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Practicing Dentistry and Treating Facial Pain in Today’s Changing Landscape

Dr. Charles Ferzli, DDS, views the two sides of his TMJ & Sleep Therapy Centre and Smiles of Cary Family Dentistry practices as distinct and complementary. The COVID-19 pandemic has highlighted their differences since his dental practice had to restrict itself to emergency patient care for two months. He and his team have resumed seeing patients since May 18 in his dental office, and his regular work with TMJ and sleep patients has remained almost uninterrupted throughout, although more patients were being followed by teleconference. Both practices benefit from his long-standing expertise with infection control practices.

Dr. Ferzli

Infection control procedures are nothing new for Dr. Ferzli, who notes an initial transformation in dentistry starting in the seventies and eighties when dentists started using gloves and autoclaving instruments. Since then, he says, dentists have been accustomed to wearing masks and gloves, spraying everything they use, and autoclaving their instruments.

“Now,” he says, “dentists are simply adding additional layers of protection for both staff and patients. And, in fact, in my practice not much has changed, because my team has always been extremely cautious about infection control. For that reason, I was comfortable seeing emergency patients during the pandemic and I haven’t had any issues to date.

“What is likely to change in dentistry,” he observes, “could be seen as a positive outcome of the pandemic. We are likely to give more personal attention to patients with less jumping around from room to room; and in order to safely work with patients, fewer patients will be scheduled each day. That allows us to give more attention to each patient than in the past.”

Changes in Dental Practice

As dentistry changed more than 30 years ago to respond to the AIDS epidemic, Dr. Ferzli anticipates changes—very likely permanent—in dental practices to respond to the unique challenges of COVID-19. “These changes are needed to adjust to the way that the virus is transmitted. So, for example, we are using hand instruments instead of ultrasonic instruments to avoid generating aerosol droplets. And we’re wearing more gowns and changing them more often, as well as face shields. For dental work we will use a rubber dam or the intra-oral suction system and we also have an external suction system, which is like a big elephant trunk in front of the patient’s face that sucks everything as we’re working on them.

Signs and Symptoms of TMJ and Sleep Problems

“Many of our patients are surprised at the extensive questionnaire we use to diagnose TMJ and sleep problems,” notes Dr. Ferzli. “The reason is that the list of issues included on our questionnaire reveal important connections and helps to provide an accurate assessment of the patient. More information is provided on the practice website; but a sampling of items we ask about, reflects the wide range of relevant interconnected symptoms. For example:

“We want to know about a wide range of pain symptoms, not just jaw pain, but headaches, ear, facial, neck, back, and shoulder pain.  Functional cues are also important, such as locked or limited jaw motion, jaw noises, or pain when chewing. Ear and sinus congestion are also revealing, as are dizziness, tinnitus, muscle twitching, even swelling in the ankles or feet.

“Sleep clues are very important—including morning hoarseness and dry mouth, difficulty falling asleep, repeated awakening, daytime drowsiness, snoring, tooth grinding and clenching.

“And if you find that you are checking off many of the items on the list, it’s important to get an evaluation to determine the nature of the health problems you’re dealing with and how to address them. Everything’s connected!”

“We of course use instruments that are autoclaved and sterilized—and that’s nothing new for us. Our new focus now is to minimize aerosols from patients’ mouths. And we are extremely cautious about cleaning the air, which is now what clinicians are thinking about. That, too, is nothing new in my practice; it has been a concern on mine long before COVID-19. In fact, three years ago, many of my colleagues laughed when I spent more than $15,000 on an air cleaning system. It is an enormous asset now in ensuring a truly safe environment for dental work. And I’ve noticed those machines are now difficult to acquire and are on back order.

“We’ve always wiped all surfaces when patients came into our offices,” explains Dr. Ferzli. “Now, we’re giving ourselves more time in between patients to disinfect the room and clean the air."

Treating TMJ and Sleep Patients

In contrast to the extra methods required for providing dental care, providing safe care for patients dealing with jaw pain and sleep issues is managed more easily for patients and staff alike. “It’s a different care model,” Dr. Ferzli explains. “Generating droplets are less of a concern there. We certainly maintain the same level of office cleanliness and observe other important precautions, but we can sit six feet apart with masks on and communicate about what needs to happen to deal with TMJ and sleep issues. The tools, such as lasers or injections, used to provide relief for these conditions don’t create any aerosols. And we can conduct follow-ups remotely, if needed. So, we are not limited in any way in our ability to provide care to these patients.”

What has changed for the TMJ/Sleep Therapy side of his practice, says Dr. Ferzli, is the number of people now experiencing jaw and sleep issues or for whom those issues have ramped up significantly. “Breathing re-circulated air and stress are certain factors for these conditions, and the pandemic has hugely increased stress levels for us all—when you consider not only the fears about the virus, but the economic impact and social upheaval we’ve all been dealing with.”

Heed TMJ and Sleep Apnea Warnings

Despite concerns about COVID-19, Dr. Ferzli urges patients not to ignore signs and symptoms of TMJ and sleep problems. “These are serious health issues, and should be addressed. The challenge is that common symptoms of TMJ disorder may not even seem to be connected to the jaw. TMJ issues might be expressed as neck, shoulder, or lower back pain—or many more symptoms. That’s why we ask new patients to complete a patient health questionnaire seeking information over 100 different health conditions (see box). The questionnaire, underscores the important connections between body parts and systems. And TMJ is perhaps one of the best examples of that interconnectivity. It has been called ‘the great imposter’ because its symptoms are so often the same as those for many other disorders.”

The symptoms that stem from TMJ and sleep apnea, notes Dr. Ferzli, can be mildly annoying or severely debilitating. “But, even if the symptoms are mild, it’s critically important to resolve these issues, because disrupted sleep and increased inflammation affect much more than immediate quality-of-life issues—and can themselves be life-threatening. Restoring sleep and lowering inflammation can actually improve patients’ prognoses with other illnesses and hopefully, keep them home and out of emergency care situations.

“So, we hope people will not only do their part to prevent the spread of COVID-19,” says Dr. Ferzli, “but will also attend to their own health. At this time of heightened stress, sleep disruption and systemic inflammation—resulting from TMJ and sleep apnea—are serious issues deserving attention. And we want patients to know that we are doing everything we can to ensure that it is safe to seek care for these issues.”