THERE IS NO SINGLE "BEST TREATMENT" FOR TMJ BECAUSE TMJ IS NO A SINGLE DISEASE OR PROBLEM. TMJ actually stands for TemporoMandibular Joint and it is a joint not a disease. Everyone has two TM Joints. TMD stands for TemporoMandibular Dysfunction but it is also a general term.
The following should help guide patients in finding the "right " doctor.
To receive the "Best TMJ Treatment" it is first necessary to have the "Best TMJ Diagnosis".
The diagnosis is actually the most complex part of treating this group of disorders.
The medical SOAP model is an essential part of arriving at the right diagnosis and treatment and is frequently not followed.
The "S" in SOAP is the subjective findings. These come from the patients history. Many dentists and physicians short change patients by not getting a thorough and complete history. Often, relevant facts about a patient's history are missed or revealed later by patients. I usually set aside a minimum of one hour for a first visit with a patient with chronic pain. My team will often schedule much longer appointments when a case appears complicated. The tentative diagnosis or diagnostic tree (differential diagnosis) is made from the patient's history and interview. It is the confirmed or reevaluated based on Objective findings.
The "O" in SOAP is the objective findings. Before objective testing is done the subjective history helps determine the proper testing that is appropriate for each patient. Objective testing includes Radiographs or x-rays. These may be plain film, cone beam, CT scans, MRI's. These are used to diagnose bony changes and soft tissue changes to the joints.
There are specific objective testing that helps determine the "Best TMJ Treatment" and confirms details of the working diagnosis. Neuromuscular Dentists use the following diagnostic tools to elucidate the complete nature of this disorder.
THE FOLLOWING OBJECTIVE DEVICES ARE USED BY NEUROMUSCULAR DENTISTS TO AID IN DIAGNOSIS AND TREATMENT OF CRANIOMANDIBULAR DISORDERS (TMJ, MPD, MPD,ETC)
EMG or Electromyography that is used to determine starting levels of muscle activity, symmetry of muscle activity, funCtional activity as it relates to posture and function. Spectral Analysis of EMG help to determine underlying physiologic sTatus of the muscles. EMG can also be used to fine tune bite corrections and to measure efficacy of treatment.
Sonography and/or JVA (joint vibration analysis) Can be used to measure the health of the joint and determine thru spectral analysis the amount of joint damage or changes.
MKG (mandibular kinesiograph) , CMS (computerized Mandibular Scans) are used to evaluate function and movement and in conjunction with ULF TENS to measure rest position.
ULF TENS is used diagnostically and as a treatment tool. The the dimensional position of the jaw is evaluated before and after muscle relaxation (as confirmed by EMG)
Blood Tests, urine chemistry, thyroid function are all objective tests that are used when appropriate. Sleep studies are an often under utilized diagnostic tool in finding the "BEST TMJ TREATMENT". Patients with morning headaches, snoring, high blood pressure and excessive daytime sleepiness should always be evaluated with polysomnography. The NHLBI (National Heart Lung and Blood Institute) of the NIH (National Institute of Health) considers Sleep Apnea to be a TMJ disorder.
Psychometric tests are also objective tests that are used in diagnosis. Unfortunately, many doctors believe that there are no real physical ailments and the TMJ is a "psychco-social" disease to be treated with drugs and psychotherapy. There are frequently psycho-social overlays to TMJ problems. Being in chronic pain changes patients in many ways. Psychometric testing often reveals the results of chronic pain rather than the cause.
The "A" in SOAP is the assessment, where all of the subjective and objective information allows the doctor to have a "working diagnosis" and to lay out an initial treatment plan.
The "P" in Soap is the PLAN or methods determined by the Physician or Dentist to be used to treat the patient. This may include use of medications, therapy or diagnostic orthopedic appliances. Many patients need numerous methods of treatment to address the disorders and problems diagnosed and revealed in Subjective and Objective examination. Frequently more than one practitioner will be involved in treatment.
DIAGNOSIS DOES NOT END WHEN A NEUROMUSCULAR DIAGNOSTIC ORTHOTIC IS PLACED IN A PATIENTS MOUTH!
It is essential to understand that diagnosis and treatment is an ongoing procedure and that a SOAP approach is used at subsequent appointments. The "BEST TMJ TREATMENT" is ongoing and as the patients improve it is frequently appropriate for the focus of treatment to change. It is important for the patient and doctor to be open and honest to achieve the best results.
I strongly believe that the Neuromuscular Dentistry approach is the best "TMJ" treatment but it is only a part of the total diagnosis.
Thursday, November 25, 2010
Sleep Appliance Causes Patient To Develop "TMJ". Is "TMJ" from Somnomed Sleep Appliance or is sleep apnea a symptom of a TMJ problem?
JEFF: I have an oral device (sonomed) for sleep apnea. It gave me TMJ. I haven't been able to tolerate cpap.
Dr Shapira: YOU STATE THAT YOU HAVE A SOMNOMED TO TREAT SLEEP APNEA BECAUSE YOU CANNOT TOLERATE CPAP.
It is excellent that you have chosen to treat the sleep apnea which can cause heart attacks, strokes, memory loss and excessive daytime sleepiness. Morning Headaches and headaches that wake patients from sleep are usually the result of sleep apnea or TMJ disorders ie "TMD"
YOU THEN STATE THAT YOU DEVELOPED TMJ BUT GAVE NO SPECIFICS AS TO SYMPTOMS. TMJ STANDS FOR TEMPOROMANDIBULAR JOINT, NOT A DISEASE. It is important to understand the SPECIFIC problems so they can be addressed. Patients wearing oral appliances for sleep apnea may experience bite changes or tooth movement but damage should not occur to the joints. It is essential to work with a dentist who has training in treating sleep apnea and TMJ disorders.
I frequently see patients whose bite changes but the feel better. Many of the changes that occur when wearing a sleep appliance are actually due to the body healing. The same developmental problems cause both sleep apnea and TMJ disorders, migraines and chronic daily headaches.
Neuromuscular Dentistry is one of the best approaches to treating headaches and TMJ disorders.
ACCORDING TO THE NHLBI SLEEP APNEA IS A TMJ DISORDER. SEE http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf You have actually developed a new symptom from the same disorder but because you didn't specify symptoms I can not specify what to do next.
The American Academy of Sleep Medicine recommends that dentists treating sleep apnea with oral appliances should be well trained in treating TMJ disorders. I SUGGEST THAT THE BEST QUALIFIED DENTISTS FOR TREATING TMJ DISORDERS ARE NEUROMUSCULAR DENTISTS.
IF YOU CAN GIVE ME SPECIFIC INFORMATION I MAY BE OF MORE HELP. Please review www.ihateheadaches.org to learn about Neuromuscular Treatment of TMJ Disorders, headaches and migraines.
The following is the result of a web form submission from:
comments: I have an oral device (sonomed) for sleep apnea. It gave me TMJ
I haven't been able to tolerate cpap
Dr Shapira: YOU STATE THAT YOU HAVE A SOMNOMED TO TREAT SLEEP APNEA BECAUSE YOU CANNOT TOLERATE CPAP.
It is excellent that you have chosen to treat the sleep apnea which can cause heart attacks, strokes, memory loss and excessive daytime sleepiness. Morning Headaches and headaches that wake patients from sleep are usually the result of sleep apnea or TMJ disorders ie "TMD"
YOU THEN STATE THAT YOU DEVELOPED TMJ BUT GAVE NO SPECIFICS AS TO SYMPTOMS. TMJ STANDS FOR TEMPOROMANDIBULAR JOINT, NOT A DISEASE. It is important to understand the SPECIFIC problems so they can be addressed. Patients wearing oral appliances for sleep apnea may experience bite changes or tooth movement but damage should not occur to the joints. It is essential to work with a dentist who has training in treating sleep apnea and TMJ disorders.
I frequently see patients whose bite changes but the feel better. Many of the changes that occur when wearing a sleep appliance are actually due to the body healing. The same developmental problems cause both sleep apnea and TMJ disorders, migraines and chronic daily headaches.
Neuromuscular Dentistry is one of the best approaches to treating headaches and TMJ disorders.
ACCORDING TO THE NHLBI SLEEP APNEA IS A TMJ DISORDER. SEE http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf You have actually developed a new symptom from the same disorder but because you didn't specify symptoms I can not specify what to do next.
The American Academy of Sleep Medicine recommends that dentists treating sleep apnea with oral appliances should be well trained in treating TMJ disorders. I SUGGEST THAT THE BEST QUALIFIED DENTISTS FOR TREATING TMJ DISORDERS ARE NEUROMUSCULAR DENTISTS.
IF YOU CAN GIVE ME SPECIFIC INFORMATION I MAY BE OF MORE HELP. Please review www.ihateheadaches.org to learn about Neuromuscular Treatment of TMJ Disorders, headaches and migraines.
The following is the result of a web form submission from:
comments: I have an oral device (sonomed) for sleep apnea. It gave me TMJ
I haven't been able to tolerate cpap
Monday, November 15, 2010
CENTRAL SENSITIZATION AND TMD: THE CONNECTION TO MYOFASCIAL PAIN, FIBROMYALGIA, HEADACHE, MIGRAINE AND RELATED DISORDERS.
I have frequently discussed the relation between headache, TMD and central sensitization. The trigeminal nerve is a frequent culprit in development of central sensitization which is why neuromuscular dentistry can be such an effective treatment. Decreases in nociceptive input from the trigeminal nerve can allow reversal of a sensitized state.
A new article in Pain "Pain." 2010 Oct 18. "Central sensitization: Implications for the diagnosis and treatment of pain." documents much of what we understand about central sensitization. These heightened central states are caused by noxious or nociceptive input into the brain. The trigeminal nerve carries a tremendous amount of information (nociception) into the CNS.
A recent article "Chronic Orofacial pain" proposes that "we propose the concept that because COFP and headaches share underlying pathophysiological mechanisms, clinical characteristics, and neurovascular anatomy, they should be classified together." This would be obvious to anyone who evaluates the anatomy and physiology of the brain and especially the stomatognathic system including the jaw muscles, teeth and periodontal ligaments. jaw joints and most importantly the trigeminal nerve. The trigeminal nerve is almost always indicated as a culprit or co-conspirator in chronic and episodic facial pain and headache .
The use of botox on jaw muscles to treat chronic headaches and migraines actually reduces nociceptive input to the trigeminal nerve from and brain from peripheral input. Neuromuscular dentistry also reduces nociceptive input withput the use of toxic nerve agents but utilizing antidromic TENS to relax muscles and establisha healthy physiologic rest position with minimal nociceptive input. Neuromuscular occlusion is simply a physiologic land spot that allows the muscle to return to a health rest position after function.
The computer adage "Garbage in- Garbage out" is what happens when nociceptive input to the brain exceeds our ability to comfortably adapt causing pain and central sensitization. Reduce the "garbage in" with neuromuscula dental techniques and the "garbage out" painful sequellae subside.
Curr Pain Headache Rep. 2010 Feb;14(1):33-40.
Chronic orofacial pain.
Benoliel R, Sharav Y.
Faculty of Dentistry, Department of Oral Medicine, Hebrew University-Hadassah, Jerusalem, Israel. benoliel@cc.huji.ac.il
Abstract
Chronic orofacial pain (COFP) is an umbrella term used to describe painful regional syndromes with a chronic, unremitting pattern. This is a convenience term, similar to chronic daily headaches, but is of clinically questionable significance: syndromes that make up COFP require individually tailored diagnostic approaches and treatment. Herein we describe the three main categories of COFP: musculoskeletal, neurovascular, and neuropathic. For many years, COFP and headache have been looked upon as discrete entities. However, we propose the concept that because COFP and headaches share underlying pathophysiological mechanisms, clinical characteristics, and neurovascular anatomy, they should be classified together.
PMID: 20425212 [PubMed - indexed for MEDLINE]
A new article in Pain "Pain." 2010 Oct 18. "Central sensitization: Implications for the diagnosis and treatment of pain." documents much of what we understand about central sensitization. These heightened central states are caused by noxious or nociceptive input into the brain. The trigeminal nerve carries a tremendous amount of information (nociception) into the CNS.
A recent article "Chronic Orofacial pain" proposes that "we propose the concept that because COFP and headaches share underlying pathophysiological mechanisms, clinical characteristics, and neurovascular anatomy, they should be classified together." This would be obvious to anyone who evaluates the anatomy and physiology of the brain and especially the stomatognathic system including the jaw muscles, teeth and periodontal ligaments. jaw joints and most importantly the trigeminal nerve. The trigeminal nerve is almost always indicated as a culprit or co-conspirator in chronic and episodic facial pain and headache .
The use of botox on jaw muscles to treat chronic headaches and migraines actually reduces nociceptive input to the trigeminal nerve from and brain from peripheral input. Neuromuscular dentistry also reduces nociceptive input withput the use of toxic nerve agents but utilizing antidromic TENS to relax muscles and establisha healthy physiologic rest position with minimal nociceptive input. Neuromuscular occlusion is simply a physiologic land spot that allows the muscle to return to a health rest position after function.
The computer adage "Garbage in- Garbage out" is what happens when nociceptive input to the brain exceeds our ability to comfortably adapt causing pain and central sensitization. Reduce the "garbage in" with neuromuscula dental techniques and the "garbage out" painful sequellae subside.
Curr Pain Headache Rep. 2010 Feb;14(1):33-40.
Chronic orofacial pain.
Benoliel R, Sharav Y.
Faculty of Dentistry, Department of Oral Medicine, Hebrew University-Hadassah, Jerusalem, Israel. benoliel@cc.huji.ac.il
Abstract
Chronic orofacial pain (COFP) is an umbrella term used to describe painful regional syndromes with a chronic, unremitting pattern. This is a convenience term, similar to chronic daily headaches, but is of clinically questionable significance: syndromes that make up COFP require individually tailored diagnostic approaches and treatment. Herein we describe the three main categories of COFP: musculoskeletal, neurovascular, and neuropathic. For many years, COFP and headache have been looked upon as discrete entities. However, we propose the concept that because COFP and headaches share underlying pathophysiological mechanisms, clinical characteristics, and neurovascular anatomy, they should be classified together.
PMID: 20425212 [PubMed - indexed for MEDLINE]
Cluster Headaches and Sleep Apnea. Cluster Headaches caused by sleep apnea and sleep apnea sequelae may be eliminated with treatment of apnea
All patients with cluster headaches that have onset during sleep should be evaluated for sleep apnea. Sleep apnea causes hypoxia (drop in oxygen) and a rise in CO2. Oxygen therapy is a recognized and effective treatment for sleep apnea. Prevention of many cluster headaches can be addressed by correcting sleep problems.
During apneic events the patients quit breathing oxygen drops followed by hypercapnia or a rise in carbon dioxide levels. This can cause acidosis that could trigger cluster headaches. This leads to an awakening and patients gasping and is associated with adrenaline release or fight or flight reflex. Repetition throughout the night can also be the trigger.
Patients with untreated sleep apnea have abnormal cortisol levels and this disturbs the ability to cope with normal life stresses. There is also an increase in insulin resistance and changes in blood sugar can also be a cluster headache trigger. The article
Timing patterns of cluster headaches and association with symptoms of obstructive sleep apnea." from Sleep Res Online. 2000;3(3):107-12 concludes that "in some patients, physiological consequences of OSA may trigger CH during the first few hours of sleep and thereby influence the timing of subsequent daytime headaches."
The National Heart Lung and Blood Institute (NHLBI) considers sleep apnea to be a Temporomandibular Disorder. The NHLBI report "CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS" discusses effects of sleep apnea in detail. Learn more about the dangers of sleep apnea and oral appliance treatment at http://www.ihatecpap.com
A section of the report titled The Craniofacial Complex and its Impact on Control of Upper Airway Resistance and Cardiopulmonary Function- Jaw Biomechanics and Function" discusses sexual dimorphism and may explain why cluster headaches are more common in men. Part of that report follows: "These compartments are activated differently during the production of different oral behaviors, suggesting that they function as output elements used in different combinations by the nervous system. These muscles are complex and unique, containing fibers of phenotypes not found in limb muscles. They are smaller, and express myosin heavy chain isoforms found only in limb muscles during development. The cardiac alpha-myosin heavy chain isoforms of the masseter and temporalis muscles are unique to skeletal muscle and resemble heart muscle. Considerable sexual dimorphism has been identified in these muscles with regard to the slow and fast fibers types of the masseter. Males have predominately fast fiber types while females predominately slow fiber types. These sex differences arise in response to androgens in males but persist even in the absence of androgens."
It is widely accepted that the Trigeminal Nervous system that controls the jaws teeth and associate dental structures is implicated in the majority of all headaches including cluster headache.
Control of the upper airway often decrease or fails during sleep as seen in this excerpt: "Control of Upper Airway Collapsibility During Sleep
The upper pharyngeal airway in humans has relatively little bony or rigid support. Since there is variability in soft tissue and bony structures of the head and neck, there must be mechanisms in place that enable the pharyngeal dilator muscles to adjust for these anatomic differences. Animal and human studies indicate that there are at least three mechanisms to control the activity of the genioglossus muscle. First, negative pressure has substantial impact on this muscle and a clear linear relationship exists between negative pressure in the airway and genioglossal activation. Second, there is pre-motor neuron input to these muscles from respiratory pattern generating circuits as shown by the pre-activation of these muscles that occurs prior to the development of negative pressure in the airway. Third, tonic activity in the muscle is consistently evident, although the mechanisms that determine the level of this activity have not been studied. During sleep, the mechanisms that control upper airway resistance are importantly impacted. Specifically, tonic activity drops markedly and the negative pressure reflex is substantially attenuated or completely lost. These findings have important implications in the pathophysiology of SDB." They probably also have important implications in the physiology and pathology of cluster headaches.
The report also discusses physiological pain processes and central sensitization found in TMJD patients that is similar to findings in cluster and headache patients in this excerpt: "Craniofacial/Deep Tissue Persistent Pain and Relationships to Cardiovascular and Pulmonary Function and Disease.
Injury to peripheral tissues following trauma or surgery often results in hyperalgesia that is characterized by increased sensitivity to painful stimuli. This is a common problem in patients with TMD. Until recently, it was thought that the increase in pain was due to changes at the site of injury but it is now known that it involves central nervous system hyper-excitability leading to long-term changes in the nervous system. Animal models of hyperalgesia produced by inflammation or nerve injury that mimic persistent pain conditions have shown that an increased neuronal barrage into the central nervous system (CNS) leads to central sensitization involving activation of excitatory amino acid transmitters and their receptors. The activation of N-methyl- D-aspartate (NMDA) receptors leads to influx of calcium into neurons, the activation of protein kinases, and phosphorylation of receptors. The net effect of these responses is increased gene expression of NMDA receptors, an alteration in the sensitivity of receptors, increased excitability, and an amplification of pain. These responses appear to be most robust in response to deep tissue injury such as occurs in TMD patients.
Modulation by descending pathways from the CNS importantly influences these events. Under normal conditions, the net effect of the descending neural projections from the brain stem to the spinal cord is to inhibit or counterbalance the hyper-excitability produced by tissue injury. It is now understood that this balance can shift to a net excitatory effect whereby descending modulation results in more hyper-excitability and more pain after injury. This central sensitization appears to be a prominent component in patients suffering from deep pain conditions such as TMD and fibromyalgia. It is believed that the diffuse nature and amplification of pain is in part due to this imbalance and that these findings have important functional implications relevant to the survival of the organism in response to the presence of persistent tissue injury. It is therefore now believed that persistent pain can be attacked both at the site of injury and where it is elaborated in the nervous system."
The report also documents connections with autonomic system derangements that are normally found in headaches, migraines and cluster headaches. These autonomic symptoms are the ones that Sphenopalatine Ganglion Blocks can relieve or eliminate. The relevant section is excerpted below:
" Alteration in Baroreceptor Activity - Impact on Pain, Autonomic Function, Motor Output, and Sleep":
"Evidence has emerged that several regions of the CNS interact in complex ways to integrate sensory perception, autonomic function, motor output, and sleep architecture. The outcomes of a number of recent studies also suggest that several of the signs and symptoms associated with TMD may result, at least in part, from impairments in neural networks that coordinate the interplay between sensory systems, autonomic function, motor output, and sleep architecture. Many of the central pathways that are critically involved with the integration of these systems are regulated by visceral afferent input, including input from cardiopulmonary, carotid sinus, and aortic arch baroreceptors. In addition, abnormalities in the function and central integration of baroreceptor afferent information has been associated with abnormalities in pain perception, autonomic function, motor output, and sleep architecture, and thus may contribute to the development and maintenance of TMD and other related disorders (e.g., fibromyalgia). There is a need for additional studies that systematically examine whether abnormal baroreceptor function contributes to the pathogenesis of TMD."
Several relevant studies on TMD and Sleep Apnea are included below:
Cranio. 1997 Jan;15(1):89-93.
Cluster-like signs and symptoms respond to myofascial/craniomandibular treatment: a report of two cases.
Vargo CP, Hickman DM.
Raleigh Regional Center for Head, Neck and Facial Pain in Beckley, West Virginia, Morgantown, USA.
Abstract
Two cases with pain profiles characteristic of cluster-like headache, both within and outside the trigeminal system, are reported. One male patient would typically awaken from sleep with severe unilateral temporal head pain and autonomic signs of ipsilateral lacrimation and nasal congestion. A female patient exhibited severe unilateral boring temporal and suboccipital head pain with associated ipsilateral lacrimation and rhinorrhea. In addition, both patients presented with signs and symptoms of masticatory and/or cervical disorders. These two cases illustrate possible treatment alternatives, as well as possible influences from cervical and masticatory structures in the development of cluster or cluster-like headache.
PMID: 9586493 [PubMed - indexed for MEDLINE]
Cranio. 1995 Jul;13(3):177-81.
Sphenopalatine ganglion block: a safe and easy method for the management of orofacial pain.
Peterson JN, Schames J, Schames M, King E.
Headache and Pain Center, Hollywood Community Hospital, Los Angeles, CA 90028, USA.
Abstract
The sphenopalatine ganglion (SPG) block is a safe, easy method for the control of acute or chronic pain in any pain management office. It takes only a few moments to implement, and the patient can be safely taught to effectively perform this pain control procedure at home with good expectations and results. Indications for the SPG blocks include pain of musculoskeletal origin, vascular origin and neurogenic origin. It has been used effectively in the management of temporomandibular joint (TMJ) pain, cluster headaches, tic douloureux, dysmenorrhea, trigeminal neuralgia, bronchospasm and chronic hiccup.
PMID: 8949858 [PubMed - indexed for MEDLINE]
Ned Tijdschr Tandheelkd. 2006 Nov;113(11):474-7.
[Spontaneous pain attacks: neuralgic pain]
[Article in Dutch]
de Bont LG.
Universitair Medisch Centrum, Groningen. l.g.m.de.bont@kchir.umcg.nl
Abstract
Paroxysmal orofacial pains can cause diagnostic problems, especially when different clinical pictures occur simultaneously. Pain due to pulpitis, for example, may show the same characteristics as pain due to trigeminal neuralgia would. Moreover, the trigger point of trigeminal neuralgia can either be located in a healthy tooth or in the temporomandibular joint. Neuralgic pain is distinguished into trigeminal neuralgia, glossopharyngeal neuralgia, Horton's neuralgia, cluster headache and paroxysmal hemicrania. In 2 cases trigeminal neuralgia is successfully managed with a neurosurgical microvascular decompression procedure according to Jannetta. Characteristic pain attacks resembling neuralgic pain result from well understood pathophysiological mechanisms. Consequently, adequate therapy, such as a Janetta procedure and specific pharmacological therapy, is available.
PMID: 17147031 [PubMed - indexed for MEDLINE]
Sleep Res Online. 2000;3(3):107-12.
Timing patterns of cluster headaches and association with symptoms of obstructive sleep apnea.
Chervin RD, Zallek SN, Lin X, Hall JM, Sharma N, Hedger KM.
Sleep Disorders Center, Department of Neurology, University of Michigan, Ann Harbor, Michigan, USA. chervin@umich.edu
Abstract
Cluster headaches (CH) frequently recur at the same point in the circadian cycle, often during sleep. They may, in some cases, represent a susceptible individual's response to hypoxemia or other physiological changes induced by obstructive sleep apnea (OSA). If and when this mechanism exists, timing of CH close to the onset of sleep-and therefore OSA-might be expected. We questioned 36 subjects with CH about the times at which their CH usually occurred and about several symptoms known to be predictive of OSA, including habitual snoring, loud snoring, observed apneas and excessive daytime sleepiness. We then used logistic regression to determine whether occurrence of CH in each of six time periods was associated with OSA symptoms. The 23 subjects (64%) who reported CH in the first half of a typical night's sleep also tended to report headaches during the midday/afternoon period. Symptoms of OSA, and in particular habitual snoring, were predictive of both first-half-of-the-night and midday/afternoon CH (p<.05). Thirty-one subjects (86%) reported that their CH were sleep-related, usually occurring during any part of the night or on awakening, but symptoms of OSA were not predictive of this timing pattern. In short, several OSA symptoms showed an association with CH occurrence in the first half of the night but not with sleep-related CH in general. These findings suggest that in some patients, physiological consequences of OSA may trigger CH during the first few hours of sleep and thereby influence the timing of subsequent daytime headaches.
PMID: 11382908 [PubMed - indexed for MEDLINE]
During apneic events the patients quit breathing oxygen drops followed by hypercapnia or a rise in carbon dioxide levels. This can cause acidosis that could trigger cluster headaches. This leads to an awakening and patients gasping and is associated with adrenaline release or fight or flight reflex. Repetition throughout the night can also be the trigger.
Patients with untreated sleep apnea have abnormal cortisol levels and this disturbs the ability to cope with normal life stresses. There is also an increase in insulin resistance and changes in blood sugar can also be a cluster headache trigger. The article
Timing patterns of cluster headaches and association with symptoms of obstructive sleep apnea." from Sleep Res Online. 2000;3(3):107-12 concludes that "in some patients, physiological consequences of OSA may trigger CH during the first few hours of sleep and thereby influence the timing of subsequent daytime headaches."
The National Heart Lung and Blood Institute (NHLBI) considers sleep apnea to be a Temporomandibular Disorder. The NHLBI report "CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS" discusses effects of sleep apnea in detail. Learn more about the dangers of sleep apnea and oral appliance treatment at http://www.ihatecpap.com
A section of the report titled The Craniofacial Complex and its Impact on Control of Upper Airway Resistance and Cardiopulmonary Function- Jaw Biomechanics and Function" discusses sexual dimorphism and may explain why cluster headaches are more common in men. Part of that report follows: "These compartments are activated differently during the production of different oral behaviors, suggesting that they function as output elements used in different combinations by the nervous system. These muscles are complex and unique, containing fibers of phenotypes not found in limb muscles. They are smaller, and express myosin heavy chain isoforms found only in limb muscles during development. The cardiac alpha-myosin heavy chain isoforms of the masseter and temporalis muscles are unique to skeletal muscle and resemble heart muscle. Considerable sexual dimorphism has been identified in these muscles with regard to the slow and fast fibers types of the masseter. Males have predominately fast fiber types while females predominately slow fiber types. These sex differences arise in response to androgens in males but persist even in the absence of androgens."
It is widely accepted that the Trigeminal Nervous system that controls the jaws teeth and associate dental structures is implicated in the majority of all headaches including cluster headache.
Control of the upper airway often decrease or fails during sleep as seen in this excerpt: "Control of Upper Airway Collapsibility During Sleep
The upper pharyngeal airway in humans has relatively little bony or rigid support. Since there is variability in soft tissue and bony structures of the head and neck, there must be mechanisms in place that enable the pharyngeal dilator muscles to adjust for these anatomic differences. Animal and human studies indicate that there are at least three mechanisms to control the activity of the genioglossus muscle. First, negative pressure has substantial impact on this muscle and a clear linear relationship exists between negative pressure in the airway and genioglossal activation. Second, there is pre-motor neuron input to these muscles from respiratory pattern generating circuits as shown by the pre-activation of these muscles that occurs prior to the development of negative pressure in the airway. Third, tonic activity in the muscle is consistently evident, although the mechanisms that determine the level of this activity have not been studied. During sleep, the mechanisms that control upper airway resistance are importantly impacted. Specifically, tonic activity drops markedly and the negative pressure reflex is substantially attenuated or completely lost. These findings have important implications in the pathophysiology of SDB." They probably also have important implications in the physiology and pathology of cluster headaches.
The report also discusses physiological pain processes and central sensitization found in TMJD patients that is similar to findings in cluster and headache patients in this excerpt: "Craniofacial/Deep Tissue Persistent Pain and Relationships to Cardiovascular and Pulmonary Function and Disease.
Injury to peripheral tissues following trauma or surgery often results in hyperalgesia that is characterized by increased sensitivity to painful stimuli. This is a common problem in patients with TMD. Until recently, it was thought that the increase in pain was due to changes at the site of injury but it is now known that it involves central nervous system hyper-excitability leading to long-term changes in the nervous system. Animal models of hyperalgesia produced by inflammation or nerve injury that mimic persistent pain conditions have shown that an increased neuronal barrage into the central nervous system (CNS) leads to central sensitization involving activation of excitatory amino acid transmitters and their receptors. The activation of N-methyl- D-aspartate (NMDA) receptors leads to influx of calcium into neurons, the activation of protein kinases, and phosphorylation of receptors. The net effect of these responses is increased gene expression of NMDA receptors, an alteration in the sensitivity of receptors, increased excitability, and an amplification of pain. These responses appear to be most robust in response to deep tissue injury such as occurs in TMD patients.
Modulation by descending pathways from the CNS importantly influences these events. Under normal conditions, the net effect of the descending neural projections from the brain stem to the spinal cord is to inhibit or counterbalance the hyper-excitability produced by tissue injury. It is now understood that this balance can shift to a net excitatory effect whereby descending modulation results in more hyper-excitability and more pain after injury. This central sensitization appears to be a prominent component in patients suffering from deep pain conditions such as TMD and fibromyalgia. It is believed that the diffuse nature and amplification of pain is in part due to this imbalance and that these findings have important functional implications relevant to the survival of the organism in response to the presence of persistent tissue injury. It is therefore now believed that persistent pain can be attacked both at the site of injury and where it is elaborated in the nervous system."
The report also documents connections with autonomic system derangements that are normally found in headaches, migraines and cluster headaches. These autonomic symptoms are the ones that Sphenopalatine Ganglion Blocks can relieve or eliminate. The relevant section is excerpted below:
" Alteration in Baroreceptor Activity - Impact on Pain, Autonomic Function, Motor Output, and Sleep":
"Evidence has emerged that several regions of the CNS interact in complex ways to integrate sensory perception, autonomic function, motor output, and sleep architecture. The outcomes of a number of recent studies also suggest that several of the signs and symptoms associated with TMD may result, at least in part, from impairments in neural networks that coordinate the interplay between sensory systems, autonomic function, motor output, and sleep architecture. Many of the central pathways that are critically involved with the integration of these systems are regulated by visceral afferent input, including input from cardiopulmonary, carotid sinus, and aortic arch baroreceptors. In addition, abnormalities in the function and central integration of baroreceptor afferent information has been associated with abnormalities in pain perception, autonomic function, motor output, and sleep architecture, and thus may contribute to the development and maintenance of TMD and other related disorders (e.g., fibromyalgia). There is a need for additional studies that systematically examine whether abnormal baroreceptor function contributes to the pathogenesis of TMD."
Several relevant studies on TMD and Sleep Apnea are included below:
Cranio. 1997 Jan;15(1):89-93.
Cluster-like signs and symptoms respond to myofascial/craniomandibular treatment: a report of two cases.
Vargo CP, Hickman DM.
Raleigh Regional Center for Head, Neck and Facial Pain in Beckley, West Virginia, Morgantown, USA.
Abstract
Two cases with pain profiles characteristic of cluster-like headache, both within and outside the trigeminal system, are reported. One male patient would typically awaken from sleep with severe unilateral temporal head pain and autonomic signs of ipsilateral lacrimation and nasal congestion. A female patient exhibited severe unilateral boring temporal and suboccipital head pain with associated ipsilateral lacrimation and rhinorrhea. In addition, both patients presented with signs and symptoms of masticatory and/or cervical disorders. These two cases illustrate possible treatment alternatives, as well as possible influences from cervical and masticatory structures in the development of cluster or cluster-like headache.
PMID: 9586493 [PubMed - indexed for MEDLINE]
Cranio. 1995 Jul;13(3):177-81.
Sphenopalatine ganglion block: a safe and easy method for the management of orofacial pain.
Peterson JN, Schames J, Schames M, King E.
Headache and Pain Center, Hollywood Community Hospital, Los Angeles, CA 90028, USA.
Abstract
The sphenopalatine ganglion (SPG) block is a safe, easy method for the control of acute or chronic pain in any pain management office. It takes only a few moments to implement, and the patient can be safely taught to effectively perform this pain control procedure at home with good expectations and results. Indications for the SPG blocks include pain of musculoskeletal origin, vascular origin and neurogenic origin. It has been used effectively in the management of temporomandibular joint (TMJ) pain, cluster headaches, tic douloureux, dysmenorrhea, trigeminal neuralgia, bronchospasm and chronic hiccup.
PMID: 8949858 [PubMed - indexed for MEDLINE]
Ned Tijdschr Tandheelkd. 2006 Nov;113(11):474-7.
[Spontaneous pain attacks: neuralgic pain]
[Article in Dutch]
de Bont LG.
Universitair Medisch Centrum, Groningen. l.g.m.de.bont@kchir.umcg.nl
Abstract
Paroxysmal orofacial pains can cause diagnostic problems, especially when different clinical pictures occur simultaneously. Pain due to pulpitis, for example, may show the same characteristics as pain due to trigeminal neuralgia would. Moreover, the trigger point of trigeminal neuralgia can either be located in a healthy tooth or in the temporomandibular joint. Neuralgic pain is distinguished into trigeminal neuralgia, glossopharyngeal neuralgia, Horton's neuralgia, cluster headache and paroxysmal hemicrania. In 2 cases trigeminal neuralgia is successfully managed with a neurosurgical microvascular decompression procedure according to Jannetta. Characteristic pain attacks resembling neuralgic pain result from well understood pathophysiological mechanisms. Consequently, adequate therapy, such as a Janetta procedure and specific pharmacological therapy, is available.
PMID: 17147031 [PubMed - indexed for MEDLINE]
Sleep Res Online. 2000;3(3):107-12.
Timing patterns of cluster headaches and association with symptoms of obstructive sleep apnea.
Chervin RD, Zallek SN, Lin X, Hall JM, Sharma N, Hedger KM.
Sleep Disorders Center, Department of Neurology, University of Michigan, Ann Harbor, Michigan, USA. chervin@umich.edu
Abstract
Cluster headaches (CH) frequently recur at the same point in the circadian cycle, often during sleep. They may, in some cases, represent a susceptible individual's response to hypoxemia or other physiological changes induced by obstructive sleep apnea (OSA). If and when this mechanism exists, timing of CH close to the onset of sleep-and therefore OSA-might be expected. We questioned 36 subjects with CH about the times at which their CH usually occurred and about several symptoms known to be predictive of OSA, including habitual snoring, loud snoring, observed apneas and excessive daytime sleepiness. We then used logistic regression to determine whether occurrence of CH in each of six time periods was associated with OSA symptoms. The 23 subjects (64%) who reported CH in the first half of a typical night's sleep also tended to report headaches during the midday/afternoon period. Symptoms of OSA, and in particular habitual snoring, were predictive of both first-half-of-the-night and midday/afternoon CH (p<.05). Thirty-one subjects (86%) reported that their CH were sleep-related, usually occurring during any part of the night or on awakening, but symptoms of OSA were not predictive of this timing pattern. In short, several OSA symptoms showed an association with CH occurrence in the first half of the night but not with sleep-related CH in general. These findings suggest that in some patients, physiological consequences of OSA may trigger CH during the first few hours of sleep and thereby influence the timing of subsequent daytime headaches.
PMID: 11382908 [PubMed - indexed for MEDLINE]
Sunday, November 7, 2010
Facial Pain, Normal Sinus CT scans, Headache, Migraine and TMD
An older study in the Laryngescope is on 104 patients with facial pain who had normal CT scans. Twenty nine of the patients had previous unsuccessful sinus surgery. The patients were approximately 80% women, TMJ disorders are usually (80%) found in female patients.
The study showed " Four percent of patients seen by a neurologist had an unsuspected serious intracranial diagnosis." It is essential that organic neurologic causes are ruled out but the 100 remaining patients had headaches of undetermined causes. Facial pain and sinus pain are a alert for MPD (myofascial pain) and TMD (temporomandibular pain). Treatment of patients with chronic headaches, migraines sinus and/or facial pain is frequently done without a neuromuscular dental evaluation even though NMD has extremely high success rates.
The Trigeminal nerve innervates the sinus cavities. It is often called the Dentist's nerve because the trigeminal nerve primarily goes to the teeth, jaw muscles, jaw joints, periodontal ligaments and is responsible in full or part for most headaches. It also controls blood flow to the anterior 2/3 of the brain thru the meninges.
Correction of underlying neuromuscular problems often allows drug free effective treatment. When CT scans are normal patients with sinus pain and facial pain should always be evaluated by a neuromuscular dentist. Neurologists should evaluate all patients with organic brain disorders but functional treatment is preferred to heavy drug therapy for the majority of patients.
Frequently Chiropracters and dentists can get miraculous results by working together especially NUCCA and A/O (Atlas Orthogonal) chiropracters. The Dentists can correct nociceptive trigeminal nerve input while the chiropracters correct cervical and head posture. Long term correction of those problems usually requires correction of descending conditions associated with improper jaw function.
Laryngoscope. 2004 Nov;114(11):1992-6.
Neurologic diagnosis and treatment in patients with computed tomography and nasal endoscopy negative facial pain.
Paulson EP, Graham SM.
Department of Otolaryngology--Head and Neck Surgery, University of Iowa, Iowa City, Iowa 52242-1093, USA.
Abstract
OBJECTIVE: To determine the helpfulness of specialist neurology referral for patients with facial pain, a normal sinus computed tomography (CT) scan, and normal nasal endoscopy findings.
STUDY DESIGN: Prospective identification of patients and analysis of data approved by the Institutional Review Board.
METHODS: The data of 104 consecutive patients presenting with facial pain, a normal sinus CT scan, and normal nasal endoscopy findings were reviewed. The patients presented to a single rhinologist in a tertiary care institution. All patients were referred for specialist neurologic evaluation and potential treatment. Further information was obtained from a patient survey.
RESULTS: Of the 104 patients, 81 were women and 23 were men. The average age was 46 years (range, 22-85). Fifty-six had clear CT scans, 48 had minimal change, and all had negative endoscopies. Twenty-nine had previous unsuccessful sinus surgery. The average follow-up period was 10.5 months. Forty of 75 patients seeing a neurologist were seen on multiple occasions. Four percent of patients seen by a neurologist had an unsuspected serious intracranial diagnosis. The most common diagnoses were migraine (37%), rebound headache (17%), chronic daily headache (17%), and obstructive sleep apnea (16%). Overall, 58% improved on medical therapy; 60% of those with a clear CT scan improved, and 53% of those with minimal change on CT scan improved (P = .749).
CONCLUSIONS: Facial pain remains a difficult symptom to diagnose and treat in rhinologic practice. Patients often undergo surgery without help. Most patients with facial pain, a normal sinus CT scan, and normal endoscopy findings benefit from neurologic consultation. Serious intracranial pathologic conditions can be excluded and diagnosis-specific pharmacogenetic therapy instituted with improvement in more than 50%.
PMID: 15510029 [PubMed - indexed for MEDLINE]
The study showed " Four percent of patients seen by a neurologist had an unsuspected serious intracranial diagnosis." It is essential that organic neurologic causes are ruled out but the 100 remaining patients had headaches of undetermined causes. Facial pain and sinus pain are a alert for MPD (myofascial pain) and TMD (temporomandibular pain). Treatment of patients with chronic headaches, migraines sinus and/or facial pain is frequently done without a neuromuscular dental evaluation even though NMD has extremely high success rates.
The Trigeminal nerve innervates the sinus cavities. It is often called the Dentist's nerve because the trigeminal nerve primarily goes to the teeth, jaw muscles, jaw joints, periodontal ligaments and is responsible in full or part for most headaches. It also controls blood flow to the anterior 2/3 of the brain thru the meninges.
Correction of underlying neuromuscular problems often allows drug free effective treatment. When CT scans are normal patients with sinus pain and facial pain should always be evaluated by a neuromuscular dentist. Neurologists should evaluate all patients with organic brain disorders but functional treatment is preferred to heavy drug therapy for the majority of patients.
Frequently Chiropracters and dentists can get miraculous results by working together especially NUCCA and A/O (Atlas Orthogonal) chiropracters. The Dentists can correct nociceptive trigeminal nerve input while the chiropracters correct cervical and head posture. Long term correction of those problems usually requires correction of descending conditions associated with improper jaw function.
Laryngoscope. 2004 Nov;114(11):1992-6.
Neurologic diagnosis and treatment in patients with computed tomography and nasal endoscopy negative facial pain.
Paulson EP, Graham SM.
Department of Otolaryngology--Head and Neck Surgery, University of Iowa, Iowa City, Iowa 52242-1093, USA.
Abstract
OBJECTIVE: To determine the helpfulness of specialist neurology referral for patients with facial pain, a normal sinus computed tomography (CT) scan, and normal nasal endoscopy findings.
STUDY DESIGN: Prospective identification of patients and analysis of data approved by the Institutional Review Board.
METHODS: The data of 104 consecutive patients presenting with facial pain, a normal sinus CT scan, and normal nasal endoscopy findings were reviewed. The patients presented to a single rhinologist in a tertiary care institution. All patients were referred for specialist neurologic evaluation and potential treatment. Further information was obtained from a patient survey.
RESULTS: Of the 104 patients, 81 were women and 23 were men. The average age was 46 years (range, 22-85). Fifty-six had clear CT scans, 48 had minimal change, and all had negative endoscopies. Twenty-nine had previous unsuccessful sinus surgery. The average follow-up period was 10.5 months. Forty of 75 patients seeing a neurologist were seen on multiple occasions. Four percent of patients seen by a neurologist had an unsuspected serious intracranial diagnosis. The most common diagnoses were migraine (37%), rebound headache (17%), chronic daily headache (17%), and obstructive sleep apnea (16%). Overall, 58% improved on medical therapy; 60% of those with a clear CT scan improved, and 53% of those with minimal change on CT scan improved (P = .749).
CONCLUSIONS: Facial pain remains a difficult symptom to diagnose and treat in rhinologic practice. Patients often undergo surgery without help. Most patients with facial pain, a normal sinus CT scan, and normal endoscopy findings benefit from neurologic consultation. Serious intracranial pathologic conditions can be excluded and diagnosis-specific pharmacogenetic therapy instituted with improvement in more than 50%.
PMID: 15510029 [PubMed - indexed for MEDLINE]
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