About a year ago a chiropractor referred one of his patients to me. She was complaining of TMJ pain that would start when she woke up in the morning and pretty much last all day, getting worse around the 4pm hour. She works from home at her kitchen table, and her chiropractor was working with her on her posture and how to be more ergonomic, but he could not help her jaw pain.
The first time I met “Anna”, a lovely athletic 28 year old, her resting face was one of worry – her eyebrows were cinched together, her lips were pierced, she had circles under her eyes. This was a person in chronic pain, and, as it was discovered by an oral exam, was from a bad dental habit: teeth clenching.
The American Association of Oral Medicine and the Mayo Clinic would like to combine clenching and grinding into the same problem, but in my experience they truly are two separate issues because they affect the teeth differently. The National Sleep Foundation describes the clinical term “bruxism” (grinding) as something done at night. Grinding is very much also done during the daytime. I should know, I grind my teeth in the car when driving. My definition of grinding is a repeated rhythmic habit of holding the mouth muscles in place and forcing upper and lower teeth to rub against each other. Grinding can start as early as when teeth are coming in. Teeth usually erupt at night, and grinding is considered a way for the mouth to get used to having teeth and using them appropriately when chewing. That being said, grinding teeth as adults can overwork the mouth muscles and, since most of these muscles are connected to the joints, can cause TMJ pain.
Grinding can be caused by misalignment of teeth, but a lot of the time – up to 70% -- this habit becomes a bad habit due to stress and anxiety. WebMD explains, “Not only can severe grinding damage teeth and result in tooth loss, [it can] even change the appearance of your face.” Consistent bruxism creates wear patterns on the teeth similar to patterns on high plush carpeting, grass, or streets. These overused teeth become flatter and shorter by wearing away the outer layer of tooth, otherwise known as tooth enamel. This enamel is as hard as bone, and yet, like bone, does not grow back. The second layer underneath the enamel is a much softer, yellower substance called dentin. Dentin is also much more prone to dental disease: hypersensitivity to cold/hot/sweets; cavities; horizontal fractures. Shorter teeth also affect the bite. People start noticing they are biting their tongues more when eating. Lips can begin to droop on the sides. Cheeks can seem to sag. Why? Because teeth help support the lower third of the face.
“Clenching is simply holding the teeth together and tightening the jaw muscles.” The AAOM says on their website, but, unfortunately, there is nothing simple about it. The pressure from clenching, over time, can cause vertical fractures or “craze lines”, as well as gum recession, tooth divots found at the gumline, muscular soreness, pain, and damage to the jaw joints, or the TMJ. However, clenching can be a cause of a more serious medical issue: sleep apnea.
The American Association of Sleep Medicine explains sleep apnea this way:
Obstructive sleep apnea is a common and serious sleep disorder that causes you to stop breathing during sleep. The airway repeatedly becomes blocked, limiting the amount of air that reaches your lungs. When this happens, you may snore loudly or making choking noises as you try to breathe. Your brain and body becomes oxygen deprived and you may wake up. This may happen a few times a night, or in more severe cases, several hundred times a night.
In many cases, an apnea, or temporary pause in breathing, is caused by the tissue in the back of the throat collapsing. The muscles of the upper airway relax when you fall asleep. If you sleep on your back, gravity can cause the tongue to fall back. This narrows the airway, which reduces the amount of air that can reach your lungs. The narrowed airway causes snoring by making the tissue in back of the throat vibrate as you breathe.
Sleep apnea can make you wake up in the morning feeling tired or unrefreshed even though you have had a full night of sleep. During the day, you may feel fatigued, have difficulty concentrating or you may even unintentionally fall asleep. This is because your body is waking up numerous times throughout the night, even though you might not be conscious of each awakening.
The lack of oxygen your body receives can have negative long-term consequences for your health. This includes:
There are many people with sleep apnea who have not been diagnosed or received treatment. A sleep medicine physician can diagnose obstructive sleep apnea using an in-lab sleep study or a home sleep apnea test. Sleep apnea is manageable using continuous airway pressure therapy (CPAP), the front-line treatment for sleep apnea, oral appliance therapy or surgery.
Obstructive sleep apnea in adults is considered a sleep-related breathing disorder. Causes and symptoms differ for obstructive sleep apnea in children….
Clenching teeth can be considered a defense mechanism. When asleep, holding the teeth in position subconsciously prevents the lower jaw to fall back, potentially collapsing the airway.
As a doctor of dental surgery, my responsibility is not simply to see teeth problems and fix them. As a doctor of dental surgery, my responsibility is to search for the why. Why did the lower right second molar fracture? Why is the upper left front tooth mobile? What is causing the upper and lower front teeth to splay out? If my patient is not in pain but is exhibiting these signs/symptoms of grinding/clenching, I will have a lab make a custom lower two-ply mouthguard. If said patient does not believe they are grinding and/or clenching, I will recommend a store-bought mouthguard. These “boil and bites” do not fit as well, and are only one layer of thermoplastic material. However, at about $20 online, it is a great way to see what kind of bad habits the mouth is performing overnight. Lines across the biting surface of the mouthguard will show grinding. Pin point divots will show clenching. Sometimes both will appear, and it doesn’t take long to be able to see them.
If my patient is in pain, like Anna, not only will a custom-made lower mouthguard be part of the treatment plan, but an occlusal analysis will be performed as well. The clinical term for bite is occlusion, and by taking a no-radiation occlusal scan provides real-time occlusal measurement - revealing the level and timing of force on individual teeth and the occlusal stability of the overall bite. Even after orthodontics, like Anna had, no one’s bite is perfect. And, for every action there is an equal and opposite reaction, meaning that teeth move up and down and side to side when chewing. Microns, but they do have movement. Because of this, teeth never really come back to where they were originally. Retainers and mouthguards do help to prevent abnormal tooth movements.
Second step will be to recommend a sleep study. I have their medical insurance reviewed by a local small business. My office is charged a small fee, and this company then reviews what type of policy my patient has. Some policies allow for home sleep visits as mentioned above, but some policies require the sleep study to be performed at a sleep center, either independent or affiliated with a hospital they are in network with. This test will then be reviewed by a sleep physician. Results will show if they are primary snorers, or have mild, moderate, or severe sleep apnea.
I myself am a primary snorer, so I made an appointment with my ENT because I am a nasal snorer. Turns out my nose bones, or turbinates, are literally touching each other, when there should be spaces in between on either side to allow for primary nasal breathing. I will have to have surgery, eventually, to have either side of these bones reduced so I can breathe better when I am asleep. I refer my primary snorer patients to an ENT if they do not already have one to see if they have my problem and/or have deviated septums. A deviated septum can be another cause for not breathing through the nose, causing the mouth to open at night to breathe, thus snoring.
Snorers, mild and some moderate sleep apnea patients can be approved by their sleep physicians for a MAD or a mandibular advancement device. A medical device made by a dental lab and paid for by medical insurance, MAD’s help keep the lower jaw forward when asleep to allow a patent or open airway. The gold standard, however, is the CPAP machine described above. Some medical insurances will not allow a MAD to be made unless the patient is truly unable to use the CPAP without some sort of distress. Claustrophobia and PTSD are examples of patients who cannot tolerate the CPAP nasal and/or mouth mask to provide the necessary oxygen lost when asleep. Please remember, sleep apnea is a CHRONIC condition, like diabetes, and it is very difficult to be “cured”, even with weight loss/exercise. Unlike diabetes, weight loss will not help stop one’s bite or bad oral habits.
Anna saw an ENT first, who also recommended a sleep study based on our combined findings. Anna first had a home sleep test, but she wanted further testing because it said that she had moderate sleep apnea. She then had a second sleep test at her local hospital which confirmed the home sleep test’s findings. Anna couldn’t believe it. She was physically fit, and didn’t have any allergies, asthma or other nasal conditions preventing her from breathing properly. How could Anna have this disease? 16 years ago she, along with most of her (and my) generation had her four second premolars, or bicuspids, removed from the middle of her mouth, bringing her teeth back to make them straight. In other words, Anna’s orthodontic treatment kept her oral airway at the age she started braces – age 12.
There is a reason why the terms “practicing law” “practicing medicine” and “practicing dentistry” exist. Practice is to perfect our treatment for better and better care. The orthodontics that is being practiced now, for the most part, is not the orthodontics we had as teens. Instead of constricting mouths to bring teeth together, orthodontic intervention is started at a younger age to help the mouth develop appropriately. Dentists are striving for a generation where braces are not needed because early intervention helped the teeth come into the mouth in alignment naturally. Of course there will be exceptions, but the goal is to help widen the roof of the mouth, or palate, allowing for more space for the size of the adult teeth as the child grows and develops. Additionally, there are some studies that show breast feeding up until their first birthday naturally creates wider palates.
Anna’s insurance allowed for a MAD to be made as her primary treatment to counteract her moderate sleep apnea. A MAD is having an upper and a lower mouthguard connected either in the front or on either side. Some are rigid, some have flexibility. Since Anna is a clencher, I made her a rigid one so her teeth didn’t have to hold her lower jaw forward anymore. The appliance would do it for her when asleep. This appliance also relieved her mouth and facial muscles from working so hard. Anna’s ENT and chiropractor were notified of her diagnosis and treatment.
The results were instantaneous! Pain-free, Anna was able to wear the appliance without difficulty, and, for the first time in years, she was able to sleep through the night with her mouth and face relaxed in a position to allow her to breathe normally. At three months, per protocol, she had another on-site overnight sleep study wearing her MAD and she passed with flying colors. I will continue to monitor the wear of the appliance at her oral hygiene appointments, as well as do yearly occlusal analysis scans to make sure her bite is stable and healthy.
Not everyone has such a great immediate success as Anna. Sometimes another type of MAD needs to be made to be more comfortable. Some do not pass their second sleep study and will have to wear the appliance and the CPAP for best quality of sleep.
Bottom line: not all oral problems are simple dental issues. Patients, I believe, have better outcomes when those of the dental and medical communities combine forces. Seek out dentists who are open to discuss problems with physicians and chiropractors and vice versa. Oral care is overall care. How we treat the mouth truly affects the rest of the body, and how we treat our bodies can very much affect our mouths.
https://www.webmd.com/oral-health/guide/teeth-grinding-bruxism#1
https://aasm.org/clinical-resources/patient-info/
http://sleepeducation.org/essentials-in-sleep/sleep-apnea
https://www.tekscan.com/products-solutions/digital-occlusal-analysis
https://journals.sagepub.com/doi/abs/10.1177/089033449801400203?journalCode=jhla
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