Learn More About TMD/Sleep Apnea Treatments
Dr. Bowden has also dedicated her orthodontic practice to the diagnosis and treatment of Craniofacial Pain and Temporomandibular Dysfunction (TMD). She has completed over 1000 hours of Continuing Education post graduate training in Craniofacial Pain, Sleep Disordered Breathing and TMD treatment. She is a Diplomate of the American Board of Craniofacial Pain, a Distinguished Fellow of the American Academy of Craniofacial Pain and a member in good standing of the American Academy of Dental Sleep medicine. Dr. Bowden is committed to identify and compassionately deliver quality care that fulfills the needs of those seeking relief from headaches, facial pain and neck pain. She also offers alternative treatment to CPAP therapy for Obstructive Sleep Apnea with oral appliances. Dr. Bowden understands the consequences of untreated Obstructive Sleep Apnea and the correlation between Sleep Disorders and Temporomandibular Dysfunction. Helping patient’s return to the higher quality of life they deserve. Her philosophy is conservative and she believes that patient relationships are based on mutual trust, excellent customer service and the best, personalized patient care available. The “team” concept is a priority in her office.
Laura Bowden, D.M.D, M.S.
Specialist in Orthodontics
Diplomate – American Board of Craniofacial Pain
Board of Directors – American Board of Craniofacial Pain July 2014 – Present
Diplomate – American Board of Craniofacial Dental Sleep Medicine
Distinguished Fellow – American Academy of Craniofacial Pain
Member – American Academy of Dental Sleep Medicine
Member – American Association of Orthodontists
We have dedicated our practice to the diagnosis and treatment of Craniofacial Pain and Temporomandibular Dysfunction (TMD). Our office offers conservative treatment for TMD, head/neck pain and alternative treatments to CPAP therapy for Obstructive Sleep Apnea. We rely on the latest research and technology available and all our treatment is medical evidenced based. Our Mission is to identify and compassionately deliver quality care that fulfills the needs of those seeking relief from headaches, neck and facial pain. Helping patient’s return to the higher quality of life they deserve.
What is TMJ/TMD?
The temporomandibular joint (TMJ) is the joint connecting the lower jaw (mandible) to the skull (temporal bone). The lower jaw and the skull are connected by a number of muscles and ligaments, which function in harmony with each other if the lower jaw is in the correct position. The head of the jaw bone (lower jaw) is called the condyle and it fits into the concavity of the temporal bone called the glenoid fossa. The TM joint resembles a ball and socket with the round condyle being the ball and the glenoid fossa of the temporal bone being the socket. For normal joint function to occur, a piece of cartilage called an articular disc acts as a cushion or shock absorber between the two bones.
Symptoms which are collectively known as Craniomandibular Dysfunction are: headaches, neck aches, ringing in the ears, stuffiness in the ears, ear pain, pain behind the eyes, ear pain, shoulder and lower back pain, dizziness, fainting, difficulty swallowing, and tingling of the fingers and hands.
When the lower jaw opens and closes, the disc stays between the condyle and the glenoid fossa of the temporal bone at all times. When this happens, this is a normal healthy TMJ and the patient can open wide without any discomfort and without any noise. With a normal opening, the patient should be able to get three fingers between the upper and lower front teeth when the mouth is open as wide as possible. In cases where the TM joint is functioning normally with the disc in the proper position, the muscles of the head, neck and shoulders function relatively pain-free.
What is TMD?
Temporomandibular Dysfunction (TMD) is the condition referring to a joint that is not normal.
The position of your teeth can affect the position of your jaw joints. Each jaw joint is like a ball and socket joint. When functioning properly, the ball and socket do not actually touch because a thin disc of cartilage rides between them. The disc acts as a cushion and allows the joint to move smoothly. Each disc is held in place and guided by muscles and ligaments.
What Causes TMD?
The temporomandibular joints are among the most utilized joints in the body, due to their prolonged use during chewing, talking, singing, yawning, etc. Usually trauma is the most common cause of TMD. Macro-trauma like a car accident (whiplash injury) or a repetitive micro-trauma like clenching and grinding (bruxism) your teeth can cause inflammation in the TMJ.
An overwhelming majority of patients who sustain whiplash injuries in motor vehicle accidents (MVA) also dislocated one or both temporomandibular joints at the same time without having impacted their face or head against the steering wheel, door column, windshield or other parts of the car.
Whiplash typically occurs if the head is thrown backward and forward while riding in a car that is hit from behind or the side. Extensive research has well documented the fact that most flexion-extension injuries occur following what is called “minor head injuries.” This means that it is not necessary to suffer a fracture or even a direct head impact. In fact, most patients report that their head was simply snapped backward and forward or side to side. This motion causes damage to the muscles and ligaments which support the jaw joint. When these muscles and ligaments are injured, this can cause an anterior displacement of the protective disc and result in a dislocated jaw joint on one or both sides.
A severe blow the head or the jaw can cause the disc to be dislocated due to the force of the impact on the jaw. Patients may experience swelling, limited opening and clicking in the joint. Patients with this acute injury should seek emergency treatment immediately to avoid further damage to the joint. Obviously, the sooner the patient can be treated, the higher the success rate.
Unbalanced muscles can be a result of clenching or grinding of the teeth. If a muscle is overworked or becomes fatigued due to a structural imbalance, other muscles must compensate. This compensation causes the body to adjust to an abnormal postural state. Compensation means the body adapts to a state that is unhealthy. Severe clenching and grinding your teeth for years can place excessive load on the joint, exhaust synovial fluid lubrication and may cause TMJ inflammation.
Displaced disc, a dislocated disc, unfavorable head posture or body posture and spastic muscles can all refer pain into the neck, face or head.
Muscle tension headaches can be so severe that they are confused with migraine headaches. Unfortunately, patients are often not examined for TMJ disorder and the “migraine” treatment works poorly.
The treatment for patients with migraine headaches is often a prescription of Imitrex. This medication is ineffective in solving problems relating to dislocated jaw joints (TM dysfunction). Patients are advised to call our office and set up a consultation to determine if your symptoms are due to TMD.
Predisposing factors that make you more prone to TMD:
- Narrow crowded upper jaw
- 5 or more missing back teeth
- Deep Overbites
- Upper teeth tipped inward
- A lower jaw that is too far back
When the lower jaw is too far back it can presses on the nerves and blood vessels at the back of the socket and causes pain. When nerves and blood vessels are compressed, the whole structure is unbalanced, affecting the nerves, the ligaments and the muscles of the head, neck and face. This can cause ear symptoms like tinnitus and stuffiness due to the compressed posterior joint space.
Usually, the protective disc (cartilage) is displaced forward and no longer serves as a cushion between the condyle (lower jaw) and the bony socket (skull) and eventually this can lead to the condyle rubbing against the bony socket. This can cause degenerative changes in the joint complex.
When the disc becomes displaced, this is what causes the various noises within the jaw joints such as clicking and popping sounds. Patients must be aware that any noises or pain that occurs during the opening and closing of the jaw is an indication that the jaw joints are not functioning properly. Patients are advised to seek treatment as soon as possible, acute treatment is less expensive and treatment time is usually shorter than for a chronic condition
More severe displacement can be very painful and eventually can cause permanent damage to the joint.
The etiologies of craniofacial pain disorder are often multifactorial. Dental causality is considered, but so should postural problems (especially of the head, neck and upper quadrant), psychological components, endocrine dysfunction or disease, airway compromises, genetic tendencies, pharyngeal dysphasia and other related problems. In short, these dental, structural, chemical and emotional factors may be considered as part of a thorough evaluation.
EVALUATION FOR TMD
Our office has the knowledge and experience needed for proper, thorough diagnosis and treatment of temporomandibular joint dysfunction. The term craniofacial pain will be used as the collective term for extracapsular disorders of the craniofacial region as well as intracapsular disorders of the temporomandibular joint (TMJ).
Discussion and limited examination take place at the initial consultation appointment. The patient reports time of onset, duration and intensity of pain in the affected area. The examination explores the pattern of jaw movement to detect sounds and tenderness to gentle pressure. A Working Diagnosis will be formulated and any recommended further testing and treatment will be discussed.
Further diagnostic testing is indicated when the presence of jaw joint dysfunction is suspected. Further testing is designed to formulate a definitive diagnosis and treatment plan. These tests include:
- Full Medical and Dental History as well as an examination of the teeth and the dental arches
- TMJ Health Questionnaire
- A complete collection of data used to assess the chronicity and severity of the chief complaint.
- Range of Motion testing using computerized magnetic jaw tracking
Patients are checked for how wide they can open, slide left and right, move the jaw forward, and whether or not there is a deviation or deflection of the jaw upon opening. We determine how fast the jaw moves during the opening and closing cycle and precisely where the joint noises (dysfunction) occur. If there is a problem achieving normal range of motion and velocity, there is usually a structural problem within the joint.Photographs
It is important to assess the posture of each patient to determine whether or not the shoulders, pelvis and hips are level. Photos are taken of each patient to check for the above as well as to check for forward head posture. If there is a problem with the shoulders, hips or pelvis or if one leg is longer than the other, then a referral to a chiropractor or physical therapist would be necessary.Full Muscle Palpation Exam
Excessive muscle contractions and trigger points indicate a problem with the chewing muscles of mastication. This causes the muscles of the head and neck to be sore when pressed by the doctor. This usually means that there is an imbalance and dysfunction present.
TMJ x-rays are important to see if the condyles (top of the lower jaw bone) are too far back where they would be impinging on the nerves and blood vessels at the back of the socket where the jaw bone fits into the skull. We use 3-D Cone Beam Radiograph (CBCT) to determine condyle position and any degenerative changes in the TMJ.
Joint Vibration Analysis (JVA)
Joint Vibration Analysis (JVA) provides a fast, non-invasive, and repeatable measurement of TMJ function to aid in diagnosis of TMJ function. Human joints have surfaces which rub together in function. Smooth, well lubricated surfaces in a proper biomechanical relationship produce little friction and little vibration. But surface changes, such as those caused by degeneration, tears, or displacements of the disk, generally produce friction and vibration. Different disorders can produce different vibration patterns or “signatures”. PC-assisted vibration analysis helps identify these patterns and helps you distinguish among various TM disorders. The JVA is simply a 3-minute, non-invasive test where headphones are placed on both jaw joints and the patient is instructed to open and close about six times.
A psychosocial screening is often of value for the craniofacial pain patient.
The TMJ scale is used for the pretreatment assessment of the craniofacial pain patient as well as a means of assessing treatment progress and treatment outcome. The test is completed entirely by the patient, thus eliminating subjective clinical bias and allowing cross practice comparison of TMD symptom severity. The TMJ scale is supported as a psychometric assessment tool and by a large body of published validation data. The tests assesses clusters of physical symptoms including joint dysfunction, pain, range of motion limitations and psychosocial symptoms including stress, psychological distress and predicts overall clinical significance of a craniofacial pain/temporomandibular disorder.
Cranial Nerve Evaluation
Because of the strong interrelationships of the 12 cranial nerves and the multiple signs and symptoms exhibited in craniofacial pain disorders, this evaluation and its subsequent findings will lead the doctor to definitive diagnosis.
TREATMENT FOR TMD
Since the teeth, jaw joints and muscles can all be involved, treatment for this condition varies. The goal of treatment is to relieve the muscle spasm, inflammation and pain as well as establish proper joint position and normal range of motion with function of the lower jaw.
This is accomplished with orthopedic appliances that cover the teeth. Some patients need to wear their appliances only at night and others need to wear the orthotics 24/7 to stabilize and decompress the jaw joint.
The orthotic covers the teeth holding the jaw in proper alignment, reducing tension in the muscles of the jaw joint, allowing healing to take place. Once pain is controlled and the jaw joint is stabilized, the bite is balanced so the teeth, muscles and joints all work together in harmony.
Objectives of the TMD orthotics are to try and establish the correct position of the mandible to the maxilla in three dimensions; transverse (side to side), sagittal (front to back) and vertical (up and down). The goal is to try and find a comfortable position for the lower jaw so that the patient can get some relief from the pain and muscle spasms. The orthotics also positions the condyle in the proper spot inside the fossa.
Since most head, neck and shoulder pain originates from muscle instability or swelling and inflammation of the joints, we may employ various physical medicine modalities to treat and help normalize these structures. These include; moist heat therapy, vapor coolant spray/stretch, ultrasound, cold lasers, electric stimulation of muscle trigger points, trigger point injections and MCP (Micro-current Point Stimulation). These joints often get very tight in people with dysfunctions and various types of mobilization or stretching techniques are employed to gain normal function of these tissues.
Sometimes it will be necessary to refer patients to other health care practitioners to help relieve some of the muscle spasms including chiropractors, massage therapists, physical therapists, SOT therapists, etc.
The patient must be made aware of the fact that, although the majority of patients do improve substantially, there are still a small number of patients whose do not respond to treatment. After conservative treatment fails referral to other healthcare providers is warranted.
Here are a few questions you may want to ask yourself, to help determine if you have any symptoms:
Do you get an unusual amount of headaches? Y N
Do you have a grating, clicking or popping sound in either or both jaw joints, when you chew or open and close your mouth?
Do you have pain or soreness in any of the following areas: jaw joints, upper jaw, lower jaw, side of neck, back of head, forehead, behind the eyes or temples? Y N
Do you have sensations of stuffiness, pressure or blockage in your ears? Y N
Do you ever have ringing, hissing or buzzing sounds in your ears? Y N
Do you ever feel dizzy or faint? Y N
Do your fingers, hands or arms sometimes tingle or go numb? Y N
Are you tired all the time, fatigue easily or consider yourself chronically fatigued? Y N
Are there imprints of your teeth on the sides of your tongue? Y N
Does your tongue go between your teeth when you swallow? Y N
Do you have difficulty in chewing your food? Y N
Do you have any missing back teeth? Y N
Do you clench your teeth during the day or at night? Y N
Do you grind your teeth at night? (Ask your family.) Y N
Do you ever awaken with a headache? Y N
Have you ever had a whiplash injury? Y N
Have you ever experienced a blow to the chin, face or head? Y N
Have you reached the point where drugs no longer relieve your symptoms? Y N
Does chewing gum worsen your symptoms? Y N
Is it painful to stick your “pinky” fingers into your ears with your mouth open wide and then close your mouth while pressing forward with your “pinky” fingers? Y N
Does your jaw slide to the left or right when you open wide? Y N
Are you unable to insert your first three fingers vertically into your mouth when it is open wide? Y N
Is your face crooked and not symmetrical? Y N
If you answered yes to some of these symptoms, you may have a TMJ disorder (TMD) Call our office for a consultation.
Here are some ways you can visually check your TM joint:
Put your fingers inside your ears. Open and close several times. If the jaw clicks or cracks, or if you feel a grinding sensation.
While looking in a mirror, open very slowly, notice whether or not your jaw swings to one side while opening and closing. Is there any pain present?
Slide your jaw from side to side, make note of any pain you may experience.
Check for muscle sensitivity:
Place your fingers in front of your ears on the joint and apply pressure.
Also apply pressure to the cheek area
If you notice discomfort or pain during this self-assessment, please call our office at (913) 971-4159 and schedule your consultation.
Disclaimer: Content on this site is to be viewed as educational only. In no way should content be taken as formal medical advice
SLEEP APNEA TREATMENTS
Sleep Disordered Breathing (SDB) includes obstructive sleep apnea (OSA), central sleep apnea, upper airway resistance syndrome, obesity hypoventilation and snoring. There is a cause and effect relationships between SDB, illness and poorer quality of life. Quality of sleep and sleep medicine are two relatively new areas within medicine, with growing awareness of the serious health consequences associated with SDB. This partial or complete cessation of breathing occurs many times throughout the night, resulting in daytime sleepiness or fatigue that interferes with a person’s ability to function and reduces quality of life. Sleep-disordered breathing adversely affects daytime alertness and cognition and has been linked to occupational and driving impairment. Sleep apnea has also been shown to increase healthcare utilization; it contributes to other chronic health conditions, such as heart disease and diabetes, and increases the risk of having a stroke.
The most common breathing disorder of sleep is OSA, which is characterized by recurrent narrowing or collapse of the back of the throat because of the loss of muscle tone that occurs during sleep. The National Sleep Foundation reports that as many as 18 million people suffer from obstructive sleep apnea. Studies show as many as 90% of individuals with sleep apnea are un-diagnosed.
At the present time, obstructive sleep apnea is defined as a medical problem and the diagnosis must be made by a medical doctor or sleep physician who is specially trained in the area of sleep medicine.
Sleep apnea is a type of breathing disorder which is a serious, potentially life-threatening condition characterized by brief interruptions of breathing during sleep. There are basically three types of apnea:
- Central Apnea
The upper airway is open, but no oxygen is getting into the system. This occurs because the patient is not getting a chemical response from the brain to stimulate the lungs and the diaphragm to assist with breathing.
- Obstructive Sleep Apnea
The lungs and the diaphragm are functioning normally, but no oxygen is entering the system because there is an obstruction in the upper airway.
Oral appliances are only indicated for use in patients suffering from obstructive sleep apnea (OSA). The signs and symptoms of OSA include snoring, excessive daytime sleepiness, gasping or choking during the night, non-refreshed sleep, fragmented sleep, clouded memory, irritability, personality changes, decreased sex drive, impotence, and morning headaches.
- Mixed Apnea
This is a combination of central and obstructive sleep apnea.
Excessive Daytime Sleepiness (EDS)
People who suffer from obstructive sleep apnea have a fragmented sleep architecture which causes them to spend an excessive amount of time in the lighter stages of sleep at the expense of the Delta Phase (deep stage sleep) and REM stage. This causes them to have excessive daytime sleepiness due to their lack of sleep at night.
Apnea and Hypopnea (AHI #)
Apnea is defined as a period of cessation of breathing during sleep for ten seconds or longer. If the patient has more than five episodes of apnea per hour of sleep, this is considered clinically significant and helps confirm the diagnosis of obstructive sleep apnea. Hypopnea occurs when the decrease in airflow results in a 4% decrease in oxyhemoglobin concentration in the blood.
Factors that affect obstructive sleep apnea are as follows:
Sedative Hypnotics (sleeping pills)
Children and Sleep Apnea
Children can also snore and suffer from obstructive sleep apnea. Often they are highly allergic and their airway is blocked due to enlarged adenoids, tonsils or swollen nasal mucosa. Clinical signs would indicate a turned up nose, allergic shiners under the eyes, mucous draining out of the nose, mouth breathing, and a nasal sound to the voice. Other signs are bed wetting, irritability, difficulty in concentrating at school and hyperactivity.
POLYSOMNOGRAM (Sleep Study Test)
The purpose of a polysomnogram is to evaluate the individual sleep architecture including the stages and cycles of sleep as well as to record the electrical activity of the brain, the eyes, muscles and heart. Most hospitals have sleep diagnostic centers and many sleep specialists now have sleep diagnostic centers associated with their office to properly diagnose OSA. The results of the sleep study will reveals whether you have OSA and how severe it is depending on your AHI #.
Major signs and symptoms of sleep apnea
- Loud and chronic snoring
- Choking, snorting, or gasping during sleep
- Long pauses in breathing
- Daytime sleepiness, no matter how much time you spend in bed
Other common signs and symptoms of sleep apnea include:
- Waking up with a dry mouth or sore throat
- Morning headaches
- Restless or fitful sleep
- Insomnia or nighttime awakenings
- Going to the bathroom frequently during the night
- Waking up feeling out of breath
- Forgetfulness and difficulty concentrating
- Moodiness, irritability, or depression
- Snoring vs Sleep Apnea
Not everyone who snores has sleep apnea, and not everyone who has sleep apnea snores. So how do you tell the difference between garden variety snoring and a more serious case of sleep apnea?
The biggest telltale sign is how you feel during the day. Normal snoring doesn’t interfere with the quality of your sleep as much as sleep apnea does, so you’re less likely to suffer from extreme fatigue and sleepiness during the day.
What’s Your Snore Score?
Your answers to this quiz will help you decide whether you may suffer from sleep apnea:
Are you a loud and/or regular snorer?
Have you ever been observed to gasp or stop breathing during sleep?
Do you feel tired or groggy upon awakening, or do you awaken with a headache?
Are you often tired or fatigued during the wake time hours?
Do you fall asleep sitting, reading, watching TV or driving?
Do you often have problems with memory or concentration?
If you have one or more of these symptoms you are at higher risk for having obstructive sleep apnea.
Source: American Sleep Apnea Association
The most effective treatment is a continuous positive airway pressure (CPAP) device that delivers pressurized air to the upper airway, via a mask, splinting the airway open. However, the effectiveness of this treatment is often substantially reduced or nullified by inconsistent or inadequate use by patients. Some patients cannot tolerate the CPAP and simply stop using it. Surgical options include: pillar implants, laser assisted uvulopalatoplasty, coblation, adenotonsillectomy, uvulopalatopharyngoplasty, tongue base reduction, genioglossus advancement, septoplasty and submucous resection of inferior turbinates. The disadvantage is that these surgeries can be quite painful during the healing period. Following the surgery, patients report voice changes and difficulty in swallowing their food. Patients should be informed of all their options prior to any treatment whether surgical or non-surgical. Some patients either do not want surgery or have had surgery and the procedure has been unsuccessful in solving the problem of OSA. These patients prefer a non-surgical, non-invasive plastic intra-oral appliance that can be worn at night only to help solve their problem.
The dental profession can offer alternative treatment options with oral appliances and play an important role in the treatment of snoring and obstructive sleep apnea.
Types of Oral Appliances
Tongue Retaining Appliances
Tongue retaining appliances hold the tongue in a forward position using a suction bulb. When the tongue is in a forward position, it serves to keep the back of the tongue from collapsing during sleep and obstructing the airway in the throat.
Mandibular Repositioning Appliances
Mandibular repositioning appliances reposition and maintain the lower jaw in a protruded position during sleep. The device serves to open the airway by indirectly pulling the tongue forward, stimulating activity of the muscles in the tongue and making it more rigid. The device also holds the lower jaw and other structures in a stable position to prevent the mouth from opening.
Advantages of Oral Appliance Therapy
Oral appliances are comfortable and easy to wear. Most people find that it only takes a couple of weeks to become acclimated to wearing the appliance. Oral appliances are small and convenient making them easy to carry when traveling. Treatment with oral appliances is reversible and non-invasive. An appliance worn during sleep prevents the airway from collapsing by creating extra space. While many models of appliances are available to treat snoring and obstructive sleep apnea, only a specially trained dentist can properly select and fit the type of appliance that is needed.
An orthodontists who treat TMJ – temporomandibular joint disorders – is an excellent choice, because they are very much aware of the jaw position when making the device. This is an important consideration. In fact, TMJ appliances can often be adapted to work for sleep apnea. Appliances are light and easy to wear. In only a few weeks, most patients are comfortable.
Please call our office at (913) 971-4159 to set up your consultation to determine if you are a good candidate for an oral appliance and determine which oral appliance is best for you.
Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997;20(9):705-06.
The National Sleep Foundation. Sleep Apnea and Sleep; 2009.
Lee W, Nagubadi S, Kryger MH, Mokhlesi B (June 1, 2008). Epidemiology of obstructive sleep apnea: a population-based perspective
Disclaimer: Content on this site is to be viewed as educational only. In no way should content be taken as formal medical advice