CPAP & TMJ pain?

[new-to-BiPAP]

I haven't yet searched cpcptalk.com about TMJ issues. But the longer I wear my CPAP the more my TMJ issues are resurfacing. For those of you with TMJ issues, have you had problems with CPAP making them worse? I suspect 3 possible issues and I am not sure how to tell which one could be the issue. 1) I have been wearing ear plugs, 2) my mask, & 3) my CPAP pillow. I have VERY lose joints so I would not be surprised if my jaw is being pulled sideways since I have been using the CPAP pillow to allow my to sleep on my stomach and that does not give my jaw much support. I plan on trying not to wear ear plugs tonight but am not sure if I can get to sleep with the machine noise without them. Any other ideas? I have not been unusually stressed or had a change in my diet so I don't think it is related to that.

[robysue]

new-to-BiPAP,

Do you wear a TMJ guard at night? If not, that might be the first step.

I do think that adjusting to CPAP can be stressful for some of us. And if we're prone to TMJ problems and night time grinding, then I think it's quite possible for adjusting to CPAP to increase the grinding and the TMJ problems. Way back when in 2010 and 2011 when I was still working hard on adjusting to CPAP/BiPAP, I did have my TMJ stuff flare up pretty bad. I think as much as anything it was the tension created by trying to get to sleep with the machine while I was being overwhelmed by the sensory stimuli coming from the machine. And of course, if you're grinding your teeth, your mouth is not opening up. Hence I also think fear of mouth leaks can increase the grinding.

At any rate, in Fall 2010, the guard still managed to keep the TMJ issues more or less under control. But I was chewing it pretty hard and it was not a brand new (hard) guard and I'd always chewed through guards in about 24 months anyway. By Feb. 2011, when I was about 4-5 months into PAPing, the guard started to crack. In March I went to my primary care dentist and he made yet another (hard) guard. By the end of April, the brand new guard developed a crack in it. And I returned to the dentist. At this point he told me he was no longer comfortable treating my TMJ because he'd never seen a guard crack so fast. So he gave me a referral to a TMJ specialist (who just happens to take my health insurance!). The TMJ ordered a bunch of tests, figured out what was really wrong with my TMJs and came up with a plan to finally treat the TMJ issues rather than simply manage the symptoms. It started with a new slightly different TMJ guard and wearing the guard 24/7 for a month while on a soft, no-chew diet, followed by a year of slowly increasing the time the guard was not in my mouth and a slow return to a normal diet, but by the end of the year, the TMJs felt better than they had in years.

Unfortunately for me, as my sleep started to deteriorate last fall and my tension headaches exploded out of control, the TMJ pain started to kick in again. And I chewed holes in the new guard. And so it's been back to the TMJ specialist again, and more new guards, one for daytime wear and one for nighttime. Things are beginning to improve again

[cflame1]

Couple of other things for TMJ... I have issues with masks that push my jaw in... full face masks with the bottom of the cushion not under my chin. It's a matter of the pressure points. I can't wear it tight, especially if it's that kind of mask.

The bite guard that RobySue's talking about. Some folks on here will talk about using a guard from Walmart (or some other store). With TMJ it's better to use one from the dentist.

[McSleepy]

I never had chronic TMJ dysfunction but I did develop a pretty nasty case a couple of years ago. I sleep on my stomach and my lower jaw will tend slip out (probably to tighten up the soft tissue in the larynx). I had been using a chin strap to hold it but wasn't very efficient. I tried various mouth guards but they seemed to actually make it worse (too thick and not placed optimally). What ended up working perfectly for me was a combination of a heavy-duty chin strap that I crafter myself and a bite guard that I kind of made myself from raw silicone trays (for teeth whitening). The unusual part with the latter was that I mold it very thin to prevent the displacement of the jaws and, most of all, that I place one tray only and on the lower jaw, not the upper. I get those very cheap ($4 shipped for three, from Amazon) and mold them not by boiling them in water and biting, but by using a ceramic impression of my teeth that a dentist had made for me and heating them with a hairdryer. Depending on how thin I mold them, they can last for many months (I don't grind much). No TMJ issues since.
I hope this information is helpful; it sure worked for me.
McSleepy

[new-to-BiPAP]

Thanks for sharing what helped you! I do wear a night guard that the dentist made (hard plastic). Normally it helps and I only have occasional flare ups.

I had wondered if maybe I was grinding or clenching more when I started CPAP. If I am having trouble getting to sleep or struggling with the machine then I do tend to clench a bit. I have been to a specialist and they referred me to a PT and he gave me some exercises. But they tended to bother my TMJ so I don't do them. I think my main problem is that I am hypermobile so I think my jaw moves too much and causes more TMJ trouble. I switched to a CPAP pillow and I noticed more problems when I started that. I am wondering, since the CPAP pillow has a cut out for the mask, if my jaw is dropping to the side since it is not supported. I tried to sleep a bit differently to try and support the jaw more but I'm not sure that it did much good.

I do have a full face mask with the mask between my bottom lip and chin. I did wonder if that could be pushing my jaw in and causing some TMJ trouble. Will have to ask my sleep doc about that if I continue to have problems. One issue is that I have a ResMed mask and am in the 30 day warranty so I don't think I can switch to a different brand and I'm not sure that ResMed has an option for the cushion beneath the chin.

Also, I do sleep mainly on my stomach so that prolly isn't the best. But I can't sleep in any other position because of pain and insomnia. Interesting idea about creating your own chin strap. McSleepy, How did you make it differently than the kind you can buy premade?

[Julie]

Hi - One thing that occurred to me is that you might be wearing the mask too tight - more so than is necessary, but only you can judge that. The second thing is that I found it hard on my neck to sleep on my front (which I do every night) until I cut a 1' long 'trench' out of my memory foam mattress, starting at the top, about 3" wide (you can play with edges and/or width after you try that) and 4" or so deep. The mask fits sort of diagonally (tho' probably more vertical than horiz.) in there and I've done it for years. Getting sheets to look good is not easy, but then who cares after all, you can cover the whole thing when you're not around.

[robysue]

I do have a full face mask with the mask between my bottom lip and chin. I did wonder if that could be pushing my jaw in and causing some TMJ trouble.

The custom guard I wear at night fits over my top teeth and has a small "ramp" that prevents the lower jaw from sliding too far backwards (and thus dislocating my TMJ).

[McSleepy]

Thanks for sharing what helped you! I do wear a night guard that the dentist made (hard plastic). Normally it helps and I only have occasional flare ups.
[...]
Also, I do sleep mainly on my stomach so that prolly isn't the best. But I can't sleep in any other position because of pain and insomnia. Interesting idea about creating your own chin strap. McSleepy, How did you make it differently than the kind you can buy premade?

The main difference is... mine costs next to nothing. It has a soft pad on the top of my head (to help with the stiff bar of my mask) and a smaller pad that goes under my chin like on military helmets (they have figured something out to do it that way). I use a 1" elastic, doing two loops for maximum elasticity and good strength. The result is a firm but gentle pressure of my lower jaw upwards. Obviously, I can move my jaw with no effort, the strap is far from forcing my jaw in any position, but it is a good reminder to keep it in the default position (remember, you're asleep, not passed out, at night).
To me the biggest difference was the fact that the bite guard is thin, and being on the bottom teeth where it has minimum displacement effect and it doesn't abnormally open the jaw.
The other fact of note is that I sleep on a soft, thin dawn pillow. I've tried all sorts of pillows and I simply could not sleep on any other, memory-foam being the worst for me. On my stomach, with the face planted in the pillow, the soft, moldable dawn pillow is the only one that allows me to fit my face (the Breeze mask stays out of the way) on the top and my hand underneath. I can imagine this being a major factor in having TMJ or not.
McSleepy

[avi123]

IMO, CPAP masks should not cause TMJ problems unless you abuse its recommended use. This is b/c they are approved by the FDA as medical devices. Chin Straps (CS), on the other hand, are sort of "lose canon". They are not regulated by the FDA.

You could screw up your TMJ from using Chin Straps improperly, and also by using most of those Mouth and Teeth Guards.

To stop Mouth Leaks you don't need a CS to force your jaws until your teeth abut, but you need it to close your lips. Air can go thru you mouth while your teeth are clenched if your lips are open. Most CS force your mandible upward and exert extra un necessary force on the TMJ.

For example, most of the CS on Amazon don't close your lips but just force your lower jaw upwards and can cause damage to the TMJ:










http://www.amazon.com/LOCARED-Professio ... _sbs_hpc_4

However there are some CS that press your lower lip upwards, and can seal your mouth leak with minimum force:

Deluxe Chin Strap III Around Ear


See it here:

http://www.amazon.com/Deluxe-Chin-Strap ... 6o8n3l0%5D
In this case, b/c the head strap is pointing backward you need the mask straps to be placed over it to hold it in place.

[robysue]

IMO, CPAP masks should not cause TMJ problems unless you abuse its recommended use. This is b/c they are approved by the FDA as medical devices.

There are lots of things in medicine that are approved by the FDA because has been proven that they effectively treat one particular medical condition, but they can also adversely effect other conditions in some patients. The key is always: Do the benefits of treating the first condition outweigh the consequences of potentially aggravating the other condition?

In the case of OSA and TMJ, it's quite possible for CPAP to increase grinding and clenching at night----particularly in the adjustment period and particularly for folks who already grind and clench too much. You're lying there trying to get to sleep with this thing on your nose and you're worried about potential leaks and if you just keep the mouth firmly shut (i.e. you start to clench or grind), you find that helps fix any leaks and so you go to sleep with your mouth firmly shut and continue to clench or grind in your sleep. Add a mask that has a tendency to put some pressure on the lower jaw because it fits over the mouth OR a mask that pushes against the top front teeth because it seals against the area between the nose and the upper lip, and you've got the potential to create some serious TMJ pain in some people.

But the benefits of treating the OSA outweigh the consequences of aggravating the TMJ because

1. untreated OSA is potentially life threatening, and
2. any additional TMJ problems can usually be addressed through a new night guard if need be.

[keepsmyelin]

I have no advice, but am dealing with a similar situation. I'm new to the forum and to my CPAP.
Really never thought I had any sleep trouble, but changed neurologists (I have MS) and the new neuro
orders sleep studies for all his patients.

They diagnosed my apnea as moderate, and at the original test, my main problem seems to be I got
no REM sleep and spent 81% of the time I slept in Stage II. The second study showed improvement
with the CPAP machine.

So I've been using it for a little over a week, and I can sleep with it, no problem. Haven't noticed
any huge improvement in how I feel, but as I said, I was not aware I had a problem in the first place.

However, it is causing an increase in pain in one side
of my face, tongue, and pharynx. Due to cranial nerve damage from the MS, one side of my face is pretty
messed up, and my tongue doesn't move much (due to muscle weakness I can't stick it out, nor can I move the
one side of my face...i.e. I have a lopsided smile ) So I'm surmising that the
CPAP forcing air into my throat, is probably moving some of those muscles that are atrophied
and creating more spasm in the area than I've had in a long time.

I'm hoping over time things will improve, and those muscles will get used to being moved and
the spasm will lesson.

Have you considered asking your TMJ doctor for meds, or more meds if you're already on some, to
help deal with the adjustment to the CPAP. I know it's disappointing when a problem you've worked
to overcome resurfaces as a result of a treatment of another health issue. Hang in there, and
hopefully you'll find a way to get the TMJ to settle down.

[avi123]

keepsmyelin, in your case I would follow the neurologist's instructions. Actually, a neurologist who also holds an MD in sleep medicine would be ideal. Like this one who I have seen two weeks ago:

http://www.dukehealth.org/physicians/paul_c_peterson

As Roby Sue mentioned in above post the proper treatment of the Sleep Apnea, at this stage, outweighs most of the other inconveniences. Stopping mouth leaks is utmost importance for achieving a good CPAP's treatment outcome.

[McSleepy]

Just a clarification, although I think the OP got this correctly: my mask is of the least-invasive kind, it applies no pressure to my jaw, face, etc. I had TMJ issues because of natural tendencies of my body while sleeping prone. My chin strap and bite guard are the solution to that problem, not a part of it.
McSleepy