Another approach, however, vastly different, is to use medications to calm the pain and at least get some degree of relief almost immediately. In some of these cases, the practitioner would prescribe Cymbalta to alleviate the anxiety often associated with the pain. Cymbalta is a well-known drug used to treat depression and anxiety. Admittedly, many TMD patients are hurting so badly that they become depressed, and anxiety sets in as they worry about how their future is looking. Unfortunately, this drug has a host of side effects that may make it not so worthwhile, but as a temporary measure, it might help for now. Some practitioners use Xanax along with the Cymbalta since it takes time for the Cymbalta to activate the desired response.

In other cases, something like Cymbalta is used in conjunction with injections into the muscles of the head and neck region to calm those muscles that have been irritated from the slipped discs. Injectables like Botox®, cortisone, prolotherapy and stem cell therapy have been documented to reduce muscular tension. This also provides some degree of temporary relief and may even help to ‘reset’ the muscles into a better pattern.

Of course, there are the surgical approach options. The least desired surgical treatment entails breaking the jaws and resetting them into a more ideal position, however, this approach may not work very well. Cutting apart the bones of the skull may be more risky than other modalities. A more conservative approach to dealing with the displaced discs in the jaw sockets entails simply putting the discs back on top of the condyles. A 20-minute surgery called plication. By far, this is more conservative and simpler than the other surgeries.

So as a patient, you have a choice: try to figure out the underlying issues and deal with them accordingly, or mask over the symptoms and hope things settle down. As I tell our people, it is up to you and I am simply here to guide you on the journey.

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The post The Case of the Confused Craniofacial Case first appeared on Sleep & TMJ Therapy.

Sleep apnea is a condition with multiple symptoms and even more treatment options. When a person sleeps at night, they should stay asleep all night with minimal movement and there should be no snoring. Unfortunately, many people these days snore and have little control over this. Snoring can be a symptom of obesity or might be present in even the slimmest people – there is no true rhyme or reason here. The best way to diagnose the problem is to do a sleep study – a polysomnogram. This requires wearing all sorts of wires across the head and neck for a two-night study in most cases. Then a board-certified sleep MD reads the results. Without getting too technical, the measurement achieved is called the AHI – Apnea Hypopnea Index. If the AHI is quite high, then the usual first measure is to wear a CPAP – continuous positive airway pressure – to force the air into the lungs. For some people, it really works well,  yet for others, it just cannot be tolerated.

Depending on who the doctor is,  the next level of treatment is usually a dentist-fabricated device that opens the jaw and brings it more forward – just like if you did CPR on a person. The dental sleep device is a very good way to help open the airway in most mild to moderate apnea cases. Sometimes the device is used along with the CPAP to allow the machine to use less pressure to get the air into the lungs.

There are many other techniques to help sleep apnea cases – they involve surgery to cut away the palatal area – often referred to as UPPP (Uvula Palatal Pharyngeal Plasty) or even balloon plasty to just temporarily open the airway. Another surgery is called MMA -Maxillary Mandibular Advancement. This effectively brings the upper and lower jaws forward permanently. Beware of these surgeries as they might disrupt the TM joints. Other techniques include various medications that serve many different purposes.

Recently, HNS (Hypoglossal Nerve Stimulation) has been developed. This involves putting, for lack of a better word, an electrical ‘shock’ wire into the hypoglossal nerve in the tongue, then running a wire down the inside of the neck to a battery pack under the skin just below the collar bone. As with any surgical procedure to do an implanted device, there are risks associated with the procedure. Once the therapy is turned on, what happens next is when the patient has an apneic event, the sensor detects this and sends a ‘shock’ and in turn the tongue begins jutting forward to open the throat. Some people seem to tolerate this technique fairly well, others not so much. Some patients may experience discomfort from the stimulation, notice tongue abrasion, experience mouth dryness, or experience discomfort from the presence of the device. Overall, this is a relatively simple technique. The question brought up there is some concern that after a year or two the tongue may no longer be responsive to the shock wire.

Overall, there are many treatments for sleep apnea and no one system of therapy is right for every patient.  Based on the AHI, the most non-invasive treatment, a dental sleep appliance,  does still work and is highly recommended.

The post Does Sleep Apnea ‘Inspire’ You? first appeared on Sleep & TMJ Therapy.

In the past, it was quite common for an orthodontist to order extractions of perfectly good teeth to make the process of moving teeth and creating space with the use of braces easier. So many children are now presenting with narrow arches and crowded teeth that it made sense (somewhat) to remove the crowded teeth, thus allowing the orthodontic work to go faster and easier. But somewhere along the way a few practitioners noticed that the removal of the bicuspid teeth would often cause the upper and lower jaws to collapse backward which would lead to a collapsing of the airway as well. They also rather astutely noticed that the palate would become smaller, which made breathing more difficult as well. There are still orthodontists today who practice the method of extracting the teeth to make room and the braces go easier. However, many more are learning that there just might be better techniques.

The extractions of impacted teeth are a completely different need but also can cause the same issue. In this situation, the teeth need to be removed because 1) the lack of space in the bone means the teeth cannot erupt or 2) the tooth is growing in the wrong direction or position. In this situation, the stress placed on the jaw joint can cause the disc to be displaced and in addition, put a strain on the muscles around the jaw joint.

Of course, another method of expansion is the good old-fashioned RPE (Rapid Palatal Expander), but even this has its issues. The RPE will often just open the palate rapidly and the midline suture might not form into solid bone — it might just be a cartilaginous suture that can move around over time. This would not be very effective. The reason is on a skeletal level this instability can cause changes and distortions in the cranium. Another approach to getting some expansion is to use the ALF appliance as much as possible with the understanding that a few months with the RPE might be OK.

Another problem that is frequently seen among dentists, pulling out bicuspids, which makes the upper and lower jaws move and therefore are no longer in the same position as previously. This change can affect how the condyles (top of the jawbone) fit into the sockets and in turn, can lead to a TMJ problem. When that condyle is re-positioned after extractions, it will no longer be in the same relationship to the disc that covers it. The disc can end up displaced over time. This is what can lead to head and neck pain. So many extraction patients end up with similar problems later in life.

There are some practitioners who will actually use a palatal expander to re-open the extraction spaces to put in dental implants to ‘restore’ what was taken away. This is actually a controversial topic. As we get a bit older, the bones in the skull do indeed become more solid and if you were to try expansion a lot — like the width of a bicuspid that had been removed — it might be too much for the body to handle. Does that make sense? It might be that the expansion is just too much of a  ‘stretch’ and moving bones around might lead to more pain. This is another reason why the more conservative practitioners would use the ALF appliance to get as much gentle expansion as possible while minimizing trauma to the facial bones.

So, in general, extractions for the sake of doing braces may not be the best idea. Be sure to be careful when considering this.

The post Are Teeth Extractions Helpful? first appeared on Sleep & TMJ Therapy.

Here we are in the middle of 2022, and I have to admit that every day I am in the office I see incredible things. At this point I am so used to hearing that our patients feel better, headaches are down and they are sleeping. This has become the norm. But every now and then it just does not work that way, admittedly, around 10% of the time I cannot help that person. And sometimes that is just because they need surgery to fix the problem. The more frustrating case is when I meet a new patient and the MRI shows severe degeneration and yet they feel no pain at all!

When there is severe disc displacement and the condyles (top part of the jaws) are eroding, it would only seem logical that there would be pain. Doesn’t that make sense? What I have learned over the years is the discs have been out of place for a very long time and the condyles are eroding due to compression in the sockets.

The body has set in the process of erosion to prevent the condyle from jamming hard into the socket. Think of it this way, most of the new patients I meet really should have had their teeth raised taller when they did braces so that the condyles would not jam up into the joints so hard. Yet, most people never had orthodontic work done in that fashion. The goal was to have their teeth made straighter to look good, a cosmetic case only. And now, years later, the shortness of the teeth has caused the condyles to jam up into the sockets, thus displacing the discs out of the joints. This is what I see almost every day of the week!

The way our body works is that it will always try to protect us from harm. Just like if you get a bacterial infection, the body fights back with chemicals to kill the bacteria. Well, when our body senses the condyles are too high up in the socket and are damaging the discs, sometimes the body will begin to erode away that jammed-up condyle to avoid pain. It’s really quite simple actually- our body is trying to help us. However, this so-called ‘help’ is not what needs to be done. What we really need to do is to make the back teeth taller to open up the joint space and reduce the impact of the condyle on the socket. I hope this makes sense. It seems to work quite well in some patients, but not so much with others. This is why we are human beings, there are many variables at play here. With certain patients, i.e., those with autoimmune disorders, for example, their inflammation levels are already quite high so it is more likely they will hurt due to slipped discs and degenerating condyles. With other patients who have little to no existing inflammation, they are less likely to feel the pain of their situation.

As you can imagine, some days it is difficult to figure out why one patient is hurting and the other just simply does not! Maybe this is what makes us human beings! Please give us a call if you have any concerns about your jaw health!

The post The Case of the No Pain Patient first appeared on Sleep & TMJ Therapy.