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TMJ and Sleep Problems: No Simple Cases

For Cary dentist Dr. Charles Ferzli, challenging cases are the norm—not the exception. Even the name of his practice—The TMJ and Sleep Therapy Centre—reflects the extraordinary complexity of diagnosing and treating mouth and head problems. “There’s really no separating TMJD (temporomandibular joint disorder) and sleep issues,” Dr. Ferzli explains. “Because there are so many contributing factors. Muscles, breathing, body chemistry, digestion, tension, trauma, allergies—the interrelationship of all these elements is important and incredibly complex.

Dr. Ferzli works with a colleague to prepare TMJ tests for a new patient.

“And, frankly,” he admits, “it’s the com-plexity of these cases that interests me. In my efforts to under-stand TMJD problems, I became a student of craniofacial pain, earning Diplomate status with the Acad-emy of Craniofacial Pain and the American Academy of Dental Sleep Medicine, and board certification from the American Board of Craniofacial Dental Sleep Medicine. But perhaps the most important lesson I learned from those studies is to appreciate the links between sleep and craniofacial pain—an understanding that led me to focus my practice on dental sleep medicine.

“I am, at heart, a student,” says Dr. Ferzli, with a smile. “And for a student, the complex connections between sleep and craniofacial pain are both challenging and fascinating. Every patient is an intriguing puzzle to be solved.”

Sleep Disturbance—Never Simple

Because of his specialty, Dr. Ferzli rarely sees so-called “easy” cases. The problems he treats can involve combinations of engrained habits, structural or anatomical problems, medications, allergies—in fact, a wide range of contributing factors.

“In my sleep therapy practice,” says Dr. Ferzi, “My focus is on helping people with sleep-related breathing problems. But such problems are not isolated—they are inextricably connected to other issues, such as jaw pain, stress, allergies, diet, structural, and dental problems—the list is long. Treating these problems begins with a thorough understanding of each patient’s sleep issues—and which factors contribute to their problems.”

And, in fact, he notes, misdiagnosis is not uncommon. “Many of my patients have previously sought help from their regular physicians who aren’t necessarily well-versed in the wide variety of sleep disorders and their signs. Nor is there broad understanding of the many factors that can contribute to sleep problems. Additionally, some patients may not meet the standard criteria for sleep studies, and consequently aren’t tested.

“And, as a specialist in dental sleep medicine,” notes Dr. Ferzli, “I look for key indicators that may not be on the radar of even sleep specialists. For example, recession in the gum line or bone growth on the ridges of the teeth may indicate tooth grinding or even a lack of sufficient oxygen—important contributors to sleep issues.”

Dr. Ferzli’s evaluation begins with a detailed questionnaire and interview to help understand how the sleep cycle is disrupted and what other issues may be involved. “Questions about snoring and daytime fatigue can reveal a great deal,” he notes. “And we also need to know about allergies, medications, pain issues, and much more.”

This evaluation process helps to identify airflow disturbances and guide therapies that help patients optimize breathing. Although he doesn’t treat narcolepsy or sleep apnea—conditions handled by a sleep physician—Dr. Ferzli does see a lot of upper airway resistance (UARS) problems in his practice. This is where the airway narrows but doesn’t collapse.

“A traditional sleep study may miss this problem,” notes Dr. Ferzli, “because it’s distinct from sleep apnea. But UARS can still cause serious problems, as people may not get sufficient oxygen during sleep.
“Since so many factors contribute to sleep and breathing issues,” he explains, “we employ a variety of tools and techniques to address UARS. We may use an appliance to prevent airway collapse or clenching and grinding; a dislocated jaw joint may need to be fixed; or exercises might help to improve the jaw’s range of motion. We use specialized appliances in many instances, but other tools can be equally effective. The goal always is to find the right treatment or combination of treatments for the individual patient.”

Pain and TMJ

Like his patients with sleep issues, the typical TMJ patient is one who comes to the practice after seeking help from many other sources—without finding relief. “This is a common experience,” notes Dr. Ferzli. “And that is due in part because of the condition itself. TMJD has been called ‘the great imposter’ for good reason. While it may manifest as jaw pain, it might also result in referred pain instead. And the patient with neck, shoulder, or even chest pain is more likely to seek relief from other practitioners, rather than from a TMJ specialist.

“Furthermore, jaw pain rarely has simple, single causes. Even when the problem is accurately identified as TMJD, fixing it almost certainly will need to address more than the jaw joint,” says Dr. Ferzli. “So, our job is to find all the sources of inflammation that are causing the pain.”

To evaluate and treat craniofacial pain, Dr. Ferzli uses an array of state-of-the-art tools, including: CBCT X-rays to determine jaw joint health, airway and areas of obstruction, neck analysis, and cancer screening; photography to examine body posture and misalignment; joint vibrational analysis to assess the health of the TMJ joint in motion; and the “jaw tracker,” an instrument that measures and records jaw movement and alignment.

Interestingly, Dr. Ferzli notes that acute pain is usually the easiest to treat. “While chronic pain,” he explains, “poses many additional challenges. For one thing, in those cases, the nervous system has been in overdrive for a long time, triggering a vicious cycle of inflammation and more pain. For another, long-standing conditions can cause damage that becomes more difficult to fix entirely.”

That detective process is often complicated by the journey a patient has taken in getting to him. “Given the complexity of dental health,” notes Dr. Ferzli. “I will often see two people with fundamentally similar symptoms who need distinctly different treatment paths.

“It’s often difficult for practitioners to identify TMJD,” he explains, “because symptoms suggest so many other issues. It could be neck pain, or lower back pain, even foot pain. It could be the beginning of carpal tunnel pain. These are all issues related to the trigeminal nerve—the fifth cranial nerve.

“Doing a trigger point injection in the area of pain doesn’t always treat the problem, because the source of pain is actually somewhere else. So, most of the treatments we offer involve decompressing the TMJ area with oral appliances. By doing so, we reduce the inflammation, improving range of movement, and decreasing pain in related muscles.

“We also recommend a diet to decrease inflammation, and often notice that, after the first week of treatment, the patient’s symptoms are lessened dramatically.”

Noting that craniofacial pain and sleep disorders are complex problems, often associated with other health issues, Dr. Ferzli works with other medical colleagues to help patients. When appropriate, he refers patients to ENT physicians for nasal evaluation, to chiropractors or physical therapists for spinal problems, or even to a psychologist or podiatrist.

“For problems this complex,” he notes, “there are no ‘single-pill’ fixes. We’ll certainly see quick symptom improvement, but full healing takes both time and persistence—from us and from our patients.”