TEMPOROMANDIBULAR DISORDERS: RELATION OF INSOMNIA AND SLEEP APNEA DISORDERS TO SEVERITY

A PAIR OF NEW STUDIES IN PAIN JOURNAL AND IN THE JOURNAL OF OROFACIAL PAIN LOOK AT INTERACTIONS BETWEEN SLEEP, TMD AND PAIN.
The first study ” Naturalistic changes in insomnia symptoms and pain in temporomandibular joint disorder: A cross-lagged panel analysis.” an exceptionally well done stuy fro Johns Hopkins looked at 53 patients with Temporomandibular disorders (TMJ, TMD) and the effect of insomnia on pain symptoms and sleep quality. The study showed that when initial-insomnia months complaints increased the following months had increases in pain but increases in pain did not cause increases in insomnia. Apparently the natural fluctuations in insomnia caused increses in pain experienced by these TMD patients.

The second article “Prevalence of temporomandibular disorders in obstructive sleep apnea patients referred for oral appliance therapy” published by the Journal of Orofacial Pain showed a very high level of TMD symptoms in sleep apnea patients. The first article on insomnia did not discriminate beteween sleep onset insomnia and sleep maintenance insomnia
in the patient population group. Maintenance insomnia is more common with sleep apnea patients. The second study had 87 patients, 46 men and 41 women so it did not represent the typical TMD population of 80% females but did represent typical findings in apnea percentages, possibly lower than normal percentage of men. The patients had apnea-hypopnea indexes of of more than 5 and less than 30 AHI. 75% of patients had chronic pain related to TMD symptoms the most common being myofascial pain(50%) that did not necessarily involve limited opening or arthralgia (joint pain).

The authors concluded “the high prevalence of TMD in the current study indicates that patients with OSAS referred for oral appliance therapy require specific evaluation related to TMD.” In my opinion the reverse staement should probably also hold true that ” the high prevalence of sleep apnea indicates that patients with TMD should be referred for diagnosis of sleep disordered breathing and oral appliance therapy for apnea should consider the dual nature of these problems that require specific evaluations related to TMD Sleep Disordered Breathing. I also feel that UARS, Upper Airway Resistance Synrome which is more common in younger healthier patients and females accounts for the normal 80% female preponderance in TMD patient populations for Temporomandibular disorders and for myofascial pain disorders and/or fibromyalgia disorders.

The NHLBI reprt “CARDIOVASCULAR AND SLEEP RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS” is an excellent reference on the relation of these disorders. http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf

Excellent information on TMJ disorders is available in the Sleep and Health article “SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER” and additional information on sleep apnea treatment with oral appliances at http://www.ihatecpap.com and additional information on treating TMD,TMJ and headaches related to those problems at http://www.ihateheadches.org

PUBMED abstract below
“Pain. 2010 Mar 30. [Epub ahead of print] Naturalistic changes in insomnia symptoms and pain in temporomandibular joint disorder: A cross-lagged panel analysis.
Quartana PJ, Wickwire EM, Klick B, Grace E, Smith MT.”

“Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences Medicine, MD, USA.
An increasing number of prospective studies suggest a bi-directional association between the pain and sleep quality. Few of these investigations have controlled for synchronous correlations, an important source of extraneous variance in lagged associations, which may have confounded conclusions of prior investigations. Despite high rates of insomnia in temporomandibular joint disorders (TMD), no studies have examined temporal associations between naturalistic fluctuations in insomnia and pain in TMD. We conducted cross-lagged panel analysis to examine reciprocal temporal associations between 1-month changes in insomnia symptom severity and self-reported pain over 3 months among 53 TMD patients. This rigorous analytic strategy represents a comprehensive method to explore possible reciprocal temporal associations between insomnia and pain that controls for both auto- and synchronous correlations. Analyses revealed that initial-month increases in insomnia were associated with next-month increases in average daily pain, but not vice versa. The direction of the effect was such that initial-month increases in insomnia symptom severity were associated with next-month increases in average daily pain. These data suggest that naturally occurring fluctuations in insomnia symptom severity are prospectively associated with fluctuations in daily pain experience for persons with TMD. Potential mechanisms by which insomnia might influence pain in TMD and therapeutic implications of these findings are discussed. Copyright © 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.”

PMID: 20359824 [PubMed – as supplied by publisher]

J Orofac Pain. 2009 Fall;23(4):339-44.
Prevalence of temporomandibular disorders in obstructive sleep apnea patients referred for oral appliance therapy.
Cunali PA, Almeida FR, Santos CD, Valdrighi NY, Nascimento LS, Dal’Fabbro C, Tufik S, Bittencourt LR.

Department of Dentistry, Universidade Federal do Parana, Parana, Brazil. pacunali@onda.com.br
AIMS: To evaluate the prevalence of pain associated with temporomandibular disorders (TMD) in obstructive sleep apnea syndrome (OSAS) patients referred for oral appliance therapy. METHODS: Eighty-seven patients (46 men and 41 women), between 18 and 65 years of age, with an apnea-hypopnea index (AHI) of > 5 and < 30 (events by sleep hour), and body mass index (BMI) of =or< 30 Kg/m(2) were evaluated according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) to determine the presence of signs and symptoms of TMD. Statistical analyses included correlations assessed by Pearson's test. RESULTS: Fifty-two percent of patients presented symptoms of TMD. Thirty-two patients (average age 47 +/- 11 years, AHI 17.3 +/- 8.7, BMI 25.9 +/- 3.8 kg/m(2)) completed the study. According to the Scoring Protocol for Graded Chronic Pain (Axis II-RDC/TMD), 75% of the patients presented chronic pain related to TMD, categorized as low disability grade I (< 50 points for pain intensity, and < 3 disability points). The most common TMD diagnosis was myofascial pain with and without limited mouth opening and arthralgia (50%). CONCLUSION: The high prevalence of TMD in the current study indicates that patients with OSAS referred for oral appliance therapy require specific evaluation related to TMD. PMID: 19888485 [PubMed - indexed for MEDLINE]