I used CPAP successfully for three years until using it during a cold led to a sinus infection which has led to chronic sinusitis, every time I try CPAP, the sinus gets worse. I saw a dentist who only does sleep dentistry and had an appliance made, the Narval which she chose because of my bruxism, very painful TMJ and fibromyalgia. Because of my other issues, we have decided to proceed slowly, but even wearing the appliance for an hour during the day creates migraine like headache, mostly on the left side. She did adjust the bottom because it was causing pain in a molar, but it's not much better. I have been sleeping without any treatment, not even the splint that an orthodontist made for the bruxism, because I feel it's making things worse. The dentist just keeps telling me to use the appliance, but the pain is overwhelming. I need help, do you think a course of PT for the TMJ before trying the appliance again would be helpful? Thank you!
The Narval device often opens the back teeth more than other devices and is hard to adjust to allow even biting forces on all the teeth. It is designed to put all forces on the back teeth. Most people with active TMJ pain are put on a device that concentrates biting forces on the front teeth like the TAP, SomnoDent with discluder, or Snore Hook, etc. Moving forces forward away from the joint often decreases the pressure muscles can create.
Do not use the Narval unless the pain is completely gone.
If your dentist wants to speak with me, she can get me through the Academy.
B. Gail Demko, DMD
Assoc. Editor of the Journal of Dental Sleep Medicine
Expert Adviser to the FDA on Oral appliance Therapy
Past President of the Academy of Dental Sleep Medicine
American Board of Dental Sleep Medicine
Thank you for your excellent advice. I'm really not sure why the dentist prescribed this particular appliance when I told her that I clench my teeth an have a lot of jaw pain. She did say she wanted to baby me because along with this, I have fibromyalgia. She said this device is "the Cadillac." It is turning out to be a Ford Pinto for me, and I'm out the co-pay, I don't think my insurance will pay for a new device.
Well, one of the contraindication to oral appliance therapy is a painful TMJ. Confronted with that, I would do a full TMJ work-up and take measures to take your TMJs back to a healthy state before contemplating OAT. If we could not get you there, I would not try OAT. I would agree with Dr. Demko, that a device like the Tap or Somnodent with discluder would be helpful in moving the forces away from the joint and decreasing the pressure from the muscles. Of those two, I prefer the Tap because the center attachment allows the TMJs to free-float and self adjust the pressure between them. Arthur B. Luisi, Jr., D.M.D., The Naples Center for Dental Sleep Medicine.
Thank you for your great advice also. The dentist did a panoramic x-ray and did just the basic ten second TMJ exam where she had me open and close while she pressed on them. How can I go about getting my TMJ back to a healthy state? Is PT available for this, massage, chiropractic? My orthodontist who makes my night splints told me years ago to neve let anyone touch my jaws. Also the sleep dentist said the splint is making my apnea worse, is that accurate? How do I protect my teeth? I feel like my only options now (and I'm working on them) is to loose weight, try to sleep on my side ( my sleep study showed no apnea on my side) and to do exercises to strengthen my jaws, soft palate and tongue.
Unfortunately, you have presented us with a very thorny set of problems. You are very deep into a never-ending cycle of pain and dysfunction. There is no quick fix. There is no silver bullet. The central question is where do you start to begin the reverse the cycle and to slowly unwind it back to normalcy? No one can address it without patient contact, but I think that we could suggest some possible avenues of attack. It might make sense to try to get back on CPAP, at least temporarily. In order to do that, your sinusitis would have to be under control and that means a trip to the ENT first and a course of treatment there before re-attempting CPAP. The benefit of being back on CPAP is that it might tend to reduce or eliminate the nighttime clenching and bruxing and begin to unwind the myofascial pain and dysfunction. It might make sense to see a real, legitimate TMJ specialist. An adequate diagnostic session would take at least an hour to an hour and a half. A ten second quickie doesn't cut it. You need to know if your TMJ problems are organic or structural problems within the TMJ or due to muscular or other problems outside the TMJ. If the problems are found to be muscular, physical therapy and other conservative measures like heat, analgesics, eating soft foods, etc, might prove beneficial. Losing weight makes sense, as does the side-sleeping, and the Tmj specialist would have to decide about the jaw exercises. I do agree that the standard, flat-plane night guard or bite guard could tend to pull the lower jaw backward and make the obstructive sleep apnea worse. I couldn't ever see going back to the Narval, personally, but if you have made a lot of progress, getting off CPAP and graduating to a pull- forward device like the Tap might be a possibility. Well that is my contribution. Will be interested to see the comments from Dr. Demko, Arthur B. Luisi, Jr., D.M.D.. The Naples Center for Dental Sleep Medicine. Practice partner, dental sleep medicine NCH Healthcare System. Practice partner, dental sleep medicine, The Millenium Physicians Group.
