The Challenge of Complexity: Where Art & Science Meet

Among many diagnostic tools Dr. Ferzli uses in his comprehensive evaluation process is the motor nerve reflex test, with which he assesses the patient’s autonomic system.

TMJ & SLEEP THERAPY CENTRE OF
RALEIGH-DURHAM

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Dr. Charles Ferzli would certainly argue that—like all medicine—his work involves a strategic blend of art and science. It has to; his Cary practice, the TMJ and Sleep Therapy Centre, focuses on two complex, often intertwined health issues.

“TMJD (temporomandibular joint disorder) and sleep disorders are complicated health problems caused by multiple factors, with misleading symptoms, and building up over time,” notes Dr. Ferzli. “So, a significant part of my job is more detective work than dental work. For that reason, our work typically begins with science. We need to understand the problems that patients bring to us. So, we examine, interview, and test our patients in multiple ways.”

Comprehensive Testing: The Science

Testing begins with a detailed questionnaire. “Many of our patients are surprised at how extensive it is,” says Dr. Ferzli. “That’s because the questions included reveal important connections among a wide range of symptoms. Not only are facial pain and sleep issues connected, but they’re linked to many other factors—including diet, medication, allergies, lifestyle, and much more. We’re looking for cues to all those connections.”

But reviewing symptoms is just the beginning, says Dr. Ferzli. “It’s critically important that we understand the precise nature and source of those symptoms. “The first tools we use are among our most valuable—our hands. Assessment begins with palpating the jaw and all the surrounding muscles. From there we progress to more high-tech methods of assessment.

Evaluating Structural Issues

“When a patient presents with jaw pain or locked jaw, for example, exams begin with a Jaw Vibration Analysis (JVA) and testing with a Jaw Tracker. The JVA tells us if there are soft or hard tissue vibrations related to clicking or grinding. The Jaw Tracker gives us information about the velocity and trajectory of the jaw joint as it moves through space. We then follow up with a CT scan to assess the health of the jaw joint and determine if the joint is degenerating.”

“When seeking the source of jaw pain,” says Dr. Ferzli, “a particularly useful test is the motor nerve reflex test (MNRT). While a patient may complain of pain in one area, that pain might have been referred from a source somewhere else,” he explains. “The MNRT allows us to pinpoint the source of that problem and address it, with a success rate of 95 percent.”

Another valuable tool—the Moti Physio—is a 3D posture analyzer. “This gives us information about the orientation of every bone in the body, as well as an overall assessment of the patient’s posture and balance—both of which affect jaw pain, sleep, and overall health.”

Evaluating Breathing Issues

“In this diagnostic process,” notes Dr. Ferzli, “it’s critically important to understand the many factors involved. The jaw problems we examine with the JVA and Jaw Tracker, for example, are affected by breathing issues. So, we test for that as well. We use a pharyngometer to map the volume of the airway, and a tool called rhinomanometry to measure airflow pressure in the nasal cavity. With these tests, we’re able to accurately assess nasal function and to identify problems likely to cause the airway to collapse during sleep. In such instances, we can determine if an oral appliance would be beneficial.”

Mouth problems and impaired breathing can affect sleep in other ways, explains Dr. Ferzli. “So, we use a variety of tests beyond normal sleep tests. We check the acidity levels in the mouth and look for signs of periodontal disease. Digestive issues may play a role; and a dry mouth can contribute to the collapse of the airway, so we note that, too.”

Evaluating the Whole Patient

Evaluation tools go beyond structural and functional tests. “The conditions we treat are complex,” says Dr. Ferzli, “and each patient is unique—their problems affected by everything from genetics and anatomy to diet and lifestyle. Sowe must evaluate the whole patient—and to do so precisely. One method is to use a saliva test to measure pH, which allows us to measure nitric oxide levels.”

Nitric oxide is an important indicator of health, he explains. “It’s connected to your immune system, helping direct attacks against foreign particles. Low levels of nitric oxide not only impair immune function but are a likely indicator of nasal breathing issues. Problems with nasal breathing impair sleep, increase inflammation, and contribute to jaw problems.”

Treating Complex Problems: The Art

The detailed history, careful exam, and long list of tests Dr. Ferzli performs have a purpose: “I don’t want to guess about the source the problem,” he explains. “I want to understand how different factors influence one another.”

And the art of what he does is to take all the information for a particular patient and develop a multi-faceted, holistic treatment plan to help the individual feel and function better. “Treatment, like diagnosis, is a complex process,” notes Dr. Ferzli. “Depending on the individual patient, a treatment plan might include the use of an oral appliance, nutritional guidelines, and referral to other practitioners for physical therapy, orthodontia, or surgery.

“And although we can often provide fairly quick pain relief, the whole process takes time—and the patient’s commitment. The problems themselves developed over time—from years of clenching, or poor dietary habits. So healing is also a process.

The Art of Treatment: Oral Appliances

Without question, specially designed oral appliances are among Dr. Ferzli’s most valuable tools for treating jaw and sleep problems. “Basically, the purpose of oral appliances is to position the jaw therapeutically,” he explains. “When designed for the specific needs of the patient they can improve sleep quality, address breathing issues, relieve pain, and permit healing.

“This is where science supports art,” says Dr. Ferzli. “Not only do we have precise information about a patient’s jaw health, posture, and other health issues, but we can measure what’s going on during sleep—from oxygen saturation levels and sleep apnea to how much time is spent in different stages of sleep.

“Using that information, we can determine exactly which device—or devices—we want to fabricate for our patients. While a relatively simple nighttime oral appliance is sufficient for some, chronic jaw joint problems may require the use of two appliances, one for daytime, and the other for night.

“Oral appliances may be designed to orthopedically decompress the jaw joint and guide the jaw into a healthier position. This allows it to function better with less inflammation, relieving pain. If someone has upper airway resistance or sleep apnea, oral appliances can optimize the airway by preventing the lower jaw from falling back during sleep. So, there are many different things that we accomplish with oral appliance design.”

Dr. Ferzli explains that most appliances are designed in the office creating impressions with digital scanners. Those impressions are sent to a lab electronically where the appliances are fabricated. “However, we also can address acute pain problems by creating appliances in the office in a single day using 3D printing technology—which is a major advancement.”

The Healing Process

Oral appliances play a critically important role in what Dr. Ferzli describes as “phase one” of the treatment process. “At this stage,” he explains, “we are treating symptoms, without changing the physical structure of the jaw. We’re decompressing the joint, relieving pain, and allowing the joint to heal. We’re improving sleep quality by preventing the airway from collapsing. But we’re not moving things around and we’re not expanding the jaw.”

Permanent structural changes occur in phase two, he explains. “This may involve orthodontically moving teeth, expanding arches, or other methods to improve joint function.

“In children, however, we have a different approach. We use orthopaedic appliances, because we are actually directing the growth of the bones of the skull in a way that optimizes the airway. We’re basically training the mouth as it grows, allowing mouth and airway to develop properly so the patient will not have any sleep or jaw problems later.”

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