Jaw problems with mouth pieces is common. But its not the mouth piece causing the problem. Lets look at a similar situation. You throw out your knee playing football. Tear ligaments, Chip cartilage. Its a mess. So you go to an orthopedic surgeon. He says yeah I can go in an repair everything and your going to need physical therapy for a few months so the supporting muscles, ligaments and tendons let the knee JOINT heal and return to its full range of movement and motion. Make sense and you expected there would be some physical therapy or the knee JOINT would be stiff and sore and take a longer time to heal after the surgery. The same issues occur when treating sleep apnea with a dental appliance. Sleep apnea causes an increase in cortisol, rapid chest breathing, poor sleep, etc. This is the cause of a lot of TMJ dyfunction (jaw problems) which is a JOINT similar to your knee. And if its not the true cause sleep apnea certainly make it worse. Half my practice is sleep apnea and TMJ dydfunction therapy. I have yet to see a sleep apnea patient in 20 years of practice that did not have a lot of teeth wear. This means their muscles have been squeezing their jaw JOINT together way too hard for way too long! The muscles are not supporting the jaw JOINT anymore and are part of the problem. Now you decide to go to your dentist and get an appliance for sleep apnea. The appliance simply brings the jaw forward to about where you bite through a sandwich. Maybe a little more or little less. The muscles should have no problem with the jaw being brought to this position. But the muscles are not healthy any more. And you may not realize it because you don't get head aches and you didn't make the connection between broken teeth and sleep apnea. So the appliance brings your jaw forward and sure enough the JOINT says OUCH!!!! Your muscles need therapy. Just now you know it. Its not the appliances fault. As I said my office is different because I treat both dental patients and sleep apena patients equally. So I have a massage therapist that works for me full time trained to use trigger point therapy, acupressure, and yoga stretches to get the muscles back loose and moving. I have a chiropractor that specializes in nerve heath that comes to my office every Tuesday to get all the muscles working together again. So we start with a lot of jaw problems but quickly solve them. Most dental practices will not have "muscle therapy" options other than tensing. So you may have to find therapy for your muscles on your own. But ask your dentist about it first. For some of my patients with really sore jaws we slow down how fast I bring their jaw forward to give the massage therapist and chiropractor time to get the muscles and tendons back in shape. Usually just a couple of weeks for the really bad cases.
So for the long response. Hope I explained it oK.
Dr Tony
I couldn't agree more. One would think that dentists who are placing oral sleep apnea appliances would be cognizant of the TMJ environment in which they are attempting to place them. And, furthermore, would have gotten more training in TMJ in order to cope. But many times, that just is not the case because general dentists are encouraged to take a few courses and then incorporate dental sleep medicine into their practices as just one more of many services. I think that this approach is a real loser and both the patients and the reputation of oral appliances suffer greatly. Dr. Luisi
This topic points out a central failing in treating sleep disorders. Generally, referrals and subsequent treatment start with the generalist. Guess there is little training in medical school on alternatives for treatment of sleep disorders; specifically apnea. OSA and central apneas? How can a generalist point a patient to and ENT and potentially surgery, a sleep study and potential dental appliance or PAP therapy? It would seem a positive sign if sleep clinics where diagnosis could occur but have doctors involved who would be familiar with all forms of sleep therapy. I think most sleep study places have only one avenue of treatment. Sleep disorder treatment has a way to go.
You have certainly got it right. Without awareness at the professional entry level, patients often never get to the specialists that they need. In fact, general family dentists are the ideal professionals to screen for OSA. They often see patients every six months and get an opportunity to view them intraorally. I am not particularly proud of it, but 11-12 years ago before I got into dental sleep medicine due to an off-hand remark from a friend who happened to be a sleep physician, I barely knew what the word apnea meant and didn't have a clue what to look for. Most dentists have gotten zero training in dental sleep medicine in school and have zero interest in the field. Thus they don't even screen for it. This is a real public health loss. Dr. Luisi
Hey Dr Tony -
You sound conversant in sleep appliances and I've been a bit frustrated getting solutions from my dentist. I've been diagnosed with sleep apnea (had a minor stroke a few years ago and I can't help but think SA may have been a contributing factor) and I've been using oral appliances since I realized I just couldn't manage the CPAP machine. I've got a Narval appliance - which is the most comfortable and easy to use I've ever had. The problem is that the posts keep popping out. When I fit the thing with the post size that give me the right jaw extension (#29) I must be grinding it off in the night. When I opt for a longer post I don't pop it out but it doesn't give me the relief I need. I'd rather not switch back to a more invasive appliance but I have no other options.
Do you?
Thanks
RM
Yeah I hear you! I wear the Narval too. And yes I have seen this problem with several patients. The problem your having most likely is that your grinding side to side at night and when you get way out to the side opposite the the bar thats popping off your clenching down enough to bend and flex the bar to the point there it pops off. So this is a muscle problem more than an appliance problem. The lab bill for the Narval is quite high so your dentist is probably not excited to make you a different appliance. But if your torquing your muscles this much you would have problems with other appliances too. You best option is to get the muscles under control. Have you done any kind of massage therapy, chiropractic, physical therapy for TMJ or upper back problems?
Would like to tell you a solution so the Naval would stay together even with extreme grinding but there just isn't one.
Tony
One appliance that is really excellent for extreme side to side grinders is the DreamTap. The two trays are joined centrally by a hook that can slide easily side to side on a long metal track. The device is sturdy, stands up to extreme grinding and takes the pressure off the TMJs. I think that many dentists do not factor in extreme side to side grinding when making appliance selections. Extreme side to side grinding is not totally obvious, but there are certain patterns of tooth wear that can be discerned to make the diagnosis if you are alert to it. And you should be. Arthur B. Luisi, Jr., D.M.D.
