by Dr. Jagdeep Bijwadia, CMO – SomnoMed
TMJ concerns are some of the most common responses I receive from physicians when asked about their reservations with oral device treatment goes something like this:
“I know the evidence for effectiveness is convincing and I would prescribe more oral devices but I worry about TMJ and side effects.”
Many sleep physicians consider the presence of TMJ symptoms as a contraindication to proceeding with a referral for an oral device. In today’s article, I will examine the issue of TMJ in more depth, and in a future article, I will review other reported side effects.
TMJ symptoms, present in about 20-30% (ref 1) of the general population. include pain, restricted mandibular movement and noises or clicking during jaw movement. Although symptoms are not life threatening, they can be reduce quality of life and symptoms can be chronic and difficult to manage.
Common treatments include occlusal splints, cognitive and behavioral treatment and pain medication.
Two TMJ Studies with Patients having Oral Devices
Two prospective studies that examine the issue of TMJ in patients treated with oral devices for obstructive sleep apnea are instructive.
- The first is a prospective study over 3 years following 54 patients with OSA treated with an oral device. (ref 2) TMJ changes were found as joint sounds with a short-term decrease and subsequent recurrence. No significant radiologic changes were found and they concluded that oral device treatment might induce some changes in TMJ but these changes seemed to be less harmful than previously reported.
- Another study published in 2009 was a prospective study following 34 patients over 6 months. (ref 3) The conclusion was that oral devices do not cause impairment to the TMJ. To the contrary, the study demonstrated that the intensity of TMJ decreased significantly during OA therapy.
In a recent review article published in Sleep (ref 3) the authors conclude temporomandibular disorder symptoms of pain and impairment in the initial treatment period tend to decrease over time and resolve after 6 to 12 months in the majority of patients.
Sleep physicians should be aware that as the oral device is titrated in the first few weeks of patient wear, muscle discomfort is relatively common and transient as the patient acclimatizes to treatment. Additionally, TMJ dysfunction as confirmed by prospective studies is – in fact – uncommon.
Conclusion: The preponderance of evidence suggests that TMJ symptoms should not stop you from referring your obstructive sleep apnea patients to a well-trained dentist.
- Guo C, Shi Z, Revington P (2009). “Arthrocentesis and lavage for treating temporomandibular joint disorders”. The Cochrane Database of Systematic Reviews (4)
- Long-term side effects on the temporomandibular joints and oro-facial function in patients with obstructive sleep apnoea treated with a mandibular advancement device. Knappe SW, Bakke M, Svanholt P, Petersson A, Sonnesen L. J Oral Rehabil. 2017 Jan 17.
- Giannasi LC, Almeida FR, Magini M, et al. Systematic assessment of the impact of oral appliance therapy on the temporomandibular joint during treatment of obstructive sleep apnea: long-term evaluation. Sleep Breath 2009;13:375-81.
- Oral appliance treatment for obstructive sleep apnea: An Update
Sutherland K, Vanderveken OM, Tsuda H, Marklund M, Gagnadoux F, Kushida CA, Cistulli PA. J Clin Sleep Med. 2014 Feb 15;10(2):215-27.
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As Chief Medical Officer of SomnoMed North America, Dr. Bijwadia is charged with helping to define strategy for the medical initiative, build clinical research educational programs and create collaborative bridges between physicians and dentists. In addition to his leadership of SomnoMed, Dr. Bijwadia has an active private clinical practice in Saint Paul MN. He previously served as Attending Physician at HealthPartners Medical Group (HPMG), where he was the Department Head and Director of the Sleep Medicine Center before stepping down to take the CMO role at SomnoMed. He holds a faculty position as Assistant Professor in the Department of Pulmonary Critical Care and Sleep Medicine at the University of Minnesota where he served as Director of the Sleep Program until 2012.
Dr. Bijwadia earned his medical degree and did his internship and residency at Mumbai University. He then moved to the United States, where he completed his internship and residency at Nassau University Medical Centre at the State University of New York, where he was named Chief Resident of Internal Medicine in 1991. Dr. Bijwadia completed a Fellowship in Pulmonary and Critical Medicine at the University of Southern California. He is board certified in Internal Medicine, Pulmonary Diseases, and Sleep Medicine. He completed the Executive Course at the Physician Leadership College at St. Thomas University, Opus College of Business in Minneapolis, Minnesota in 2011 and Health Insurance Executive Certification at the American Health Insurance Plans and Kellogg School of Business. He also completed the Executive MBA Program at St. Thomas University Opus College of Business.