Melanie Asked:   Can severe TMJD cause burning/stinging-like pain in various places in the head/face/ears as well as  similar sensations in extremities? I also have an elevated ERthr.sed rate and heightened pain in several areas but am a little young for temporal arteritis, though am having blurred vision at times as well?

Dr Shapira response:

Melanie, never rule out Temporal Arteritis due to severe problems can be associated with it.  TMD can be related to pain, burning and stinging in head, neck and upper extremities but not directly responsible for stinging in lower extremities.

Indirectly it can be implicated due to autonomic nervous system.  An SPG block is a simple relatively non-invasive method to evaluate connection.  Lidocaine is applied topically over the sphenopalatine ganglion in the nose.  

When nociceptive inputs from the trigeminal nerve are amplified in the reticular activating system of  the central nervous system they can predispose the entire body  to lower pain thresholds.

TMD problems also have a strong correlation to anxiety disorders that also predispose patients to entire body symptoms.

Burning is a symptom that is associated with nerve irritation or neuritis.  Stinging is often seen both with myofascial pain as well as pain associated with irritated nerves.

Temporal Arteritis, Cranial Arteritis or Giant Cell Arteritis (Neck or upper quadrants) is an inflamatory condition that can lead to blindness and other serious consequences.  Being evaluated for Temporal Arteritis has no down side.  Temporal Arteritis usually affects vessels that are branches of the carotid arteries.  

These problems are considered Idiopathic or cause unknown but they are believed to be inflamatory in nature.

Common symptoms of Temporal Arteritis include unilateral throbbing headaches and tenderness of the scalp to touch.  It is not uncommon to experience flu like symptoms with Temporal Arteritis including fever, generalized aching, loss of appetite, weakness, severe tiredness and muscle pain in upper quadrants.

Vision problems include blurred vision, double vision and partial loss of vision or blindness.  An elevated Sed rate should be considered a warning sign.  While it is possible that most of these symptoms are from a TMJ Disorder it is essential that a complete medical diagnosis rule out organic disease.

Please visit my new website http://www.thinkbetterlife.com for more information on TMJ disorders and treatment of chronic pain utilizing Neuromuscular Dentistry as part of comprehensive diagnostic work up and treatment plan.

Chronic pressure and pain in the nose. Is this a "jaw problem"?

Kunai:

I suffer from chronic pain and pressure in my nose. Can this symptom be caused by a jaw joint problem?

Dr Shapira response: The pain and pressure in your nose may not be due to a "jaw joint" problem but may be referred pain from cranial muscles and/or a Trigeminal Nervous System problem. Neuromuscular Dentistry addresses noxious input into the trigemino-vascular system that may be the underlying cause of your pain.

Kinai: I suffer from chronic light sensitivity vision problems, and I suffer from chronic pain and pressure in my nose.

I also suffer some other symptoms (eye pain, etc.), as well. I had a brain MRI and a Orbit/Eye done in the past, but the results came back negative ("normal").

Dr Shapira: Normal results are always good. These sound like autonomic cephalgia's and may respond well to Sphenpalatine ganglion blocks that can be self administered with a cotton tip aplicator into the nose at home. Many patients have miraculous results from this rather innocuous treatment while others see no benefit.

I have many patients with diverse problems dissaper with just neuromuscular orthotic.

VESTIBULAR MIGRAINE; THE SIGNS AND SYMPTOMS HAVE LARGE OVERLAP TO TMJ (TMD). ARE VESTIBULAR MIGRAINES BEST TREATED BY NEUROMUSCULAL DENTAL ORTHOTIC

A recent article in HEADACHE (June 2011)"Migraine and Vestibular Symptoms-Identifying Clinical Features That Predict "Vestibular Migraine" looks at patients who have an overlap of vestibular symptoms, such as lightheadedness, unsteadiness, vertigo, balance disturbance and headache.

The study showed just under half of the patients had onset of pain and vestibular symptoms together. This is frequently seen in patients withcraniomandibular neuromuscular disorders and usually responds extremely well to a neuromuscular orthotic, use of ULF TENS, Trigger point injections, spray and stretch elimination of TP's and SPG (Sphenopalatine Ganglion) Blocks.

NEUROMUSCULAR DENTISTRY SHOULD PROBABLY BE A FIRST LINE TREATMENT FOR PATIENTS EXPERIENCING VESTIBULAR SYMPTOMS AND HEADACHE OR MIGRAINE AFTER ORGANIC DISEASE IS RULED OUT.

TMJ DISORDERS HAVE LONG BEEN CALLED "THE GREAT IMPOSTER" because they mimic so many other disorders. All patients with vestibular symptoms and head or neck pain shoud read "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" IN SLEEP AND HEALTH JOURNAL.
http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor


The article's conclusions are not diagnostic at all. They cover episodic, acute onset and chronic disorders. The authors stated "Vestibular migraine is a heterogeneous condition with varying symptomatology. As with migraine itself, symptomatic expression varies along a spectrum that extends from episodic to chronic. As the histories of many of the patients we evaluated would not meet current International Classification of Headache Disorders criteria, we suggest that new criteria which account for the heterogeneity and natural history of the disorder may be required to adequately diagnose and treat those who suffer from VM"


Headache. 2011 Jun 7. doi: 10.1111/j.1526-4610.2011.01934.x. [Epub ahead of print]
Migraine and Vestibular Symptoms-Identifying Clinical Features That Predict "Vestibular Migraine"
Cohen JM, Bigal ME, Newman LC.
Source

From Roosevelt Hospital, Headache Institute, New York, NY, USA (J.M. Cohen and L.C. Newman); Merck, Sharp & Dohme Corp., Whitehouse Station, NJ, USA (M.E. Bigal).
Abstract

Background.- Migraine and symptoms that may suggest a vestibular disorder (referred to herein broadly as vestibular symptoms-VS) often co-exist. In part due to a lack of standardized diagnostic criteria, this relationship remains unknown to many physicians. Objective.- To determine common clinical features that may be associated with "vestibular migraine" (VM). Methods.- We retrospectively reviewed charts of patients diagnosed with VM at a headache center. In this group we recorded certain demographic and clinical features related to their disorder, including the most common triggers of the VS and the specific characteristics of the symptoms that suggested VM. Results.- Our sample consisted of 147 patients (68% women, mean age = 45 years, 39% with aura). Migraine onset preceded the onset of VS by a mean of 8 years. A total of 62 patients (42%) had gradual onset of VS, while in 48 (33%) symptoms began suddenly. The most commonly reported symptoms that led to the diagnosis of VM were: unsteadiness (134; 91%), balance disturbance (120; 82%), "light-headedness" (113; 77%), and vertigo (84; 57%). VS and headache occurred concomitantly in 48% of patients. A total of 67 (47%) patients had VS that were chronic from onset, 29 (21%) had episodic symptoms, and in 46 (32%) the VS had evolved from episodic to chronic (with an average duration of 7.04 years required for this evolution to occur). Conclusions.- Vestibular migraine is a heterogeneous condition with varying symptomatology. As with migraine itself, symptomatic expression varies along a spectrum that extends from episodic to chronic. As the histories of many of the patients we evaluated would not meet current International Classification of Headache Disorders criteria, we suggest that new criteria which account for the heterogeneity and natural history of the disorder may be required to adequately diagnose and treat those who suffer from VM.

© 2011 American Headache Society.

PMID:
21649658
[PubMed - as supplied by publisher]

Related citations

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]

CLUSTER HEADACHE AND TMJ DISORDER

QUESTION: My fiance has been having these headaches (her doctor thinks they are cluster headaches) for months now. The headaches are intense and always have the same focal point in the front left part of her head. She also has chronic neck pain and has been diagnosed with TMJD.

DR SHAPIRA: I WOULD STRONGLY RECOMMEND HAVING AN EVALUATION WITH A TRAINED NEUROMUSCULAR DENTIST. THAT IS A COMMON AREA FOR MANY TYPES OF PAIN RELATED TO NECK AND JAW PROBLEMS. REFERRED MUSCLE PAIN FROM THE TEMPORALIS MUSCLE, MASSTER MUSCLE ,STERNOCLEIDOMASTOID OR TRAPEZIUS MUSCLES COULD EASILY BE A CAUSE OF THE PAIN. MOST PAINS ASSOCIATED WITH TMJ DISORDERS ARE MUSCULAR IN ORGIN.

CLUSTER HEADACHES ARE MEDIATED BY THE TRIGEMINAL NERVE AND CAN BE A SECONDARY EFFECT OF TMD OR NEUROMUSCULAR PROBLEMS.

TMJ DISORDERS ARE OFTEN CALLED "THE GREAT IMPOSTER" BECAUSE THEY ARE SO OFTEN MISDIAGNOSED OR APPEAR TO BE A DIFFERENT PROBLEM SUCH AS CLUSTER HEADACHES.

CLUSTER HEADACHES FREQUENTLY RESPOND WELL TO OXYGEN TREATMENTS AND/OR SPG OR SPENOPALATINE GANGLION BLOCKS.

Neuromuscular Dentistry treats Migraines, Tension-Type Headaches, Chronic Daily Headaches and Sinus Pain related to Trigeminal Nerve and TMJ Disorders

Chronic pain is frequently multifactorial in nature. Neuromuscular dentistry has been very successful in treating TMD, Migrines, Tension Type headaches and other disorders. Frequently it is not a total cure but 50-80% reduction in pain is usually attained within several visits. There are many disorders and symptoms associated with TMD including:
Ear Aches or Otalgia
Sinus Pain
TM Joint Clicking and Popping
Ear Stuffiness or Eustacian Tube Dysfunction
Dizziness
Vertigo
Temporal Pain
Occipital Headaches
Morning Headaches
Sleep Apnea
Snoring
Sore Throats
Neck pain or stiffness
Feelings of a foriegn object in the throat
Pain in or behind the eyes
Scalp pain or feeling like your hair hurts

Most of these symptoms are mediated by the Trigeminal nerve and the Trigeminovaqscular system. These Nerves also connect to facial nerves, occipital nerves, glossopharyngeal nerves and to the autonomic nervous system. What happens in these nerves cause biochemical changes in the brain. Recent stuies shown the neural plasticity can create permanent changes in the brain. If chronic pain is the stimulus it can lead to central sensitization.

Changes inthe brain can be reversed over time but the exact amount of recovery will vary with individual patients genotypes, how long the pain has been present , other comorbidities that the patient carries. Some patients experience immediate3 and almost miraculous pain relief while others have a slower longer version of recovery. I always tell my patients to work for 50 - 80% improvement in pain. That is then our new starting point and we again seek 50 - *0 % reduction in pain.

There is "no cure" for long term chronic pain because lives have been changed due to living with pain. A cure would require a do-over of the years you had pain. There are no do-overs therefore we look to improve your future quality of life to the maximum. Some patients still have to do exercises or watch diet or even continue different medications. Other patients have remarkably and incredible improvements as described by Dr Barry Cooper in Cranio where he talked about "overwhelming success". This is why we use a diagnostic orthotic as the first step of treatment. We try to avoid permanent changes until the patient feels substantially improved. This is not a judgement that any doctor can make for the patient. It is a subjective evaluation by the patient themselves. Only the patient knows how well or poorly they are doing. We may have objective data showing physical improvement but the final test is have we improved or dramatically improved the patients quality of life. If the answer is yes we can talk about long term stabilization. The diagnostic orthotic is the first phase of treatment for those patients.

If the patient has improvement, whether it is only 25-30% or if they are at 80-90% the decision that the diagnostic orthotic treatment is successful remains the patient's. If they do not feel sufficiently improved they should not feel pressured into continuing treatment or making permanent changes. You should treat the diagnostic orthotic like a CAT SCAN or MRI but instead of images we have improvement in the quality of life. If improvement is not sufficient then a diagnostic approach should continue.

While NEUROMUSCULAR DENTISTRY IS REMARKABLY EFFECTIVE AT TREATING MANY CONDITIONS THERE ARE OTHER CONDITIONS THAT ARE NOT RELATED TO THE TRIGEMINAL NERVOUS SYSTEM, MYOFASCIAL PAIN OR JAW JOINTS.

TMJ disorders are frequently called The Great Imposter ("SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" IS A MUST READ FOR ANY PATIENTS WITH MIGRAINES OR TMD http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor) but we must remember that other disorders can also masquerade or more frequently coexist with these problems. Many times a diagnostic orthotic relieves many of the symptoms but the remaining symptoms have a different cause. The expression that "you can't see the forest for the trees" applies. When the majority of symptoms are relieved you now find that you can identify a particular problem that was lost in a long and winding maze of symptoms. As NMD unravels the maze a specific problem can now be identified and treated.

Sleep Apnea Appliances Can Help Resolve TMJ Clicking and Improve Headache Symptoms

Patients with morning headaches usually have either TMJ disorders or Sleep Apnea. Sleep Apnea can be treated with CPAP or an Oral Appliance. Patients who have TM Joint clicking and are undergoing treatment for headaches or TMD can benefit in several ways from having a night-time apnea appliance and a daytime neuromuscular orthotic.

A problem that is sometimes encountered with oral appliances for sleep apnea are undesired bite changes. These changes can actually be helpful when treating TMJ clicking and popping and headaches. The bite changes that occur are actuallly the healing of the TM Joint. The jaw usually postures forward unloadding the retrodiscal lamina of the TM Joint that is compressed in patients with clicking. The retrodiscal lamina rehydrates and does not let the condyle go into retrusive pathology which serves to stabilize the disk.

The Daytime appliance allows this position to stabilize and heal. In patients who are not undergoing treatment exercises are done to prevent this healing from occuring. The joints will frequently heal if placed in a healthy position. A recent paper showed no damage to the joints with sleep appliances.

The American Academy of Sleep Medicine recommends that dentists fitting patients with oral appliances for sleep apnea be well versed in treating TMJ disorders. There are many good reasons for this recomendation. Dentists who do not uderstand how bite changes affect the joints and the muscles as well as head posture can create difficult problems they do not have the expertise to treat. Please check my I HATE CPAP website (http://www.ihatecpap.com) for more information about the dangers of sleep apnea and on how oral appliances are used in treating sleep apnea.

What to expect at your headache or TMJ disorder consult.

When you see a doctor for the first time for a TMJ disorder you should expect to have to give lengthy and detailed history. There are usually forms to fill out. What is important is that this history should be reviewed with the patient and how the history relates to the current problem should be explored. The initial consult is usually at least 45 minutes but can last for several hours.

In most cases the doctor can provide instant relief of some of the painful conditions by deactivating muscular trigger points. This is usually done by use of a technique called Spray and Stretch that utilizes a vapocoolant spray. These techniques were developed by President Kennedy's personal physician Dr Janet Travell. In most patients it is possible to connect their symptoms to their history in an understandable fashion.

If there is a acute close-lock of the TM Joint time is of the essence and immediate reduction is best if possible. Prescribing anti-inflamatories should never take the place of attempting to reduce an acute disc dislocation.

Permanent and/or irreversible treatment should rarely be the initial treatment. Adjusting the teeth or doing equilibration of the back teeth should be avoided when there s acute muscle spasm. The exception is if a recently placed restoration is in hyperocclusion and percipitated the problem. It should be carefully evaluated because acute spasm can change the bite.

A thorough examination of the muscles and joints is usually performed before initiating treatment. A Neuromuscular Dentist will usually take impressions and a bite utilizing TENS (transcutaneous electrical neuro stimulation) as well as EMG and computerized mandibular scans. This information helps the dentist understand all aspects of the problem before initiating treatment.

Many insurance companies deny coverage of TMJ disorders and Neuromuscular diagnostic work-ups. This is done to "save money" but in reality it has a heavy toll in the quality of patients lives and their future health and welfare. Insurance companies are not in the business of caring for patients. Insurance companies are in business to make money for their shareholders. The larger the premiums they collect and the less they pay in benefits the better the bottom line. A healthy bottom line is the primary concern of insurance companies. These companies are in business to creat profit and shareholder value. The executive of insurance companies make millions of dollars in bonuses for increasing profitability. Unfortunately for patients increasing profitability usally is done by denying patients medical benefits. The more effective an insurance company is in reducing payments for care the more profitable they become.

The insurance companies often use terms such as reasonable and customary to explain why patients are not given the coverage they were promised. I have been treating sleep apnea with oral appliances for close to 30 years. In the early years I was the only dentist in the state of Illinois doing this type of treatment. I would still receive letters telling me my fees were more than "usual and customary" even though I was the only doctor doing these treatments.