Dilemma: trade-off between open airways and joint pain

[McSleepy]

I wonder if someone here might have experienced something similar or has any related knowledge that I might find useful. My breathing has been fine but lately I have started developing pain in the temporomandibular (TMJ) joint, and I might be facing a choice between one or the other. Here is some history.

I don't know that there is a connection but about 5 months ago I switched from my old Respironics BiPAP machine to my current S8 VPAP Auto 25. For years I had been doing all right (although I had no data to confirm it) at pressures of 20/10 cm H2O, until I moved to the mountains and reduced the pressure a bit to 17/9 (actually, with another -3 cm on EPAP due to the BiFlex). This is what had worked for me, for various reasons, some of them being compromises for my nasal blockage, which I resolved about 6 months ago (viewtopic.php?f=1&t=59128&p=555825). After that, and with the new machine, which gives me data, I settled to pressures of 14/9. And here is the first important point: I wonder if the lowering of the pressure might have forced me to (unconsciously) make an adjustment. My ENT has confirmed that the soft tissue in my throat can collapse badly - no wonder here, we know that's the main cause of OSA. It is also well known that displacing the lower jaw forwards helps keep the pharynx open. Well, lately I have found myself doing that - letting my jaw slide forwards - certainly at night, but also any time I relax. The problem is that I started waking up with an overbite (to the point where I cannot close my mouth) and it takes me sometime to put it back, but I have to consciously work on it through the day or as soon as I'd relax it, it would tend to slide forwards. Since about a couple of weeks, I have also developed a moderate pain (quite unpleasant when eating) and I think my right TMJ might have become inflamed. Even though I have been consciously working on replacing my jaw back where it belongs (contracting the muscles to pull it back every time I think of it) and the pain having subsided a bit in the lat couple of days, I'm starting to get concerned about this phenomenon.

The problem is that you want the benefit of the jaw displacement - it probably helps with my CPAP treatment (my AHI, according to the machine data and an in-house oximetry study) is under 1 every night and the SpO2 is over 90%. But you also want to prevent any malocclusions from forming. My family is between dental insurances right now and I'm waiting to see my daughter's orthodontist, who is very experienced. I fear it won't be easy, though. One of my concerns is that the standard treatment of jaw displacement is an oral appliance that you bite on. However, short on wiring my mouth shut, I don't think that's going to work. The reason is that when I sleep, my jaw is open (although my lips are sealed) and such an appliance would not hold it. Even now, as I'm writing, I keep catching myself with the jaw open - sliding down and forward - and I have to remind myself to pull it back and shut. I even have to help myself by pushing the jaw back with my hand to achieve proper occlusion. Maybe the solution is a compromise: keep the jaw slid forward just enough to help my larynx stay open (and let the CPAP do the rest, even if I have to raise the pressure a bit), yet not too much to cause TMJ problems. But even if that is the solution, then the question remains how to achieve that.

There are other considerations and details that I could share but I'd fist like to see what kind of feedback I can get.

McSleepy

[Janknitz]

No answers for you, just a few observations:

I do notice that my lower jaw comes forward just a few milimeters from the pressure of the CPAP when I'm wearing my nasal pillows mask, and it changes my bite. It feels funny in the morning. In contrast, when I use a FF mask (Quattro), I know it pushes my lower jaw back a little.

My dentist tells me that people who use an oral appliance instead of CPAP have TMJ issues sometimes, and he teaches them some exercises to get their jaw to go back in the proper place. If they are diligent about doing these in the morning, the problem stays under control.

I'm wondering if in your case an oral appliance worn with the CPAP PLUS some exercises in the morning might help?

[robysue]

And here is the first important point: I wonder if the lowering of the pressure might have forced me to (unconsciously) make an adjustment. My ENT has confirmed that the soft tissue in my throat can collapse badly - no wonder here, we know that's the main cause of OSA. It is also well known that displacing the lower jaw forwards helps keep the pharynx open. Well, lately I have found myself doing that - letting my jaw slide forwards - certainly at night, but also any time I relax. The problem is that I started waking up with an overbite (to the point where I cannot close my mouth) and it takes me sometime to put it back, but I have to consciously work on it through the day or as soon as I'd relax it, it would tend to slide forwards.

Clarification on the word I highlighted in BOLD ITALICS. Do you really mean an overbite or an underbite here? What you are describing sounds much more like an underbite---where the bottom teeth are too far forward in the mouth to mesh correctly with the upper teeth. In an overbite, the bottom of the teeth are too far back in the mouth to mesh correctly with the upper teeth.

Since about a couple of weeks, I have also developed a moderate pain (quite unpleasant when eating) and I think my right TMJ might have become inflamed. Even though I have been consciously working on replacing my jaw back where it belongs (contracting the muscles to pull it back every time I think of it) and the pain having subsided a bit in the lat couple of days, I'm starting to get concerned about this phenomenon.

Intentionally or unintentionally misaligning that jaw is very likely a significant contributing factor (and maybe the only factor) in triggering that TMJ pain. Does the TMJ also "pop" when you're chewing your food? Do you grind your teeth in your sleep? I think not based on what you write about later on. But teeth grinding is another major source of TMJ pain. So if you don't grind your teeth at night, that points even more to the problem being your current habit of misaligning the jaw to the point of developing an underbite.

The problem is that you want the benefit of the jaw displacement - it probably helps with my CPAP treatment (my AHI, according to the machine data and an in-house oximetry study) is under 1 every night and the SpO2 is over 90%. But you also want to prevent any malocclusions from forming.

Unless I'm missing something, the jaw problem started when your pressure was reduced with the new VPAP machine. On the old BiPAP with pressure set at 17/9 and Bi-Flex set to 3, you had no problems with how you were feeling and you had no TMJ pain. With the new S8 VPAP set to 14/9, you're unconsciously moving that jaw forward and triggering TMJ pain. Seems to me that there's no reason to endanger your teeth, jaw, and TMJ at all---why not increase that IPAP back up to 17 and see if that allows you to quit unconsciously moving the jaw forward in an effort to breathe better. A properly set pressure level should not need you to misalign your jaw to get effective treatment. There are, of course, some folks who use oral OSA appliances---which intentionally misalign the jaw---in combination with CPAP as a way of reducing very high pressures to something that is more easily tolerated. But as near as I can tell you were comfortable with your old BiPAP set to 17/9 with Bi-Flex = 3. So why not try setting the VPAP to 17/9 and see if that takes care of the TMJ problem.

And by the by---one dirty little secret that doesn't get much airplay is that a significant minority of people who try the oral OSA appliances abandon them due to issues related to TMJ pain and the need to consciously spend a fair amount of time each morning working the jaw back into its normal position. And the further the jaw has to be advanced for the device to be "effective" in terms of reducing the AHI, the more likely serious TMJ pain will be an issue.

My family is between dental insurances right now and I'm waiting to see my daughter's orthodontist, who is very experienced. I fear it won't be easy, though. One of my concerns is that the standard treatment of jaw displacement is an oral appliance that you bite on. However, short on wiring my mouth shut, I don't think that's going to work. The reason is that when I sleep, my jaw is open (although my lips are sealed) and such an appliance would not hold it.

If you are thinking about the standard TMJ night guard---its purpose is to prevent teeth grinding at night. The custom made ones, however, fit your teeth very snugly and don't require biting to stay in place. But they also are not designed to realign the jaw.

Now there are types of TMJ/mouth guard/retainer that can be used to keep the jaw bone itself properly aligned. I had one years and years ago as a retainer when my braces came off: It was one piece and was custom molded to both my upper and lower teeth. To put it in, I fit it over the top teeth and then shut my mouth to fit the bottom teeth into the retainer. It required serious conscious effort to take this thing out of my mouth and simply relaxing the jaw a bit was NOT enough to dislodge those lower teeth. As I recall I would often have to use my finger to pry the thing off the top teeth while forcefully opening my mouth to get the thing out in the morning. After it was off one set of teeth, I'd have to pull it off the other set with my fingers.

Even now, as I'm writing, I keep catching myself with the jaw open - sliding down and forward - and I have to remind myself to pull it back and shut. I even have to help myself by pushing the jaw back with my hand to achieve proper occlusion. Maybe the solution is a compromise: keep the jaw slid forward just enough to help my larynx stay open (and let the CPAP do the rest, even if I have to raise the pressure a bit), yet not too much to cause TMJ problems. But even if that is the solution, then the question remains how to achieve that.

Again, as someone with lifelong TMJ problems, I don't see this as a compromise situation: Increase that IPAP pressure back to 17 (if it's tolerable to you) and see if that fixes the problem completely. If you can sleep with your VPAP at a high enough pressure to deal with the OSA without your needing to slide your jaw forward, then do that. Don't risk creating a (serious) dental problem just to avoid two or three CM of IPAP pressure.

[dusty0318]

I'm having similar problems with my left jaw. For whatever reason when the mask goes on, the jaw clenches tight. The dentist is going to fix me a SMALL mouthpiece to place between my front teeth that won't let the back teeth hit together. I have a lot of crowns and can't afford to crack one.

Hope you can find a solution quickly.

[robysue]

I'm having similar problems with my left jaw. For whatever reason when the mask goes on, the jaw clenches tight.

This may be how you are keeping the air from getting into your mouth and forcing it to blow down the airway where it belongs.

The dentist is going to fix me a SMALL mouthpiece to place between my front teeth that won't let the back teeth hit together. I have a lot of crowns and can't afford to crack one.

Sounds like a TMJ type night guard. They are actually very small and very comfortable to sleep with. And they make a huge difference both in terms of TMJ pain and in protecting those back teeth and crowns from being cracked. I actually have a root canal that was the result of a badly cracked tooth. And the tooth was most likely damaged over the years by my tooth grinding at night both before getting the first TMJ night guard and on many, many nights over the years where I simply forgot to put the night guard in because I couldn't find it---usually due to my cat deciding it was his toy. So you're right to worry about that.

One positive thing about all the rigamarole with the xPAP equipment is that I now have a morning routine that leads to me properly take care of the night guard instead of tossing it on the night stand where the cat always thought it was a toy.

[VA3AEQ]

The brandname of the typical TMJ mouthguard is NTI. The website is :
http://www.headacheprevention.com/
I chose my dentist because he was the only provider within 300 miles that can fit such a mouthguard. They do work and are comfortable to wear. I grind my teeth quite severely at night and they last 2 years before I grind through them. I do not have nay TMJ pain anymore either.

Interestingly, Since starting CPAP I have had a new NTI device fitted. I still grind my teeth, even with the Quattro FFM that pushes my lower jaw backwards.

[McSleepy]

Thank you, everyone, for the input! robysue, you provide a lot of detail and I will address some of your questions and concerns.

To clarify, the position of my teeth when I wake up: the lower teeth are forward relative to the upper teeth in how they would mesh; you made the correct assumption. I have little doubt that it is the cause of my pain, even though I do not experience any popping of the joint. I am not aware of any teeth grinding and judging by my good knowledge of my body, and no reports from my wife (I've asked her multiple times), I am quite convinced that I don't do that.

I don't know for certain that the lowering of the pressure was the cause of this problem but I am afraid it might not get cured by simply raising the pressure back up. The reason is that I don't think it takes any effort now to slide the jaw forward when I lie down - it is not like I go to sleep with a normal bite and then, after I fall asleep and start experiencing breathing difficulties, I relax the jaw and it slides forward. That happens the moment I stop fighting it, even when I am awake. I think I am going to need help to change that. And I don't need convincing - tolerating this condition is not an option for me. As soon as we get the dental insurance (should be any day now), I will go see our orthodontist. I am, though, a little concerned about the appliances you mention, specifically, about how difficult it is to remove them. The reason is that, after years of using CPAP, last year I started developing some phobias; although, I haven't had any episodes since my nasal passages were opened last November. But I am a little concerned about a device that would prevent me from being able to spontaneously open my mouth (even though I never, ever do) - it's the thought of it that might bother me. This is something that I'll have to deal with, it certainly won't stop me from proceeding down that path.

As for the immediate change in pressure - I would do it immediately if I knew it would help with the current problem. Like I said above, right now my jaw starts in the bad position, so my breathing is fine as it is, I don't see what would cause the jaw to retract. Now, if I do succeed in getting the jaw back where it belongs, I would make the adjustments. In other words, if I could make my jaw stay where it's supposed to and see higher AHI, I would certainly raise the pressure to lower the AHI back down; or even raise the pressure as preventive measure. I still hope for a better solution that will help me stay with the lower pressure but certainly not at the cost of this kind of problems. And, yes, I can tolerate 17cm just fine (with possibly an occasional mild aerophagia) but my sleep doctor (and especially the DME) believe that my pressure support is what is too high, since I can't tolerate an EPAP higher than 10cm.

So, the plan seems to be to find a way to keep my jaw where it does not cause problems to my TMJ, and then adjust CPAP pressure, if necessary (hope not!) Seeing the orthodontist for that should be the best approach. In mean time, I wish I could do something to keep my jaw up, but I can't think of anything, short of a helmet with a chin-strap. Chewing gum seemed to help reminding me, but I've heard that it also stresses the teeth. I wonder if I could just bite on something - while awake, the biggest thing is reminding myself to keep the jaw shut (and, thus, properly aligned).

Thanks for the useful feedback!

McSleepy

[cflame1]

McSleepy...
I've got a bite guard that I wear all night, every night... it just covers my bottom teeth and seems to work for me, with my machine and mask.