For Dr. Charles Ferzli, of the TMJ & Sleep Therapy Centre in Cary, issues of balance are central to his practice. “The diagnosis and treatment of TMJ is fundamentally about restoring balance,” he observes. “TMJD is shorthand for temporomandibular joint (TMJ) disorder. Any problem—any imbalance—with the complex system of muscles, tissues, ligaments, and bones that make up the jaw joint can result in this painful, sometimes disabling disorder.”

The name of Dr. Ferzli’s 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 and sleep problems,” he 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.

“It is the complexity of TMJD that makes the ‘balancing act’ so challenging,” observes Dr. Ferzli. “A temporomandibular joint out of balance can result in chronic pain, sleep disorders, vertigo, postural issues, even digestive problems. TMJD is often referred to as the ‘great imposter’ because its symptoms are so wide ranging—including headaches and earaches, neck and shoulder pain, and tinnitus.

“We don’t often see easy cases,” notes Dr. Ferzli, “because jaw and tooth pain rarely have simple, single causes. And often my patients come to me after having been to many different places and after many different tests—and still in pain. Our job is to find the sources of the inflammation that’s causing all that pain.”

Tracking the Source of Jaw Joint Problems

“TMJ problems may be caused by jaw injuries, teeth grinding, arthritis, and everyday wear and tear,” explains Dr. Ferzli. “But there’s rarely a single cause. Rather, it’s a combination of factors that contribute to the disorder.

“For example, poor oral hygiene results in TMJD, because it often contributes to tooth loss. And, if you lose your posterior molars, there’s no posterior support for the bite, and the jaw joint can rotate back, resulting in compression of the temporomandibular joint.”

Postural alignment issues may also cause TMJD. “Balancing issues start from the feet up,” he explains. “As the body adjusts to address problems, realignments ultimately affect the jaw joint.”

And, notes Dr. Ferzli, “since TMJD is an inflammatory condition, anything that contributes to inflammation—including diet and emotional and psychological stress—can play a role. Stress, for example, may cause clenching or breathing problems. Sensitivities to certain foods causes nasal inflammation, which leads to breathing problems, and thus to TMJD. In fact, the typical American diet, which is highly inflammatory, contributes to a large percentage sleep and breathing issues.

“And, breathing issues are one of the most significant—and least appreciated—problems that we see,” says Dr. Ferzli, “which illustrates both the complexity of TMJD and the importance of testing. Breathing issues—especially mouth breathing—contribute to jaw joint problems; jaw joint problems interfere with sleep by obstructing airways. As a consequence, we’re not getting enough oxygen, sleep is interrupted, and we wake up hurting and tired. The breathing issues cause clenching, which further exacerbates the jaw joint problems. It’s a vicious circle.”

Testing: Critically Important

“Because imbalances in the jaw joint have a variety of causes and can lead to a variety of problems,” says Dr. Ferzli, “thorough testing is critically important in understanding and treating TMJD. For example, jaw-joint pain affects the body’s posture and therefore the patient’s balance and gait. TMJ issues may also obstruct airways, contributing to sleep problems including sleep apnea. So, I don’t want to guess about the source the problem,” he explains. “I want to understand—thoroughly—how different factors influence one another. To do that, we use a detailed history, a careful exam, and long list of tests.

“To start,” says Dr. Ferzli, “I usually have new patients simply walk up and down my hallway—first as they normally do, and then with a tongue depressor. Usually, you can notice that their balance and gait are much improved when their jaw joint is decompressed. That’s a quick simple test that helps to confirm that there is a TMJ problem. From there, we use a wide variety of assessments.

“In the exam, we’ll palpate the jaw and all the surrounding muscles, and assess the neck muscles and those at the base of the head. Then we do a jaw joint vibration analysis, and range-of-motion tests.

“A valuable tool called a jaw tracker, evaluates the functioning of the jaw joint, and X-rays help us measure the health of the jaw joint. A neurologic test—called a motor nerve reflex test—is used to check the nervous system to determine which parts of the body are causing postural instability. We also evaluate nasal passages and oral airways to check for obstructions during sleep.

“These tools help take the guesswork out of diagnosing critical health issues” explains Dr. Ferzli. “They help translate the subjective experience of pain into a localized, identifiable, and thus treatable problem, thereby greatly improving the reliability of our treatment approaches. Test results also often identify problems—such as nasal obstruction or postural issues—that need treatment from other specialists, such as an ENT or chiropractor.”

Treating TMJD

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, breathing exercises, and referral to other practitioners for physical therapy, orthodontia, or even surgery.

“Typically, treatment begins with education. We take all the information gathered for a particular patient and develop a multi-faceted, holistic treatment plan to help them feel and function better. And we want the patient to understand all the factors contributing to their problems and how the various components of the treatment plan contribute to the healing process.

“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.

“I see my job as not simply treating people,” Dr. Ferzli adds, “but making them aware of the possibilities and what they can do to heal.”