In several studies, a majority of TMD patients have reported unrefreshing sleep and furthermore that poor sleep quality and symptoms associated with TMD have a bi-directional relationship. Pain-related awakenings from sleep have been shown to have a profound negative effect upon the intensity and severity of masticatory myofascial pain and pain threshold.1-3 A polysomnographic study studies the prevalence of sleep disorders in TMD patients revealed that 45% of the population of patients studied were diagnosed with one sleep disorder and 26% with two sleep disorders.1 A population of patients whose primary subjective complaints of nighttime teeth grinding were found to have a prevalence of sleep-related breathing disorders, specifically obstructive sleep apnea, of 70%.7 How often do we hear such complaints from many of our non-TMD or sleep disorder patients? It is interesting to note that a repeated prevalence study looking at a general dental population found that 5% of all female and 32% of all male patients who visit their hygienist for recare are likely to have an undiagnosed SRBD.9 The table above is a summary of the findings of this study, which validates the results of a previous study performed by the same team of researchers. This statistically significant information should is very sobering and alarming considering that the average dental (or medical) student receives 3 or less hours of formal education on the subject of sleep during the entire 4 years of undergraduate Dental or Medical school. Practicing dentists share the burden of identifying such patients because as things are, currently, the patients’ primary care physician is currently no more likely to be prepared to identify patients at risk for potentially life-threatening sleep-related breathing disorders. Herein is presented such a case. The patient presented here, has had multiple medical problems, among them complaints of TMD. Many of her medical problems, which were previously addressed pharmacologically or with reassurance only, fell into the category of “Functional Somatic Symptoms”. The adverse physical, emotional, and economic toll that her symptoms were having on the quality of her life was significant. Had it not been determined that the litany of physical complaints were likely comorbidities of another problem, namely, sleep-disturbed breathing, the outcomes of treatment would have been tragically insignificant. The outcome of this case, however, was quite the opposite and will continue to positively impact the well-being of this patient for the rest of her life because we were able to understand that her TMD symptoms were but a comorbidity of a SRBD, not a stand-alone problem.
Case Study: “TMJ Pain of 5 years duration.” Chief Complaints Meet LY; she is a 46 year old female who presented to our office with the following Chief Complaints: 1. TMJ pain & clicking noises 2. Facial pain - “both sides of my face”
History Of Present Illnesses LY reports the onset of her symptoms occurred approximately 3 years ago. She also recalls that about that time that she began to awaken in the morning with tight jaws. She also reports that she was also began taking Adderall at that time for her “attention problems” and “fatigue” and wondered if her jaw clenching and taking the medication were related. LY then visited her general dentist for help with her “TMJ” and “facial pain” she was provided with an intraoral splint; specifically a mandibular flat-plane appliance, which she was advised to wear at night; this splint seemed to make her symptoms worse. She continues to use it but only when her pain is acute and intolerable.
Past Medical History LY has been under the care of a rheumatologist for a number of years for symptoms consistent with fibromyalgia. She was also diagnosed with psoriatic arthritis. Additionally, she has more recently been experiencing symptoms which her primary care physician has described as heart “murmurs” as you can see from the segment of the patient questionnaire (PQ) LY often awakens with her chest pounding and with chest pain. An EKG was performed and was considered normal. Since the EKG was normal, her physician advised her that her palpations may likely be “stress or anxiety” related and prescribed a number of medications to help control symptoms as seen below in PQ: medications. Upon review of the entire patient questionnaire, it is clear that LY is and has been bothered by problems with sleep to the point that she had then been awakening with chest pain, sore jaws and often bothered by nocturia and diaphoresis (she revealed this at a later date during additional discussions). Symptoms of sleep disorders, excessive daytime sleepiness, headaches and other symptoms common to patient with TMD are often not volunteered by the patient because they do not often see the relevance. Mindful now that these afflictions often co-exist, we did indeed assess LY for risk factors for SRBD. I will also add at this time, as you can see from the responses in her questionnaire, that LY also had complaints of “restless legs”. WWW.SLEEPGS.COM PAGE 19