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** TMJ (Jaw Dislocation) and PAP Masks.. **

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** TMJ (Jaw Dislocation) and PAP Masks.. **

Postby AlryTeaThen » Tue Feb 12, 2013 4:19 pm

Hi,

My name's Chris.. =)

I have had a bi-pap machine for just over 2yrs and recently started having problems with my jaw dislocating on the left side..

A couple of months ago I started wearing my mask (mouth and nose) head straps tightly and have noticed my jaw is now clicking and popping - a few days ago it started "dislocating"..

Unfortunately, I am just now realizing (perhaps years of brain damage caused by severe sleep apnea is the culprit - a tad bit SLOW! =) ) that my jaw dislocation is most likely caused by my mask..

Anyone else have experiences with "TMJ" (Temporomandibular Joint Syndrome) as a result of wearing a CPAP mask?

What kind of treatment did you seek?

Was the problem solved?

Any help/input appreciated.. =)

* (I have an appointment with my sleep centre this coming week to discuss the "TMJ" problem..)


Thanks Much!
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Re: ** TMJ (Jaw Dislocation) and PAP Masks.. **

Postby GmaFoley » Tue Feb 12, 2013 4:30 pm

I have had TMJ before my CPAP experiences but my dentist made me a mouth piece to wear so my teeth stay where they should be... Find a dentist that works with TMJ..
ResMed S-9 Autopap with humidifier, Mirage Quatro FX for Her (Nasal), Quattro Air - FF
The Lord walks by my side, step by step, day by day...
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Re: ** TMJ (Jaw Dislocation) and PAP Masks.. **

Postby snuzyQ » Tue Feb 12, 2013 6:37 pm

Hi AiryTeaThen and welcome to the Forum.

Yes...This phemoena has been well-documented in the science journals and this happened to me as well. Here is the issue with this: The greater part of the present medical community believes that TMJ syndrome is a psychosomatic disorder and not a functional one. Most of them will be very quick to agree with you that you have suffered brain damage from years of untreated severe apnea...and will want to refer you into psychiatric care!

You and I KNOW that our problem is functional...caused either by pressures from our headgear AND/OR the pressures from our therapy (yes...even the higher CPAP pressures of 11cm and upwards can move the TMJs around a bit). My sleep centre acknowledged this, but had no advice other than to refer me back to my regular doctor. My regular doctor concluded that there must be something anatomically wrong with me...so...he wanted to send me to an ENT surgeon for a review and scans before likely surgery. (Those of us who get TMJ syndrome from our CPAP masks are actually anatomically predisposed to this.) OSA is primarily an anatomical issue, too. The doctors see this as an opportunity to potentially kill 2 birds with one stone. Unfortunately, the surgery does not kill either of the birds...and often makes matters much worse for the patient (the surgical success statistics bear this one out).

Here is the catcher: Your insurance company will cover all of the above. Your insurance company will NOT cover TMJ syndrome or any/all treatments for it. So, if you choose any other course of treatment for your problem, other than the one I have just stated, you will have to pay for it out of your own pocket. This will also be the case if any of your present doctors gives you a diagnosis of TMJ syndrome...your health coverage will simply disappear with regards to any treatment for it that follows.

Here is what I did: My pain HAD to be addressed for me to continue with my CPAP treatment. I also have severe apnea, so CPAP treatment is not optional for me...I MUST have my CPAP. My first step was to thank my doctor kindly for the generous offer of surgery, then told him I would seek the outside counsel of a myofacial disorder specialist dentist to find something that would allow me to continue with my CPAP treatment. I put this in writing so that there would be a paper trail. I then went to my TMJ specialist...a dentist who treats folks for TMJ, and gave him my history of sleep apnea CPAP, ear aches, jaw pain and the works. He determined that I would not be able to tolerate the standard MAD, (Mandibular Advancement Devices). However, his standard treatment for this problem is a custom made MAD called a TwinBlock appliance, built to support the TMJs while the lower jaw is placed in a fixed, fully-advanced position. I wear this device at night with my CPAP mask. It is amazingly comfortable and it completely took away my pain! I looked forward to masking up from my very first night with it.

The key to remaining pain free is to have a day time device that holds the jaw in the night time position all day long. This was accomplished by the use of crozats...two tiny appliances, one uper and one lower to keep my jaw stabilized and the TMJs at rest. These were much harder to adjust to as one must relearn how to eat, talk, laugh and sing with the crozats in place. The tips of the crozats are my grinders for eating. At first, my appearance made me very unhappy, but I relaxed, realizing that it would take time for my facial muscles and lips to relax into this new strange position. After two weeks, most folks could not even tell I was wearing an oral appliance and my jaw looked normal, not portruded at all. It will take at least 2 years for my teeth to grow into my new bite. I must wear the crozats full time during the day until then. I clean them after eating with cool water and a toothbrush, nothing else.

My CPAP data improved dramatically from the very first night of oral appliance therapy. I emailed my sleep centre with the one-week data which followed, and my sleep doc reduced my pressures from 14cm down to 10cm. My TMJ specialist says that he can't be sure quite yet, but, in time, I might be able to discontinue CPAP altogether because my oral appliances are so effective in reducing my apneas. This, of course, would have to be confirmed by a new sleep study with device in place. If my sleep doc recommends I discontinue the CPAP, I would be followed by a new sleep study each year to make sure my treatment needs had not changed. In the meanwhile, my coverage for CPAP supplies would end the day I stopped my CPAP.

The total cost for the two appliances was $1,200. I pay an additional $260 for each of the adjustments and there are 3 of these during the first year of treatment, most likely 2 in the second year. Once the day time device is no longer needed, I will need one adjustment for the night time device per year. The night time device will last me at least 10 years as I am not a bruxer (I don't grind my teeth) before I will need to replace it. I am 60 years old now...I may run through 3 more devices in my remaining lifetime.

The law requires all health insurance companies to cover any condition which is caused by any of their doctors' prescribed treatments. I know this. My health insurance company is required to pay my bills for these oral appliances. They will not like this and will fight me like tigers. It will be a total knock-down-drag-out fight and I will have to be very patient and persistent to perservere. I will not start this fight right now. I need all my energy to get better from my sleep apnea and to make my therapy work for me. In a few months, perhaps, I will gather together my ammunition and start in on this. Or...maybe I will never fight it. Life is short and one must count the cost. It is not necessary to hire an attorney to see something like this through...only time and energy and willingness to suffer a lot of frustration.

I hope that my experience helps you in some way. Good luck to you.
Severe OSA...both hubby and me. CPAPin' through life.
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Heated Humidifier
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Oral appliance for OSA and TMJ syndrome
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Re: ** TMJ (Jaw Dislocation) and PAP Masks.. **

Postby DeeNJai » Wed Dec 18, 2013 7:32 pm

Hi
My dentist has just made me a night guard because he has noticed that my jaw was clicking a lot especially on the right side. He swears that I grind my teeth but I struggle to get my teeth together even when awake. I have used the last two nights and my AHI have been okay. the first night it was 1.6 and last night 2.9 hopefully it will help. I have problems with my jaw when eating as I find chewing hard at times. I cant chew for very long before I get pain.
Dee
REMStar Auto with A-Flex 4 - 20 cmH2o

Average 7 days AHI: 4.54
Average RERA: 1.42
Average SV#2: 17.43 a night
Average weekly leaks: 15.39%
90% Leaks: 20%
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Re: ** TMJ (Jaw Dislocation) and PAP Masks.. **

Postby Nozzelnut » Wed Dec 18, 2013 8:32 pm

SnuzyQ thank you for the detailed explanation.

It points me in the right direction to take care of some things.
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Re: ** TMJ (Jaw Dislocation) and PAP Masks.. **

Postby robysue » Thu Dec 19, 2013 12:36 pm

Wanting to add some support to SnuzyQ's answer.

In my case, the TMJ problems preceded the OSA by several decades. But they were always managed decently enough by the standard TMJ guards that a family dentist can easily make---except that I tended to chew through them at an accelerated rate.

After starting CPAP, I cracked my current guard, went to my family dentist and he made another one. That one cracked after less than 2 months of wearing it with my nasal pillows mask. The family dentist was frank with me and told me he was no longer comfortable treating my TMJ and referred me to a dentist who specializes in treating TMJ and oralfacial pain (and who also does make oral appliances for OSA).

In my case, the TMJ specialist is covered by my insurance. The kicker is he never charges anything under "TMJ". All the claims go through codes for "oral facial pain" problems. After doing some diagnostic studies to get some real data concerning the mechanical functioning of my TMJs, he designed a treatment plan that allowed my TMJs to actually heal from the years of being dislocated every time I opened or shut my mouth. The treatment plan consisted of several coordinated things:
  • a slightly more specialized guard to encourage my jaw to close in a position that is more forward (and where my TMJs want the jaw to be. At the start of the treatment cycle, I was wearing the guard 24/7 including when I was eating.
  • a no-chew diet for two months, followed by a soft chew diet for another couple of months followed by a slow return to a normal diet
  • ample use of moist heat on the TMJs. At the start I was using a moist heating pad for 20 minutes per side three or four times a day.
  • a very slow weaning of the day time use of the oral appliance.
Things pretty much worked as planned---except that I chewed through the guard much faster than the specialist had anticipated. So he made another one. And I chewed through it. So he made a third. I didn't chew through that one right away. And after about a year or so of treatment, my TMJs were feeling substantially better (as in almost entirely pain free every day) and the specialist said, "We don't need to see you any more unless you start having problems again."

Problems started up about nine months later and included my chewing through the guard along with substantially increased pain. After a quick call to the specialist, they got me in for another evaluation and to make another guard. And recommendations to wear the new guard 24/7 as needed and to go back to a soft-chew diet and start using moist heat. All of which helped, but I chewed through in less than a month. And then they made me a day guard as well as the night guard. And I chewed through it too. This past fall, the specialist was looking at the two recently demolished guards (one upper and one lower), and said that he had an idea of what might be causing me to demolish the guards so quickly and we scheduled an hour long appointment for him to take a whole bunch of additional measurements before crafting yet another guard. This time, he took multiple measurements of how my TMJs wanted to functionally close and how my teeth wanted to functionally close. The two do NOT agree on how my mouth should close. And this discrepancy together with the fact that the previous guards would favor one over the other caused a feedback loop to be set up in my brain when wearing a guard. Which lead to the chewing and grinding. So the new guard was designed with all this in mind and it's now almost 3 months old. I've had two follow-ups to see how its officially holding up and how the TMJs are doing since the guard was made. Both times, the specialist made a few modest adjustments to the guard, but both he and I are pleasantly surprised by the fact that the wear/chew marks on this guard are minimal so far. And the TMJ pain is back down to a very low level and sometimes is even gone. And I've been able to wean myself off daytime use of the guard without any real problems in terms of TMJ pain.

And all of this---including the cost of something like 5 or 6 night guards in the last 2 years---has been paid for by my health insurance because it's been billed under a medical code for oralfacial pain instead of "TMJ disorder." All I've had to pay for are the co-pays for the office visits and the co-pays for the original diagnostic testing.

The points of my story?

1) It's worth asking TMJ specialists if they take health insurance instead of just dental insurance. If they do, they've probably figured out a way to code the treatment they provide in a way that gets them compensated while allowing you to pay your normal copays.

2) It can take some time and patience to properly treat the TMJ issues as opposed to just "managing" them. Hence it's important to find someone who is willing to work with you long term if need be on addressing the TMJ issues. I was (and continue) to be amazed at how much better my TMJs function in the daytime now that my mouth is closing in a slightly different way that has my lower jaw somewhat further forward than how it was closing before treatment.
current settings Min EPAP = 4, Max IPAP = 8 and Rise time = 3

8/1/2010 sleep study results:
AHI = 3.9 [AHI = (#OA +#CA + #H w/desat) per hour]
RDI = 23.4 [RDI = (#OA +CA + #H w/desat + #H w/arousal) per hour]
Dx: Moderate OSA
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