Approaches to TMJ ?

[kaiasgram]

My regular dentist referred me to a specialty dental practice this week for eval and treatment of TMJ. The issue that prompted the referral was that I had an appointment on Monday to have an old crown replaced, but before she (my dentist) even began the work, she stopped and told me that my bite had changed so dramatically in the past year that she would not replace the crown until I got my normal bite back. My back teeth (both sides) don't even make contact anymore when I bite down.

I just called the specialist's office to find out about his fees and treatment approaches. When I asked about treatment I was told that the dentist treats TMJ with a dental appliance. I asked if the appliance could be used easily while on CPAP and she said "Oh, you have sleep apnea -- the doctor will be able to take you off of CPAP because the dental appliance will treat both your TMJ and your sleep apnea.

What a claim to make since (A) they have never seen me and have no information about my sleep apnea, my airway, my sleep study.... and (B) the research does not support making such a sweeping efficacy claim in any case. So much for that referral.

So my question is about what other approaches have worked for any of you who have needed TMJ tx.

As an aside, my dysfunctional bite and my jaw pain have developed during the past two years since I've been on CPAP. I suspect I was way overtightening my chinstrap in the early months of therapy and this caused some misalignment of my bite. Another thought I've had is that before getting diagnosed I may have been unconsciously pulling my lower jaw forward in an effort to keep my airway open at night. I remember that I was also keeping my head turned way to one side when I went to bed (I sleep on my back). That too may have been in an effort to keep my airway more open. These are just what-the-heck-seems-possible ideas, but it does make some sense to me that one could be trying to compensate for a collapsing airway well before knowing that's the problem.

In any case, I now need to address the whacked-out jaw issues and I am not going to work with the "I take all my patients off CPAP" specialist. I may hate having to be on CPAP but I know better (thanks to this forum) than to think there's a magic escape based on what I was told on the phone today.

OK, done with the rant and back to my TMJ/bite correction question. TIA for sharing your experiences.

[Loreena]

So weird that you posted this. I have an appointment in 2 weeks to see an ortho for an ALF appliance. I didn't know what this was until I googled it last night. I found the thread below and found it informative and am definitely leaning toward this appliance now. Also, he quoted me a ballpark of between $5 and $8 grand, which seems to fit in with what I found. He said that rapid maxillary expanders expand too rapidly and do not allow the bone to grow in between the sutures, instead just cartiledge grows and this allows for collapse of the palet later on. Wow! Apparantly the ALF appliance helps with TMJ, can open extraction spaces, and expands the jaws. I am extremely excited about my appointment. I too have TMJ and the first order of business he said is to get an MRI of my skull to determine the dislocation of the jaw joints because this needs to be remedied first before the palet expansion. I don't know the regimen of this whole thing yet, but again, I am extremely excited to get started. Hope this helps.

http://www.archwired.com/phpbb2/viewtop ... 0&start=15

NOTE: My sleep apnea problem is so severe that I will never get off cpap. My goal with the ALF appliance is to expand my upper and lower jaw so that my tongue will have more room. Whether others get off cpap using this appliance, I do not know. I just need some relief for my tongue. I was never promised by the ortho that I would ever get off cpap, just that it would provide expansion and help the TMD problem also.

[ChicagoGranny]

When a new health problem comes up, I always like to start out reading Mayo Clinic articles - http://www.mayoclinic.org/diseases-cond ... n-20043566

[jootee]

I have tmj also. I have worn an appliance for years. If I miss one night I get terrible headaches that last all of next day. I went for a sleep study 3 months ago and expected to get one of these "combo" tmj sleep apnea mouth appliances. It was terribly dissapointing when the results came back as severe apnea and an appliance wouldn't cut it. After a tearful day I agreed to a cpap trial and will never go without my machine, it has been life changing for me in only 3 weeks. Anyway, I tried to just do the machine without my tmj guard and I knew I still was grinding so now I just use both and that works for me although I find I sometimes drool (nice huh) thank goodness I have a husband who loves me!

[Nozzelnut]

Currently going through treatment for TMJD/bruxism. I tried my going through my regular dentist. He gave me a night splint and that helped a little. Not really getting the relief I needed, I had a couple appointments with orthodontists. The ortho I chose to work with has additional training to treat TMJD. He started me with a flat plane splint that wouldn't let me close to the point where I would clench and grind. I wore that at night for about 4 months and it actually worked. My bite shifted back, closer to normal, and the joint pain largely went away; which was great, but my teeth had moved quite a bit from the clenching and grinding.

I could either wear the splint for the rest of my life or I could fix the problems that the clenching/grinding created. I chose to fix the problem and get braces. Good news is I'm fixing the problems, the bad news is it's going to take about 17 more months. Good news; all this treatment should help with my OSA; bad news is to really fix my bite it will require orthognathic surgery next year.

In addition to your dentist, you might want to set up an appointment with a local orthodontist there may be bigger issues with your bite than the dentist can fix..

[robysue]

Kiasgram,

You ask:

So my question is about what other approaches have worked for any of you who have needed TMJ tx.

I've had serious TMJ problems for years. As in 30+ years. I've worn a whole series of custom made night guards in the last 3 decades because I have historically chewed through them like a rabbit eating carrots.

About 6 months after starting PAP I got a brand new nightguard from my regular dentist. And within 4 weeks it was cracked and the dentist sent me to a TMJ specialist. My specialist is also a sleep dentist, but he has never pressured me to think about an OSA oral appliance. He's understood from day 1 that I do want to make the PAP work and that keeping the TMJ under control is part of that process. He did indicate (correctly) that the first of the night guards that he crafted for me might help the PAP do its job better: The AHI did go down (a bit) and more significantly, the 90% EPAP dropped from 6 to 5 (and even 4 on some nights), which makes my stomach very happy.

My TMJ specialist started off with a fair number of tests to figure out exactly what was wrong with my TMJ and my bite. He even ordered an MRI study of the TMJs. And then at the consult after he'd gotten all the results and had a chance to study them, he told me that my problem was that my TMJ was dislocating itself literally every time I opened and shut my mouth. What followed was a different style night guard (which was quite compatible with my PAP) that was temporarily to be worn 24 hours a day, seven days a week and a no-chew diet for 2 months to provide my TMJs with a chance to heal. The guard encourage my lower jaw to come forward a tiny bit and the no chew diet was to keep the wear and tear on the TMJs at a minimum until they had a chance to heal. Oh, and I was to use a moist heating pad on the TMJs for 20 minutes three times a day.

It took longer than expected for my TMJs to heal and it took longer to wean me off the daytime wear of the guard. I had about 9 months of follow up appointments with the oral appliance techs with a TMJ that slowly but surely healed and became pain free. And the TMJ's no longer popped everytime I chewed my food or spoke to someone. But I also chewed through another two guards in the process. We (the tech, the TMJ dentist, and myself) all thought we had everything solved and they cleared me for no more follow ups, unless I started to have problems.

About a year later things started to go from good to ok to things hurt sometimes to the TMJs hurt a lot. I was also dealing with a pretty substantial increase in the migraines and the insomnia all at the same time. And I was doing heavy duty chewing on the guard. So I called the TMJ guy back. They got me in to see the TMJ dentist, who was surprised at the wear and tear on the guard and who did another pretty thorough exam. This time round we tried a slightly different guard, which I started to chew through pretty quickly. Went back and the tech said we need to get you in to see the dentist. Saw the dentist, and this time he had a new idea: The current guards were doing something to trigger the chewing. They were keeping my jaw where it wanted to be, but my teeth were not happy. Or maybe it was the other way round. More testing with a crazy device to measure how my jaw wanted to close and how my teeth wanted to close independently of each other. And a brand new guard made in a different way that was designed to try to keep both the jaw happy (so there's little or no TMJ pain) and my teeth happy (so there's no urge to chew through the thing). This guard has managed to last for 9 months or so with a couple of minor adjustments and not much chewing. It doesn't do as good of a job of relieving the TMJ pain when it's at its worst, but I don't get sore from chewing as much either. (Excess chewing hurts in a slightly different place.)

I'm sorry to have taken so long to write about my situation. But I wanted to let you know that not every TMJ guy is going to automatically assume that he can or should treat both the OSA and the TMJ with one appliance.

Most OSA appliances work by forcing the jaw into an abnormal position at night in order to make the airway larger and less prone to collapsing. They are larger than TMJ appliances and they often put some real strain on the TMJs. Compliance with OSA appliances is better than CPAP compliance, but it is far from 100%. A lot of people do give up on the oral appliances due to pain or bite issues. And serious TMJ problems is often regarded as a potential contraindication for an OSA oral appliance.

While I think it is a good idea to see a TMJ specialist, it is absolutely important that you convey that you are happy with CPAP and do NOT want use an OSA oral appliance. You need to insist that the TMJ guy treat the condition YOU want him to treat and not the condition that he wants to treat.

[kaiasgram]

Thanks for sharing some of your treatment experiences folks.

No worries robysue, I won't be talked into abandoning my CPAP. I saw that my referring dentist checked the box next to "Sleep Apnea" as well as "TMJ" on the referral slip so the specialist may have thought I was seeking treatment from him for my OSA. Still, I'm leery of this particular specialist for the bold claims his staff is making over the phone to prospective patients.

It seems TMJ has multiple causes and I'm not sure about my case. I've never been a grinder but I have been a clencher and have used a night guard successfully for several years. No other major dental problems. No previous orthodontia. No previous issues with malocclusion of any kind. Oh, and no insurance coverage for TMJ diagnosis or treatment.

I was wondering if anyone would post about having success with alternative approaches like massage or acupuncture.

[BlackSpinner]

Still, I'm leery of this particular specialist for the bold claims his staff is making over the phone to prospective patients.

meh - sales people will say anything. They are not the actual doctor.

I was wondering if anyone would post about having success with alternative approaches like massage or acupuncture.

They help with the pain but not with the underlying issue. I used to do acupressure/ massage and people would feel great but it didn't stay. I would teach them some self help routines but that was only for the muscle issues.

[robysue]

Oh, and no insurance coverage for TMJ diagnosis or treatment.

My TMJ specialist billed my health insurance under a code for facial pain of some sort. This turned out to be very luck for me since my dental insurance only pays for a guard every 2 or 3 years (or maybe it's 5). And nothing for any testing to be done. The health insurance picked up almost everything, including the costs of the (multiple) guards. (Which really surprised me: Somehow the guards for the "facial pain" were NOT considered "durable medical equipment" and so I didn't have the whopping 50% copay that I've got for the PAP supplies.)

You might inquire about whether or not the specialist takes regular health insurance or just dental.

[kaiasgram]

Thanks BS and RS -- I may in fact have to settle for temporary pain relief and muscle relaxation for the time being since I do not have dental insurance and my medical will not cover the specialty services (I checked). While it may not correct the dysfunctional bite issue it will at least have some value to me and my quality of life because it can get pretty bad sometimes.

RS, I do plan to see my primary care doc to see if there's any way for me to get some -- or any -- diagnostic and treatment services for this through the medical system (e.g. getting a relevant diagnosis but one that is coverable, like you described).

Thanks very much for your care and input.

[RipSnorter]

I had a really bad TMJ problem over many years.

It got to the point where my jaw was basically dislocating itself. The good news in my case was the esecond time I got a bite plane and used it it sorted the problem out quickly.

Interestingly, one of the reasons that was mentioned was grinding my teeth in my sleep, which just like with OSA is not something you're necessarily aware you're doing.

I hope your outcome is as good as mine.

[RogerSC]

I talked with my sleep doctor about this after my sleep study, at my first followup visit. He told me that the oral devices help about 30% of the people that try them for sleep apnea, and would most likely bring my AHI down to no lower than about 8, still above the "normal" level. I decided to stick with cpap, even though I wasn't enamored of it since it brought my AHI down to around 1.5 average the first month before the followup visit. He gave me a referral to a local specialist that does oral appliances for cpap, that I'd heard of. Small town *smile*.

So I agree that this is a sales thing, to get you to use that particular specialist...just a little disingenuous, since they haven't even seen you to evaluate whatever is going on for you. It would make me very cautious about a specialist who was using that kind of sales gimmick, but I'd still check it out.

Anyways, hope that you get on top of the TMJ, not a fun thing. Sorry that you're having this problem, I'm pretty sure that a good specialist can help you with this.

[49er]

RogerSC,

Not to get this thread off topic but this citation, which I have posted many times on this board, indicates a much better success rate for dental appliance in getting the AHI below 5 , particularly if an adjustable one is used. As you will see from the statistics, they are more successful for folks with mild and moderate apnea although there were a few severe ranges that the success rate was around 55%

https://advancedbrainmonitoring.app.box ... 7pjn8s11y4

I do agree that there are alot of rip off artists out in the field but in my opinion, if you find someone really good, which is easier said than done, this could be very worthwhile treatment, particularly if you can't adjust to pap therapy. I actually think a good sleep medicine dentist who will go the extra mile to get a fitting correct may be even more key in the success rate.

Sorry, I don't mean to be anal retentive about this but since so many people struggle big time with pap therapy in spite of their best efforts, I wouldn't want to discourage them from trying an alternative even though there would be plenty of hoops to jump through to find a competent sleep medicine dentist and to make sure you were getting optimal treatment.

Finally, if anyone is seriously considering oral appliance therapy as an alternative, please go to http://www.apneasupport.org/sleep-apnea ... n-f20.html and read all posts by sleepdent and ask him any necessary questions. He is extremely knowledgeable and gives you straight answers in my opinion.

49er

I talked with my sleep doctor about this after my sleep study, at my first followup visit. He told me that the oral devices help about 30% of the people that try them for sleep apnea, and would most likely bring my AHI down to no lower than about 8, still above the "normal" level. I decided to stick with cpap, even though I wasn't enamored of it since it brought my AHI down to around 1.5 average the first month before the followup visit. He gave me a referral to a local specialist that does oral appliances for cpap, that I'd heard of. Small town *smile*.

So I agree that this is a sales thing, to get you to use that particular specialist...just a little disingenuous, since they haven't even seen you to evaluate whatever is going on for you. It would make me very cautious about a specialist who was using that kind of sales gimmick, but I'd still check it out.

Anyways, hope that you get on top of the TMJ, not a fun thing. Sorry that you're having this problem, I'm pretty sure that a good specialist can help you with this.

[M'ohms]

I had TMJ for about a year. When I started physical therapy in Feb. of this year (for shoulder rehab) , I mentioned the TMJ. The PT told me that TMJ can be relieved by 2 things: a mouth guard (from the front of the joint) and cervical traction (from the back of the joint). I was treated with traction for the duration of my PT, which was 6 months. My TMJ went away after about 8 treatments and has never returned.

[BuddhaCat]

I have both TMJ and OSA, and they've been diagnosed in close proximity to each other. I started TMJ treatment first with a specialist (he's the only provider in a very wide geographic area, hence very long wait times). I was prescribed a repositioning splint which I am supposed to wear day and night, and also PT. Both have been helpful. My jaws are hurting less and I have fewer headaches in general. BTW, I have night-time bruxism and clenching. The TMJ specialist told me that the OSA oral appliance isn't contraindicated for my particular TMJ, but that it would probably aggravate my TMJ and he doesn't want to go down that path for a while (if at all). So CPAP is my treatment for now.

My PT specializes in PT of the jaw. He's terrific and has used a combination of massage, gentle pressure, ultrasound, heat, and exercises I do at home.

I wish this were easier but it just isn't. These problems are complex and intertwined and (for me) years/decades in the making. Hang in there . . .