TMJ and Its Link to Headaches, Sleep Apnea

July 23, 2015
BY PETER BLAIS, RPSGT

Nearly everyone on occasion experiences a throbbing headache that interferes with concentration at work or school or saps the joy from the day. For many people, the pain can be traced back to their teeth, their bite relationship, and the alignment of the lower jaw, which may also lead to a diagnosis of obstructive sleep apnea (OSA), says Fred Abeles, DDS.

“Pain doesn’t happen randomly or because of bad luck,” says Abeles, who is author of the bookBreak Away: The New Method for Treating Chronic Headaches, Migraines and TMJ Without Medication. “There’s a cause and effect to almost everything in the human body.”

With many headaches, Abeles says, the cause is the temporomandibular joint, or TMJ—the place at the front of the ear where the lower jaw and the temporal bone on the side of the head meet. Sometimes the bite and the lower jaw are out of alignment, putting additional strain on muscles, which leads to the headaches. And for many, TMJ headaches aren’t going away because people try to mask the pain with medication rather than correct the underlying cause, Abeles says.

But how do dentists know a headache is caused by TMJ, which may additionally help them diagnose OSA in their patients? Abeles says these are some of the warning signs:

• The jaw clicks or pops. Any joint in your body should work silently and seamlessly, Abeles says. When a jaw makes sounds when you open or close it, it’s a clear sign that the lower half of the joint is not in the proper position. Even if the popping and clicking don’t produce pain, he says, the muscles that have to support and stabilize the joint become fatigued and will produce pain.
• The bite feels off. The TMJ is the only joint in the human body that has 28 teeth stuck between the opening and closing motion of the joint to complicate things, Abeles says. Every other joint is completely controlled by muscles, and the position of the joint, its movement and range of motion are mediated by muscle.The TMJ position is dictated by where our teeth come together in our bite. So if your bite feels off or your teeth don’t fit together well, there’s a good chance your TMJ joints are off too.
• Pain around the forehead, temples, back of the head, or radiating down the neck. Ninety percent of pain comes from muscle, Abeles says. If your muscles are not functioning well because of fatigue from supporting one or both of your TMJ joints in an improper position, they produce pain. It’s much like when you exercise or work hard and feel muscle pain later, he says. The only difference is that TMJ is more subtle and chronic.
• Forward head posture. Our heads are supposed to be centered over our shoulders. If yours is in front of your shoulders when you are upright, you have “forward head posture.” That relates to your bite and your airway. The human head weighs about 8 to 10 pounds. The farther forward it is off the center axis, the more strain it places on neck muscles and vertebrae.
• Snoring. Snoring is a red flag that respiration during sleep is disturbed, Abeles says. Several factors can lead to snoring, but one of the most important is the position of the lower jaw. If your lower jaw is a little too far back, then the tongue is farther back as well. If the tongue is slightly farther back than optimal, it vibrates against our soft palate, closes off our airway and we snore. The snoring doesn’t cause the headache but it could be a sign the lower jaw is too far back. As a result, the muscles that support the jaw in an improper position produce the headache pain.

SO HOW DOES TMJ DISORDER RELATE TO SLEEP APNEA?

The temporomandibular joint, Abeles notes, is the only joint in the human body whose position is dictated by where a bunch of teeth come together. No other joint in our body has this distinction. When the 14 teeth of our upper jaw mesh together with the 14 teeth of our lower jaw (our bite relationship), that’s where the lower jaw aligns. In fact it cannot align anywhere other than where our teeth habitually fit together.

If the bite relationship positions the lower jaw slightly too far backward in a retruded position, then not only will the lower jaw and our temporomandibular joints be positioned further backward, but the tongue will be retruded, since its position is determined by where our mandible is located in space. As the mandible is retruded, it alters not only the position of our TMJ but also our tongue, which then affects the degree of opening in our airway.

So altered mandibular position can affect both the position and mechanical function of the temporomandibular joints and also airway patency as dictated by the position of the tongue. Sleep-disordered breathing (SDB), including sleep apnea, can result from a partially obstructed airway.

Abeles shares these statistics: 75% of people with TMJ dysfunction have signs that suggest SDB; a narrow maxillary arch (upper arch of teeth) is 90% predictive of OSA; and a retruded chin is 70% predictive of OSA.

WHAT THERAPIES CAN DENTISTS USE TO HELP PATIENTS DEAL WITH SLEEP APNEA?

The most effective, Abeles says, is referred to as a mandibular advancement device (MAD) or oral appliance. These oral appliances come in many forms but the purpose is the same. When worn during sleep, they prevent the mandible from falling backward and closing off the airway. Most CPAP (continuous positive airway pressure) devices inflate the airway laterally. Mandibular advancement devices open the airway in an anterior/posterior dimension, so the two devices may even complement each other in certain indications.

Physicians can lower the pressure on their patients’ CPAP device and still maintain a proper AHI (apnea hypopnea index) in many cases. Or in cases of mild to moderate sleep apnea that do not require CPAP, an oral appliance can be used exclusively.

HOW CAN DENTISTS ACCESS THESE THERAPIES AND EDUCATE PATIENTS ABOUT THEIR USE?

Abeles says there many wonderful post-graduate training programs available for dentists to gain great proficiency in treating sleep disorders in their practice. He recommends the Las Vegas Institute for Advanced Dental Studies, where he is clinical instructor and regional director.

Competence must precede confidence, he says. Once a clinician has achieved the requisite expertise and experience in the field, educating patients is easy. The entire dental team becomes an integral part of the process. Simple screening forms such as the Epworth Sleepiness Scale can be integrated into the day-to-day functioning of the dental office, Abeles says. Any team member can discuss these important issues with their patients when appropriate. “These patient discussions could truly be life-saving. Remember, 17% to 20% of the American population has OSA and 90% are undiagnosed,” Abeles says.

HOW DO DENTISTS DETERMINE WHICH PATIENTS ARE APPROPRIATE FOR THESE OSA THERAPIES?

Dentists can use ambulatory sleep diagnostics that their patients can take home to create a sleep study. AHI, oxygen saturation, hypopnea, RDI (respiratory disturbance index), and many more metrics can be determined with a simple, portable device their patients can take home and use after brief instruction. Abeles cautions that these diagnostic devices are not a substitute for a PSG (polysomnogram) being administered by a board certified MD sleep specialist, but rather are an effective screening device. If the results of the home sleep study indicate a concern, the dentist should not diagnose or begin treatment based on the results but rather they should then refer the patient to a sleep physician, with a report of their preliminary findings, Abeles says.

Abeles is a renowned TMJ expert. He has been featured on NBC and CBS, consults with leading dental manufacturers on the development of new products, been on the cover of the profession’s biggest magazines, and instructed dentists throughout the United States and Canada on state-of-the-art techniques for treating headaches and TMJ dysfunction.