach as it is simply following the self-destruction of the TMJ – similar to “do nothing”.
  3. Orthopedic approach. This is what I follow and have for 30+ years. It has strong support from orthopedic literature, and organizations including the American Academy of Craniofacial pain, International College of Craniofacial Pain. The American Academy of Orofacial Pain is also embracing the orthopedic approach in recent years.
  4. The use of orthopedic orthotics (just as an orthotic can correct a leg length problem and eliminate hip/back pain) to place the damaged joint under traction, allow disc repair and re-alignment. The reflex-driven muscle tension/pain is almost always resolved. Once improved, a long-term use of a stabilizing orthotic supports the joint in a proper, comfortable position without damaging the teeth. This does result in a slight “gap” between the back teeth (due to re-alignment of the jaw from the distorted growth – the 90% of us). I recommend use of this device indefinitely or for 1-2 years to insure the condition is stable and comfortable. Some patients elect to undergo carefully guided orthodontics or crowns (if dentally indicated) that maintain the exact alignment the orthotic had, but this is the minority.
  5. Surgery. All websites and groups support that this is a “last resort” in cases when damage is so widespread from trauma, misdiagnosis, systemic disease or craniofacial syndromes. Surgical entry into the TMJ does considerable damage and always require post-surgical orthopedic therapy (# 4 above) due to the significant, post-surgical bone damage and joint destruction.

The bottom line is: You acquire a TMJ disorder because of unequal growth of the jaws. Genetics, large tonsils and/or adenoids, having a “tongue tie”, or other environmental influences on growth in the first few years of life. Correction of a TMJ disorder, will always change the alignment of the jaws and, “the bite”. If you use an orthopedic approach the “bite change”, is really a correction of abnormal jaw growth. If caught early we can use orthopedic orthodontic principles to guide growth and lessen the chance of developing a TMJ problem later.

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You, The Well-Informed Parent: Advocate for Your Children and Teens!

In my last post, it was my intention to pay attention to how your children are sleeping (or not). If YOU are awake much of the night…perhaps you need a screening for a sleep breathing disorder!

A variety of symptoms can present when children/teens don’t get the proper quantity and quality of sleep regularly. Children and teens will typically present with nighttime symptoms of bedwetting, restless sleep (kicking and banging around) or are twisted in the sheets when you go in to wake them. Hyperactivity, trouble focusing on quiet tasks, impaired growth, avoiding dry, chunky, or more difficult to swallow foods may also present.

The lack of parasympathetic sleep (restful and restorative- think “rest and digest” for parasympathetic) has an immediate and long-lasting effect if deep sleep is impaired. Early in growth it is typically the consequence of enlarged adenoids and/or tonsils. It can also be related to being “tongue tied’. This will also affect the types of foods your children will trend away from; dry foods, hard to chew foods. They may swallow without a closed lip seal or “smack” when eating. Myofunctional therapists and speech therapists trained in MFT can evaluate this condition and, once the frenum is released and airway cleared, begin to retrain the brain improper tongue positioning, speech, swallowing, etc.

If the airway isn’t cleared or isn’t developing properly due to those effects, it can be very difficult to “re-train proper swallowing or speech” until the physical barriers are dealt with.

Orthodontic treatment for under-development of the maxilla (upper jaw) may be needed to get the maxilla back towards normal size to allow the tongue and airway to properly function.

Clinical evaluation as well as radiographic of the airway, jaw growth and size, deep tonsils and adenoids and proper nasal/ maxillary growth can clearly show the physicians the medical necessity they are required to provide that “justifies” tonsil/adenoid removal.

As I tell my patients, nothing can stand in the way of a well-informed parent when advocating for their child’s wellbeing.

A list (downloadable PDF) of common signs and symptoms and visuals that parents can look for that will suggest your child or teen has an airway problem are located on our website under the Sleep Breathing Disorders tab.

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Is Your Child Oxygen Deprived? mouth breathing and the ramifications

If you find your child mouth breathing most of the time while sleeping or when sitting quietly, they have been oxygen deprived.

Humans are typically the only “animals” that routinely breathe through the mouth instead of the nose. Watch your pets or animals; unless they just finished a bolt of running, they breathe through the nose, quietly and peacefully.

Sleep has different “stages” that we cascade through during a normal night’s sleep. The 1st three stages are part of “Non-Rem” sleep and progress from initial drowsiness to deeper, restful sleep. REM (or dream-state) sleep is also important for neurocognitive restoration. Our brains and body require that all stages of sleep be attained for optimal health.

Mouth breathing can interfere with these important parts of sleep and may prevent REM sleep from occurring. In adults, you might recall when you wake after having a few adult beverages….you “sleep” but you don’t feel “rested”. That’s because alcohol interferes with some REM sleep stages. Your brain doesn’t get the restoration it requires nor does the rest of your body.

Mouth breathing has a similar effect, especially in kids. It can interfere with REM sleep. Do you dread trying to wake your kids for school? Maybe they aren’t getting all of the stages of sleep necessary during sleep. Is their mouth open when you walk into the bedroom?

If they consistently mouth breathe at night that’s a problem. Proper nasal breathing is critical for growing children, and adults. During early childhood, an inability to nasal breathe can manifest with problems breastfeeding, or bottle feeding, latching, etc. Facial development will be altered in a negative way. The jaws will have unequal growth that can lead to TMJ problems, sleep issues, and brain development.

A longitudinal study (Avon Longitudinal Study of Parents and Children) looked at the effects of consistent mouth breathing of 11,000 children under the age of 7 and found a significant connection between SDB (Sleep Disordered Breathing) and ADHD, aggression tendency, anxiety, and other behavioral manifestations.

Most significantly and concerning was the finding that SDB symptoms that are present before age 5 were associated with a 40% greater chance of special education needs by age 8.

**The ability to properly breathe in early childhood sets the course of some neurocognitive abilities, facial growth tendencies and strong pre-dispositions for future TMJ problems. **

In my experience, most physicians aren’t aware of the critical importance of aggressive airway management before age 10 and often shrug off snoring, bedwetting, frequent respiratory illnesses, enlarged tonsils, et. al. that we see most every week in children and teens with TMJ problems manifesting as pain and problems opening the mouth.

A list (downloadable PDF) of common signs and symptoms and visuals that parents can look for that will suggest your child or teen has an airway problem are located on our website under the Sleep Breathing Disorders tab.

Get a TMJ/Sleep trained Dentist to help educate your pediatrician or doctor about early intervention. We are here to help you navigate the details.

Look for more on this topic to come…

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