The Case of: A little bit More About TMJ Disorder and Sleep

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Recently, I wrote a little blog about how perhaps, just maybe, we should take the time to analyze WHY a patient requires a biteguard/nightguard device. Last week I went to the office of a friend of mine and I mentioned how I am seeing so many new patients these days who tried the biteguard and it did not work too well- it made their symptoms worse actually. The problem with this approach, as I told him and his team, is that if the biteguard masks over underlying TMJ disorders or sleep apnea issues, then the appliance may be causing more problems than it is worth.

In some of my more recent studies, I was reading about this in:
Journal of Dental Sleep Medicine
Balasubramaniam et al.
The Link Between SDB and TM Disorders: An evidenced based review
SB may mask an UARS problem

Now, in English, and without all those abbreviations, this article explains how there is a definitive link between SB (Sleep Bruxism) and UARS (Upper Airway Resistance Syndrome). What this means is that a person clenches/grinds perhaps to open their airway so they can breathe better. The research actually now shows that more than half the time a person will clench or grind their teeth because their airway needs to open more. So now, ipso facto, (don’t you just love that term? ?) if we as the dentist make a biteguard without informing the person that they have an underlying sleep bruxing problem that might be causing apnea that maybe, just maybe, we are contributing to the decline in their overall health? Hmmm…makes you think a little, doesn’t it?
What I actually explain to a potential patient is that I understand the purpose of the bite guard, however, the more current thinking is that there very likely could be underlying issues that must be identified prior to having you wear this device. As a TMD practitioner, I am acutely aware of this and do my best to identify why you are clenching or grinding, and if you might have sleep issues as well.

The bottom line folks is that prior to wearing a bite guard of any kind, you really should take the time to identify what else might be going on. In my practice, I will frequently meet a new patient who feels they spent a lot of time and money on their appliance, only to discover it made things worse. Well, dear readers, sometimes that is because they wore the appliance at night, and this allowed the slipped discs in the jaw joints to move a little into a better position. Then, the next morning they take out the appliance, bite down into a bagel for breakfast, and they get a searing shot of pain from the jaw joint. This occurs because now the disc has moved a bit from having the guard open up the jaw space, and now you bite down and bang really hard into the disc- that plain hurts! So here we have a case where the appliance is effectively masking over a TMJ disorder that really needs to be dealt with. I basically explain to this person that their bite guard just helped us identify they have a TMJ problem.

Now let’s look at the other side of the equation: sleep issues. If you have an Upper Airway Resistance Syndrome issue- the airway is so narrow that you wake up frequently at night. It’s not apnea, but close enough to cause all sorts of health problems. So here you are wearing your biteguard for nighttime use. The bite guard sort of opens the airway vertically, sort of. This then can mask over the underlying sleep problem, and this is now a dilemma. Did you know that sleep apnea directly correlates to cardiovascular disease, diabetes, atherosclerosis, and even cancer? YUP- that’s right. So if you want to mask over this absolutely MASSIVE problem, who is responsible? Is it your dentist? Is it you? Is it both of you who should take the blame? And believe me, one day someone will likely take the blame. And if you are a general dentist who made that nightguard and did it in good faith, of course, won’t you feel really bad if your patient walks in one day and reports they have severe sleep apnea and diabetes and heart disease? And, won’t you feel even worse if their lawyer calls you up and asks: Dear Doctor: did you not diagnose the underlying apnea and TMJ problem prior to fitting in that biteguard for Mr. Smith?

Need I go on folks? If this blog can reach enough people and they are really listening, then perhaps these people will save themselves lots of issues when they hear their dentist say these words: Dear patient, you need a nightguard.