MIGRAINE AND RESTLESS LEGS LINKED: TMD, TMJ, MIGRAINES, HEADACHES, AND SLEEP DISORDERS HAVE NEW TREATMENT OPTIONS

A new article in November 30 issue of The Journal of Neurol Neurosurg Psychiatry ( 2009 Nov 30.)
“Association between Restless Legs Syndrome and Migraine” continues to tie together sleep disorders, migraine and tension headaches with Temporomandibular Disorders (TMJ, TMD, TMJD). The article by Chen PK, Fuh JL, Chen SP, Wang SJ concluded that “Our study demonstrated an association between migraine and RLS among different primary headache disorders. Comorbid RLS in migraine patients worsened sleep quality. A shared underlying mechanism may account for the correlates between migraine features and comorbid RLS.”

This is an important study that affirms the connections between TMD (TMJ) or Temporomandibular disorders with sleep apnea, snoring, upper airway resistance, chronic daily headaches, Tension-type headaches and Migraine. The NHLBI (National Heart Lung and Blood Institute) of the NIH has declared that TMJ disorders cause both sleep apnea and cardiovascular problems in their report “CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS”. It is precisely these connections that spell the future of treatment of both headaches and sleep disordered breathing disorders including sleep apnea, UARS or upper airway resistance syndrome, snoring and morning headaches. It is well established that TMJ disorders and/or sleep disordered breathing are the major cause of morning headaches. Dr Ira L Shapira, a Chicago Dentist, has created a website (http:// www.ihateheadaches.org) that explains the connections between TMJ disorders and Migraines and Tension-Type Headaches.

The cause of all of these problems is a similar underlying pathology in the mechanical, physiologic, and neuromuscular functioning of the stomatognathic system, or in layman’s terms teeth, jaws, tongue etc. The dentist who has long been considered merely a mechanic of the teeth turns out to have an incredible effect on the entire body. The Trigeminal Nerve or Dentist’s Nerve is responsible for approximately one half of the total input to the brain from the body. The field of dentistry is sometime thought of to be about filling teeth or whitening teeth but many dentists across the country have combined physiologic treatment into their practices and this is changing the health of the country. A Sleep and Health Journal article (http://www.sleepandhealth.com/neuromuscular-dentistry) on Neuromuscular Dentistry (originally published by The American Equilibration Society) explains how all types of headache patients can be treated with neuromuscular dentistry instead of drug regimens. A second article that is a must read for anyone with chronic headaches or TMJ disorders “SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER” can be found at http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor

The treatment of Sleep Apnea was once surgery of CPAP and the idea of a dentist treating it seemed outrageous. Dental Sleep Medicine and Oral Appliances are taking central stage in the field of sleep medicine and sleep disordered breathing. It turns out that most of the ENT surgeries for treating sleep apnea and snoring showed high morbidity (patients problems post surgery) and poor success. In fact most patients who had UP3 surgery or Uvulopalatopharyngealplasty still required CPAP to control their sleep apnea. The LAUP and Radiofrequency surgeries while still painful had lower morbidity but showed no increase in effectiveness.

CPAP is still considered by some sleep physicians to be the Gold Standard of treatment but the majority of patients reject CPAP treatment for a wide variety of reasons including skin problems like facial ulcers and acne. Sinus problems associated with CPAP include sinus pain, sinus stuffiness, worsening of problems with allergies, sinus pain, sinus infections, sinus fullness and dry mucosal tissues in the nose and sinuses. Patients have reported all bronchitis, pneumonia, dry throat, and stomach bloating and vocal cord irritation symptoms.
Ear pain, ear stuffiness or Eustachian tube dysfunction, dizziness, middle ear infections or otitis media, and itchy and uncomfortable feelings inside the air canal have also been reported. There was a case reported of both a mother and son who experienced ongoing vertigo after only a few days of CPAP that took weeks to resolve.

Dental Sleep Medicine is rapidly becoming a major treatment for treating mild to moderate obstructive sleep apnea, UARS, snoring, sleep disordered breathing and restless legs related to apnea and sleep disordered breathing. Unfortunately many patients do not know about oral appliances as an alternative treatment to sleep apnea. This is sometimes because physicians are not used to referring patients to dentist and because dentists often fail to inform physicians about the treatment they render to patients. The American Academy of Sleep Medicine has accepted oral appliance therapy and Dental Sleep Medicine as a first line treatment for mild to moderate sleep apnea and as an alternative to CPAP for severe sleep apnea when patients do not tolerate CPAP. Dr Ira L Shapira is a Diplomate of the American Board of Dental Sleep Medicine and created the website www.ihatecpap.com to inform the public about the dangers of sleep apnea and the various methods of treatment including CPAP and Oral Appliances. The site is primarily directed to patients who are intolerant of CPAP therapy. The majority of patients fail CPAP therapy with a recent report saying that over 60% of patients discontinue treatment with CPAP. There are two primary problems with CPAP compliance, discontinuation of CPAP therapy and insufficient time of CPAP use. The research has shown that to receive the full effects of CPAP therapy patients require daily use of their CPAP for 7 to 7 1/2 hours. Research has also shown that even among the 40% of patients who actually utilize their CPAP machines usage is only 4-5 hours a night and 4-5 nights a week. In spite of research that shows this is insufficient treatment it is the same standard that is considered a “success” in CPAP treatment for research purposes. If wearing CPAP 7-7 1/2 hours seven days a week was the definition of CPAP success then the numbers of successful patients reported in the literature would plummet. This is an unlikely scenario since CPAP manufacturers finance most research on CPAP or there is a quid pro quo where the CPAP companies provide equipment used for studies gratis.

There is a group of patients who are extremely successful with CPAP treatment. Approximate 25% of patients love their CPAP machines from day one and continue to use it on a regular basis. Some studies show that patients who do not tolerate therapy initially never become accustomed to its use while other studies show improved CPAP success when there is excellent approach by trained sleep techs or DME providers to the delivery and problem solving needed for most patients to achieve success.

Patients given a choice between oral appliances and CPAP chose appliances 20 to 1 over CPAP. The I HATE CPAP website has a section on oral appliances (http://www.ihatecpap.com/oral_appliance.html) that has examples of many of the FDA approved appliances available to the public. A study on the American Academy of Dental Sleep Medicine website reports of successful treatment of severe apnea with oral appliances. The TAP appliance or Thorton Anterior Positioner has been shown to be the most successful appliance treatment for severe sleep apnea. Keith Thornton the inventor of the TAP Appliance is now also changing the way CPAP will be delivered. Working with Fisher-Paykal, a major CPAP manufacturer he has created the TAP-PAP appliance that allows a standard nasal mask to be connected to the TAP # appliance. The combination of the mask and CPAP is a much more comfortable means to retain the mask without the use of straps. Using the TAP Appliance with CPAP also allows much lower pressures for CPAP therapy to eliminate many of the problems associated with CPAP use.

The TAP-PAP combination allows a more comfortable CPAP to patient interface but more importantly allows for custom CPAP masks that are retained by appliances. These can be used with respirators as well for treating patients with severe neuromuscular diseases.

Dr Ira L Shapira created the I HATE CPAP and I HATE HEADACHE websites to help patients find help with these difficult medical disorders that medicine can frequently not treat adequately without a dental collaboration. Dr Shapira did research in the 1980’s as a visiting assistant professor at Rush Medical School where he worked with Rosalind Cartwright PhD who is primarily responsible for the entire field of Dental Sleep Medicine. He also studied with Dr Barney Jankelson who created the initial concepts that neuromuscular dentistry still uses today and created a company Myotronics that is the leading manufacturer of instrumentation used by Neuromuscular Dentistry.

Dr Shapira is a Diplomate of The American Board of Dental Sleep Medicine, a Diplomate of the American Academy of Pain Management, and a Fellow of the International College of CranioMandibular Orthopedics (ICCMO). He is a former national and International Regent of ICCMO, its current Secretary and the representative to the Alliance of TMD organizations or the TMD ALLIANCE has a general dental practice (http://www.delanydentalcare.com) in Gurnee, Il and has recently started Chicagoland Dental Sleep Medicine Associates with offices in Skokie, Schaumburg, Chicago, Vernon Hills and Bannockburn. Patients in Northern Illinois or southern Wisconsin can contact Dr Shapira by phone toll free at 1-8-NO-PAP-MASK OR 1-800-TM-JOINT or thru his websites at http://www.ihateheadaches.org or http://www.chicagoland.ihatecpap.com/