pdf of this article


For more information dentistry, contact:



1150 NW Maynard Road, #140
Cary, NC 27613
Telephone: (919) 323-4242

The Subtleties and Complexities of TMJ

Dr. Charles Ferzli, founder of TMJ & Sleep Therapy Centre of Raleigh-Durham, has intimate knowledge of how a patient’s bad dental habits can adversely affect their health. A major hurdle in dentistry, he observes, is to convince patients to come in and be tested, and then to have the necessary work done promptly and completely to promote and protect their dental health.

Dr. Ferzli uses an image of his own skull to illustrate the placement and impact.

Health&Healing: In this issue, we’re exploring the health problems created by negative lifestyle habits and addic-tions. What kind of “self-inflicted adversity” do you find in your practice?

DR. FERZLI: Poor oral hygiene and neglect are significant problems not only for oral health, but for over-all health. And it’s important to note that some neglect is the result of long-held fears of dentistry; some is just that people don’t understand the connection between symptoms they have and their oral health. That is especially true of TMJ—because TMJ problems can manifest in many ways and symptoms—such as headaches or back and neck pain—might not seem to be connected to the mouth and jaw.

For example, I have a patient who would always complain of headaches, grinding, and wearing of her teeth. She had broken some teeth, which we replaced with implants. I had the hardest time convincing her to come in for a more thorough evaluation. I knew there was something going on that she wasn’t addressing. She was always tired, she wasn’t sleeping well, and she suffered from depression and anxiety, all co-morbid conditions of poor sleep. It took me six months to prevail, but I finally got her in for testing.

I suspected that she had an upper airway issue, and I sent her out for a sleep study. She didn’t test positive for sleep apnea, but she was waking up a lot during the night. The usual diagnosis is upper airway resistance syndrome. I treated her with an oral appliance that would keep her airway open to maximize airflow during the night. She failed the motor nerve reflex test for the jaw joint, which had some chronic inflammation, so I treated her with a daytime appliance as well. She’s been a different person since she’s been on these oral appliances, doing much better. She came, she listened, and she’s improving.

H&H:  Explain what TMJ is and how poor oral hygiene can lead to it.

DR. FERZLI: Temporomandibular joint disorder, or TMJD, is a disorder of the nerves and jaw muscles caused by injury to the temporomandibular joint. The joint is the connection between the jawbone and the skull. The injured TMJ can lead to pain with chewing, popping, and clicking of the jaw, tooth grinding called bruxism, swelling on the sides of the face, nerve inflammation, and morning headaches, including migraines.

Poor oral hygiene can certainly contribute to TMJ, because it often contributes to tooth loss. For example, if you lose your posterior molars, then there’s no posterior support any more for the bite, and the jaw joint can rotate back and results in compression of the TMJ. That puts more pressure on the jaw joint itself, and people can end up developing TMJ problems that way.

H&H: To what extent does TMJ make it more difficult for you to provide dental care?

DR. FERZLI: One example is that there are patients who cannot recline. We immediately know that they are guarding their airway, because they’re gaggers; or they can’t recline because their airway passage is compromised and they won’t be able to breathe. We seat those patients in a 45-degree position. We also use a saline nasal spray to open up their nasal passages, allowing them to breathe better and recline.

There are also patients who can’t keep their mouths open very long because they clench their teeth. We use little bite blocks to keep their teeth separated, which allows them to rest their jaw muscles and their teeth on the bite block.

Then we have patients who can’t open their mouths very wide. A normal opening is 50 millimeters, while others can only open 30-40 millimeters. This indicates a dislocated jaw, a disc that is not tracking properly, or a closed lock. I used to think that this was normal for some people, but with further education, I now realize that they have jaw problems that hasn’t been diagnosed, have chosen not to treat, or are unaware of.

H&H: Are there other ways in which patients’ habits impair their oral health?

DR. FERZLI: Obesity and smoking adversely affect oral health—significantly. Obese patients usually have a lot of fat in their tongue and airway, and as a result of that, they end up developing sleep problems. The airway may shut down, causing the oxygen levels to decrease while increasing carbon dioxide in the bloodstream. Patients who can’t breathe well will clench their teeth a lot during the night, eventually ending up with TMJ and sleep problems. They also tend to have sensitive teeth, receding gums, and headaches.

Smokers who don’t sleep well can’t regenerate in their sleep, and have more inflammation in their system. Their airways will be more inflamed. When there is more inflammation, there’s less chance of that person being able to heal on their own.

A Patient’s Experience

Leslie Calderone recounts her experience addressing and resolving TMJ problems with Dr. Ferzli’s assistance:

When I was a teenager I was diagnosed with TMJ. In order to correct it, my dentist suggested that I get braces. Since then I’ve had porcelain veneers put on the majority of my teeth. I’m 42 now and I’m having issues with tooth decay and my dental problems weren’t being resolved by the dentist. A friend of mine told me about Dr. Ferzli and how he works dental wonders. About five years ago I started seeing him and I was hooked!

Leslie Calderone.

Dr. Ferzli has a questionnaire for new patients, that includes screening for TMJ or sleep apnea disorders. The results of this process opened up a whole new spectrum of my dental issues all related to my TMJ.

The testing revealed that pretty much everything is connected in the body. I’ve had issues with my neck and cervical spine, and that’s connected to my jaw. For example, the body measurements and CT scans that Dr. Ferzli did showed that one of my hips sits higher than the other. I came to realize that a lot of my pain issues are due to my TMJ and can be resolved.

Right now, I’m feeling much better. I used to be a mouth breather while sleeping and now with the night appliance that I wear, I breathe through my nose, which prevents me from clenching my jaw and opens up my airways. I also wear an appliance in my nose that opens up my nasal passage. I sleep much more soundly. I’ve had one episode of neck pain, and that was because my night-time appliance needed to be adjusted. Once that was done, everything was fine. I admit that it’s been hard getting used to wearing appliances day and night, but overall, I’ve seen a great improvement.

My therapy with Dr. Ferzli—which has included restoring the porcelain veneers and two implants—is continuing. He needs to make sure that everything is staying in, and that I’m making progress—which I am. I can really tell the difference. He’s one of those dentists that when people say, “Oh I hate going to the dentist!” I reply, “No, I don’t mind going at all.”