TMJ and Sleep: The Special Challenges of Complexity

Dr. Ferzli, here with a patient, uses a variety of tools to measure bodily functions in order to determine causes—and solutions—for TMJD and sleep problems.


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“It’s no accident that my practice is ‘The TMJ and Sleep Therapy Centre,’ notes Cary dentist Charles Ferzli. “I have learned that, in the majority of cases, jaw joint (TMJ) problems and sleep issues are inseparable and complex. Many other issues—including pain, inflammation, mouth breathing, stress, even depression—almost always accompany these problems.

“In fact, by the time a patient comes to us with severe pain or sleep issues—such as jaw pain, locked jaws, migraines, or sleep apnea—they bring not one problem, but a complex collection of problems. The healing process requires a careful disentangling of these issues. Everything contributes to the problem; everything needs attention.”

Referred Pain, Referred Problems

The path leading patients to his practice, notes Dr. Ferzli, illustrates the complexity of TMJD/sleep issues. “Most patients come to us after unsuccessfully seeking help from other practitioners—such as ENT physicians, dentists, headache and pain specialists, and chiropractors. That’s because, while TMJD typically manifests as jaw pain, it can also produce what’s known as ‘referred pain’—pain in other parts of the body. Migraines and ear pain are common, other patients report severe pain in arms, neck, or shoulders.

One Patient’s Healing Journey

Kathryn’s experience with TMJD and her healing path were familiar patterns in Dr. Ferzli’s practice. Brutal migraine pain brought Kathryn to Dr. Ferzli in early 2022. “I had horrible migraines, with numbness, nausea, tingling—aching all over. It had been going on for months, and although I had a history of scoliosis, the migraines were new, and didn’t respond to migraine medication. I had to be driven to my first appointment with Dr. Ferzli and the first exams had to be done in a darkened room because the migraine pain was so severe.”

“Kathryn is a classic example of someone dealing multiple issues that contributed to each other,” says Dr. Ferzli. “She was a heavy mouth breather, which caused her to clench at night, causing sleep apnea and exacerbating her TMJD. Pain from scoliosis contributed to the tensions in her jaw joint—further interfering with sleep.”

Also typical was the path she had followed in attempting to address her problems. Kathryn had spent 10 years in the military; upon discharge she had been diagnosed with TMJD, but the only treatment suggested was to use an over-the-counter night guard, which had not helped. Migraine medication and  physical therapy were only slightly helpful, and her pain increased, bringing her to the point of the overwhelming pain she experienced when she first met Dr. Ferzli.

“At that first appointment,” says Kathryn, “Dr. Ferzli asked me about my medical history and did a series of tests. And he explained how the jaw problems and sleep issues I was dealing with contributed to the pain I was having—including some of the aches and pains I assumed were related to my scoliosis.

“When I started using the oral appliances—one for day and one for night—the change was huge. In just a few weeks I saw an enormous amount of pain relief, not just with the migraine but also in my lower back. I used the daytime appliance initially, and now I just use the nighttime appliance—which I expect to use indefinitely. In addition, I’ve been using nasal strips that help with nighttime breathing. “The result has been life-altering. The numbness is gone. I still get occasional migraines, but not often and they are not nearly as severe, and I’ve been able to taper down the migraine medication. The constant pain I was dealing with two years ago was a 9 on the 1-10 scale; now it’s a 1. I’m just so incredibly grateful to Dr. Ferzli and his wonderful staff!

“Misaligned jaws are responsible for other problems that interfere with sleep,” he adds, “So, some patients come to us when treatments for sleep problems have been unsuccessful. They may have been treated for sleep apnea, but their sleep problems persisted because the focus was only on sleep apnea and didn’t address jaw problems or other breathing issues.

“Many symptoms and health problems can be traced to the complex problem of TMJD and sleep, and understanding the connections is essential. Unfortunately,” he adds, “too often those connections are not understood and there is a tendency to treat either TMJD or sleep apnea. It’s not uncommon, for example, for patients to get an oral appliance to treat their jaw problem, but they don’t get better because the sleep issues persist. Oral appliances to adjust jaw position are extremely important in any treatment plan, but they’re not the only component—we have to address all aspects.”

The Healing Process

Unraveling the tangle of factors underlying TMJD and sleep issues is a comprehensive process. Foremost in this process,” says Dr. Ferzli, “is evaluation—knowing exactly what the contributing issues are—breathing issues? Inflammation? Allergies? Structural issues? Medications? Stress? We begin with a detailed intake form to identify all the patient’s symptoms. It includes a whole column of TMJ symptoms and a whole column of sleep symptoms. When patients have symptoms in both columns, I explain that it’s the interrelationship of breathing, sleeping, and jaw/structural issues that produces the problems they’re experiencing.

“From there we use tests to assess a variety of factors—including pain levels, balance, range-of-motion, sleep patterns, airway passages, and more. We want to know whether there are structural issues impeding breathing and sleep; the health and position of the jaw joint; and to identify specific sources of pain.”

Oral Appliances for Symptom Relief

Among the first steps in the healing process, says Dr. Ferzli, is to address the structural issues that cause pain, interfere with sleep, and impair breathing. “An oral appliance can provide immediate relief and pave the way for further healing,” he explains. “A correctly designed oral device will prevent the lower jaw and tongue from physically falling back and crushing the airway during sleep. That’s critically important because, when you adjust the jaw position at night, allowing for better sleep, you are addressing many problems at once: better sleep is restorative; proper jaw positioning relieves tension and allows for improved breathing; better breathing supports better sleep, and so forth.”

Breathing issues may need to be addressed in other ways, notes Dr. Ferzli. “Sometimes we need to treat nasal problems as well—either by referring to an ENT to address structural problems, or by managing the nasal passageway with nasal sprays or dilators. Mouth breathing is the source of many sleep and jaw problems, contributing to clenching and interrupted sleep. So, sometimes patients need to use exercises to improve their ability to breathe well from the nose. And such exercises are not addressed when the focus is just on TMJ problems.

“Similarly,” he adds, “when an oral appliance is used to address sleep issues, it doesn’t typically address jaw joint issues. A correct appliance needs to put the jaw joint orthopedically in the right spot to ensure there is decompression of the jaw joint during the night. Often patients will need an oral device if they have chronic TMJD problems. However, relying only on a nighttime oral appliance doesn’t address the need to decompress the jaw joint 24/7. So, patients often need both daytime and nighttime devices. We also use laser therapy and prescribe an anti-inflammatory diet or supplements to treat inflammation. All these things contribute to healing of the jaw joint as well as improving sleep.”

The Patient’s Role

“Understanding the complex connections of breathing, sleep, and jaw joint issues is critically important,” says Dr. Ferzli. “However, success in treating TMJD/sleep issues also relies on education and what I call ‘patient buy-in’. It’s important that patients understand the many factors involved, as well as the role of diet, stress, allergies, and other problems. For each patient, it’s different.”

But, ultimately, Dr. Ferzli emphasizes, “the key to healing is a partnership with the patient. Healing doesn’t depend on a pill or even just an orthotic. Whole healing requires attention to diet to reduce inflammation, stress reduction, and learning to breathe properly. That’s a challenge, and patients have to be ready. “But,” he adds, “when the patient is ready to embrace the complexity, healing is inevitable.”