Finding the Healing Path for Sleep and TMJ Problems


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Frenectomy: Simple Surgery, Major Benefit

While Dr. Ferzli focuses primarily on non-surgical solutions to breathing and sleep issues, for the problem of tongue-tie, the solution is a frenectomy—a simple surgical procedure that he does in his office. “A frenectomy,” he explains, “is the surgical treatment for tongue tie. Tongue-tie occurs when a small fold of tissue prevents the tongue from having the proper range of motion; it can’t extend up or forward because it’s tied to the floor of the mouth.

“This starts as a very small problem, and one that can be easily remedied initially—doctors can release tongue-tie when an infant is born with a simple surgical procedure. But if the issue is missed—and it frequently is—it can have wide-ranging and very serious consequences.

“A significant concern related to tongue-tie,” says Dr. Ferzli, “is its impact on sleep—and that can translate into many systemic health problems. The tongue and breathing are connected to jaw position and movement,” he explains, “both of which influence the type and quality of sleep. At rest, the tongue should sit on the roof of the mouth. But if it falls into the airway—as it does with tongue-tie—it can interfere with proper breathing.”

A frenectomy not only helps prevent many of these problems, but, notes Dr. Ferzli, “it can also release tension—and thus relieve pain—in the head, neck, and back. The surgery is a relatively simple procedure. We use a laser to release the tongue-tie, and the protocol is to have them do myofunctional or tongue exercises, for proper range of motion.”

Dr. Ferzli discusses treatment options with a patient.

It would be misleading to suggest that when Dr. Charles Ferzli talks about “sleep problems” he’s simply referring to people who have difficulty falling asleep. “We do, of course, work with patients who complain of this,” he says. “But it would be more accurate to say that my practice focuses on the essential role that sleep plays in every aspect of our health, and on determining the best path to restoring healthy sleep cycles.”

Quality sleep is the foundation for health—for healing, growth, and cognitive processing, Dr. Ferzli explains. “And, in fact, many health problems are sleep-related. There’s a vicious cycle that occurs: health issues impair sleep; impaired sleep causes or worsens health issues.

“So, the consequences of impaired sleep, can be profound. People who lack sufficient, healthy sleep are not just tired, it affects their mood, their patience, their ability to remember and to learn new things. And they’re more likely to be sick—or remain sick—because they have more inflammation and more pain.”  

Understanding Sleep Problems

“Given the importance of sleep to our overall health,” says Dr. Ferzli, “it’s essential that we understand the underlying causes of sleep problems. And you’ll notice I said ‘causes,’ because, invariably, many factors interfere with a healthy sleep cycle. These include health problems (such as high blood pressure, allergies, TMJ, diabetes); environmental issues (such as too much light, room temperature); and lifestyle factors (including stress, medications, diet).

“However,” says Dr. Ferzli, “while all these play a part in any sleep disorder, I would argue that breathing issues are the single most important reason for impaired sleep.”

Breathing Issues

“A number of breathing issues will seriously impair sleep quality,” notes Dr. Ferzli, “including obstructive sleep apnea, upper airway resistance, mouth breathing, and tongue-tie (see box). Our first steps are to determine the nature of the problem, and then its source.

“With obstructive sleep apnea, the upper airway becomes blocked during sleep, reducing or completely stopping airflow,” he explains, “which in turn causes you to wake, constantly disrupting sleep, and affecting oxygen levels.

“Upper Airway Resistance Syndrome (UARS) is a similar condition where air flow is constricted during sleep. While not as severe a condition as sleep apnea, it reduces the flow of oxygen to the muscles resulting in increased cardiovascular issues, fatigue, depression, and insomnia.

“However, by far the most common breathing problem affecting sleep,” says Dr. Ferzli, “is mouth breathing. It is also the least appreciated.” 

The Problem of Mouth Breathing

“We’re designed to breathe through the nose,” notes Dr. Ferzli, “but many things will cause a person to breathe through the mouth, and it can become a habit. Environmental factors, allergies, and anatomical problems that trigger nasal congestion are the common causes of mouth breathing.”

Whatever the cause, once the habit of mouth breathing is acquired, it is likely to produce many other problems, he explains. “It may result in low oxygen concentration in the blood, which is associated with high blood pressure and heart failure. Dental issues—such as gum disease or tooth decay—are commonly associated with mouth breathing. And it also causes people to clench and grind their teeth—particularly while sleeping. This, in turn, produces chronic jaw joint issues, headaches, or ear pain.

“The problem caused by mouth breathing that we see most often,” says Dr. Ferzli, “is sleep impairment. Getting less oxygen to the tissues can elevate the heart rate and even cause an adrenaline surge during the night, waking people up. Sleep interruptions in turn reduce the necessary restoration that takes place during healthy sleep.”

Addressing the Problem:
When Surgery Plays a Role

“We find that many of the factors contributing to breathing problems—including some structural issues—can be addressed without surgery,” says Dr. Ferzli. “And we always begin with alternative methods to improve nasal function. However, if these do not work, then surgery is recommended, and we’ll refer these patients to ENT physicians.”

Alternative Paths to Healing

“At the TMJ & Sleep Therapy Centre,” explains Dr. Ferzli, “our first goal, always, is to accurately determine the source of a patient’s problem—whether the problem is jaw pain, obstructed breathing, or impaired sleep. With that understanding, our objective is to find the best possible healing path, ideally without surgery and or medication.

“For the most part, the source is not one issue, but a complex interplay of issues,” he observes. “And we have many tools for determining what factors are involved and how they interact. In the case of breathing issues, for example, we determine if nasal breathing is impaired because of a physical obstruction of the airway or because they’re a habitual mouth breather. We’ll use CT scans to evaluate the nasal passages, and will take functional measurements of air flow and nasal resistance. And, if there is obstruction, we’ll test to identify the structural causes.”

While surgery is sometimes the only solution for impaired nasal function, Dr. Ferzli notes that he has considerable success with other treatments. “Nasal sprays and nasal dilators are examples of simple tools to significantly improve someone’s nasal function, making surgery unnecessary. Using the rhinomanometer—a tool that measures air flow and resistance—we can determine if either a nasal dilator or a nasal spray—or possibly a combination of the two—is likely to solve the problem. “Understanding the complexity of sleeping and breathing problems is critically important,” he adds. “Often there are multiple issues at play. For example, we have seen many patients using a CPAP for their sleep apnea with only partial success. And the problem has been that not only are they dealing with structural issues causing airway blockages during sleep, but their nasal passages are restricted. By clearing the nasal passages—perhaps with a nasal dilator—the CPAP will allow them to breathe better.”