Airway Obstruction

Q: My 12 year old has had problems breathing for years. She has trouble sleeping and breathing through her nose. Her teeth are crooked and the orthodontist is saying that jaw surgery may be necessary to straighten her teeth properly. I am worried about the surgery, are there any other options? M.Y. in Dover

A: Generally speaking, jaw surgery should be avoided until the child is finished growing. For girls this could be 16-17 and for boys 17-18, although these numbers can vary. There are exceptions to this rule, so don't avoid necessary surgery.

You seem to be describing a problem that could have started at a very early age. Your child, for any number of reasons, might have been a 'mouth breather'. For proper facial development and good posture, children need to be able to breath through their nose. Noses can be obstructed because of allergies that clog the nose, swollen adenoids, and/or tonsils that clog the nasal airway. Studies have shown that bottle fed babies may have more allergies and bottle feeding can cause a poor tongue position that allows the upper and lower jaws to be narrower. These narrower jaws can reduce the size of the nasal airway and lead to a smaller nasal airway and increased mouth breathing.

As growth continues, this mouth breathing starts to show up as a chronic open mouth with an arched upper lip and a dry lower lip. Over time, the child can develop a long narrow face with a thin nose, and dark circles under the eyes (allergic shiners). As an untreated adult you might have a 'gummy smile', poor posture with a forward head position, poor sleep habits, snoring, and neck pain.

So how do we approach your problem? Ideally, we would go back in time and look into her possible nasal airway problems at 3 years old. Since we don't have a time machine, you need to speak with a dentist that understands and treats his/her patients with 'functional' appliances that influence growth and development, not just straighten crooked teeth. You need to have your child's adenoids and tonsils checked. Allergy testing needs to be done and a dental exam that reviews more than just how the teeth come together should be performed.

On a related note, I often receive questions about children who grind their teeth. In adults, this is often related to stress or bite imbalances. However, in children there is some evidence that this is related to clogged ears (you know that full feeling that you get with pressure changes). Again, this is related to allergies and airway problems and can sometimes be resolved with proper treatment.

The earlier this type of problem is detected and treated, the easier it is to treat and the better the results are, but even at 12 years old and into adulthood we can make significant improvements.


Cheek Biting

Q: I am 65 years old and in the last year I seem to be biting my cheek more and more. Do you think my bite is shifting? F.S. in Huntsville, Alabama

A: While it's possible that your 'bite' is shifting, 'cheek biting' is a fairly common occurrence. I think most of us have gotten our cheek caught between our teeth accidentally. Unfortunately, once a cheek is bitten, it swells, and probably gets bitten 3 or 4 more times over the next week. In most cases, the cheek heals in time and everything returns to normal.

There are, however, many other more pathologic forms of cheek biting. Some can be corrected, others are more difficult to correct. I will try to touch on a number of possibilities and maybe you will find one that fits your condition.

Some people bite their cheek as a nervous habit similar to grinding teeth. If you're doing it during the day you can try to consciously stop. But if it is happening at night, your dentist can make a removable appliance for you that keeps your back teeth from coming together so you can't bite your cheek.

The other types of 'cheek biting' fall into a similar group. Under normal conditions, when you close your back teeth together, your upper teeth fit outside of your lower teeth. This allows your upper teeth to hold your cheeks and lips away from your lower teeth so they don't get caught in between when you chew. So if your teeth do not come together (occlude) properly, you may have a problem. New crowns or bridges may need adjustment. Old dentures may have shifted or worn down. Missing teeth can even cause a problem. As you get older your mouth can become dryer, or you may have lost some muscle tone or even built-up a little more fat in your cheeks that would make it harder for your upper teeth to keep your cheeks pushed back from your 'bite.'

Sometimes a little sanding on your teeth or a new denture can solve the problem. I have even seen patients stop biting their cheeks after losing weight. A thorough exam by your dentist should help solve your problem.


Grinding One's Teeth

Q: My 2-year-old grinds his teeth at night. Should I be worried?

A: Until recently my answer would have been that young children grinding their teeth is not that unusual and they usually stop on their own after a while. Besides, there is very little we as dentists could do about it any way. In adults we called it stress and in children we just hoped it would stop on its own.

However, there is some indication that it may be due to ear infections and swollen tonsils and adenoids. If your child is grinding his or her teeth have your doctor make sure that his or her ears are OK and that the child's nose is clear without swollen tonsils or adenoids.


Snoring

Q: My husband has been snoring for years and he wakes me up almost every night. I know there are some treatments available, but I don't know who to talk to. Do you have any suggestions?

A: If your dentist understands snoring, he or she would be a very good place to start. Dentistry offers a couple of good treatment options.

Snoring is the noise created by air going through your mouth and causing the back of your tongue and 'roof' of your mouth (soft palate) to vibrate against each other. This is similar to air escaping through the nozzle of a balloon.

The treatments are all aimed at either increasing airflow through your nose or increasing the size of the airway between your tongue and soft palate. Allergies, sinus infections, large adenoids, or even broken noses or a deviated septum can make nose breathing more difficult and can be corrected with varying results. Drugstores even have flexible adhesive strips that fit over your nose to help increase the airflow. Mouth related problems that cause a decreased airway and snoring are allergies (swollen tonsils), being overweight, sleeping on your back, or having a particular lower jaw shape or position.

Dental offices can provide two main treatments. With the most preferred method, a small, comfortable, removable appliance is made that keeps your lower jaw forward at night. This forward jaw position moves your tongue forward and away from your soft palate. The breathing space is increased and snoring stops. A more permanent and more invasive method to relieve snoring is to remove a portion of your soft palate and/or tonsils. This can be accomplished with lasers, radio-frequency tissue volume reduction (RFTVR) or even conventional surgery with varying degrees of success. RFTVR is a newer procedure that I have heard may allow you to go directly back to work.

It is important to note that severe snoring can be associated with a more dangerous condition called sleep apnea. With sleep apnea you go through periods of time not breathing at all. Sleep apnea needs to be treated quickly and aggressively.

The sooner your husband's snoring is controlled, the better for all involved. My first choice for his treatment would be the dental mouth guard.


TMJ

Q: My jaw clicks and pops when I chew and I have almost daily headaches. My physician says that I don't have a sinus or ear infection. He suggested that I check with my dentist because I might have 'TMJ'. What is TMJ and do you think that I have it? B.H. in Centerville

A: It's very possible that you have TMJ syndrome, but let me give you some background information. Tempero-mandibular joint syndrome, or TMJ, is only one of a bunch of names for a group of facial pain symptoms. Most of these symptoms are related to the jaw joint, the muscles associated with chewing, and your teeth position. That's why your dentist can probably help.

The clicking and popping that you are describing is your jaw joint dislocating. There is a donut shaped disk in your jaw joint that is out of place. Many people have this clicking and as long as it is mild and infrequent, no treatment is necessary. Sometimes it can be painful just in front of your ears -- which is why you might have thought you had an ear infection.

The most common reasons for the disk to be out of place are a blow to the jaw (like an accident or fight) or grinding or clenching your teeth. However, some people just seem to have a genetic predisposition to this problem. Your eating habits, posture, exercise habits and stress level can also affect your TMJ symptoms.

Your muscles, bones, and teeth that allow you to chew, talk, and smile are a finely tuned miracle of nature. But when they are out of balance, the pain can be awful. Finding the cause of the imbalance and determining the proper course of treatment can sometimes be very difficult, and even well educated dentists may differ on their treatment suggestions.

The most common treatment for TMJ syndrome is a bite guard, or specially made mouth guard, that fits over your top or bottom teeth. The type of bite guard usually depends on your dentist's philosophy of treatment. Other treatments include medications (usually muscle relaxants and/or anti-inflammatory), orthodontics, crowns on your teeth, physical therapy, or chiropractic manipulation.

It is not unusual for people to have suffered with facial pain for years before finally finding the cause and the treatment. Some of the other symptoms that TMJ patients can experience include fullness or ringing in their ears, broken or sensitive teeth, limited jaw opening, back and neck pain, and even vertigo or balance problems.

Remember, no one will ever look out for you better than yourself. As you discuss your problems with your dentist or a specialist, learn as much as you can so that you can not only help pick the proper treatment, but also modify your own behavior to help yourself get better.

Q: I have been having pain in front of my ears for 2-3 years. My ears and sinuses have been checked and the doctors say that it is TMJ. My dentist made me a mouth guard and it helps, but I would like to know if there are more permanent ways to make my TMJ pain go away. R.L. in Hockessin

A: TMJ stands for tempero-mandibular joint (your jaw joint). When someone says that you have TMJ they are usually referring to pain in the joint, ears, or chewing muscles.
You can have neck pain, headaches, ringing in your ears, and/or your teeth can hurt. It is not unusual for this to show up in people who grind their teeth, have misaligned teeth, bad posture, or after a whip lash type injury (car accident).

There are many different types of 'mouth guards' and some work better than others. Some are made of a soft material and some hard. There are guards that fit your top teeth and others that fit your bottom teeth. The mouth guards are generally used to protect your jaw joints and teeth and if designed properly, to relax the muscles in your head and neck. It has been estimated that 80-90% of facial pain is related to muscle tension or spasm.

In some of our patients it is easy to get their muscles comfortable, but in others it can be very difficult. You seem to have had good luck with your mouth guard (orthotic). Now what do you do? You can live with your orthotic indefinitely if you are comfortable with it. It will need to be remade periodically as it wears out of course. But you can move beyond a removable piece of plastic in your mouth, if you are interested.

Because most of your discomfort comes from muscles that are crampy or in spasm, a muscle relaxing/jaw-tracking machine can be used to find your most relaxed and comfortable jaw position. This EMG machine measures your muscle activity and will actually tell your dentist when you feel better. Your dentist can use that position to either move your teeth with orthodontics/braces, reshape your teeth with mild sanding, or build your teeth up to keep you in that new and relaxed position.

Because many of these TMJ problems become neck, back, and postural problems, you might also benefit from consultations with physical therapists and chiropractors that understand and treat these problems. Alternatively, you may be having treatment at a chiropractor for a whiplash injury. Your chiropractor can make you feel better, but if your neck and jaw pain keep returning, a properly made dental orthotic may be the treatment that you need to help you get better.

You do have options and it may not be necessary to wear your mouth guard forever. Not all dentists have an interest in this field of dentistry or have an EMG machine, so ask around before you decide on your course of action.

Q: I have had TMJ pain for years. Sometimes it seems worse that at other times, but lately it has been very painful. I have tried medicines and bite guards with varying degrees of success. Are there any other treatments available that I may not have heard about? J.J. in Virginia

A: There are almost as many ways to treat TMJ problems as there are dentists, so I'm sure that we have something that you haven't tried yet.

TMJ pain has many names. The TMJ is your 'jaw' joint or 'Temporo-Mandibular Joint.' The head, neck, and/or facial pain is called, anything from, TMJ syndrome to myofacial pain dysfunction syndrome. The great majority of this facial pain (some say as much as 90%) is muscular in nature. The symptoms can be as simple as pain or muscle tightness in your cheek or as strange as dizziness or back pain. It is very common to have clicking or popping in your jaw joint when you eat and many patients grind their teeth.

Most medications used to treat these TMJ problems are directed at the muscles. We use anti-inflammatory drugs and muscle relaxants. As with any medications, you take them to help your problem, but you may want to limit their long term use.

If you have had athletic injuries, you know the value of icing sore muscles and then using moist heat. These same remedies also work for your back, neck, and facial muscles.

Some chiropractors, physical therapists, massage therapists, and others have had specialized training in treating TMJ pain. Many times I have found that to properly treat a patient, a combination of therapists and therapies are helpful. It is rare that I have had a difficult facial pain patient that did not benefit greatly from a physical therapist. Ellen Levine at The Back Clinic has been a great help over the years to my patients.

Neuromuscular dentistry can also be used to treat TMJ pain. This is not a dental specialty, but an approach to some of our more complex dental problems. Neuromuscular dentists use EMG (muscle scans) and computer equipment to find your jaws most relaxed muscle position. The neuromuscular approach is a little more involved and time consuming, but I have seen wonderful results on patients that have had limited success with other treatments. More information on neuromuscular dentistry can be found at www.leadingdentists.com.

It is widely believed that much of TMJ pain is stress induced. While I still believe that this is true, I have seen that balancing a patient's occlusion (or bite) and improving their posture can help eliminate stress and the resulting pain symptoms.

I hope that this helps and you are able to find a treatment that is right for you.

Q: About 3 weeks ago I was in a minor car crash. My neck was banged around a little but quickly got better. Just recently, however, my jaw began clicking when I eat. It has never clicked before and it's a little uncomfortable. Could this be related to the accident? M.M. in Wilmington

A: This could definitely be related to the accident. It is very common for 'whiplash' type injuries to cause TMJ problems. As I've said in previous articles, TMJ or temporo-mandibular joint dysfunction problems are a general group of problems that cause anything from facial pain and clicking jaw joints to dizziness and blurred vision. The clicking or popping that you describe is your jaw joint clicking on and off a cushiony pad that helps to protect the joint when the joint is working. Over time this can erode the cushion and cause worse problems.

If you picture your head as a bowling ball sitting on top of a pencil (your spine) you can imagine how hard your muscles need to work to keep everything in balance. The muscles from your back are attached to your neck and your neck is attached to your jaw muscles. If you create a big enough imbalance anywhere in the system you are going to have problems. By the way, how is your posture and do your neck and shoulders ache?

Everyone has a 'certain' ability to compensate for problems and sickness. This ability is different for each person. Imagine your ability to heal yourself as an empty bucket. You can gradually fill the bucket with problems until one day the bucket overflows and you can no longer heal yourself and you feel pain or get sick.

Your muscle and jaw alignment were probably not the best before the accident. But after the accident, your 'bucket' overflowed and you were no longer able to compensate or overcome these imbalances. Now you must correct the original problems that you had before the accident even occurred. It reminds me a little of taking dance lessons. You might only want to learn to cha-cha, but you must begin at the beginning and learn the basic steps first.

You can approach the problem in one of two ways. You can treat this as a one time 'acute' problem that needs a band-aid and hope that the clicking and popping in your jaw goes away. You can do this with a night time bite guard made by your dentist while you are taking anti-inflammatory medications and maybe some muscle relaxants.

The other way to approach the problem is to look at it as a long term 'chronic' problem and help to correct the original imbalances that were present before the accident occurred. As a neuro-muscular dentist, I prefer this second approach, but it isn't always necessary. The goal is to relieve the patient's symptoms and whichever approach works is OK with me.

In many cases it is necessary to get treatment help from a chiropractor or physical therapist that is familiar with these head and neck types of problems. A group approach is almost always best.


Thumb Sucking

Q: My 6-year-old daughter is still sucking her thumb. We have tried talking to her and painting that bad tasting stuff on her thumb but she hasn't stopped. We have been hesitant to have her dentist place an appliance in her mouth that has spikes on it. This is supposed to keep her thumb away, but it looks very uncomfortable. How important is it that she stops and do you have any suggestions?

A: Thumb sucking can be a very difficult and stressful problem to stop. I usually recommend getting serious about stopping by around 4 years old and certainly by age 6.

Unfortunately, thumb sucking causes more than crooked front teeth. The pressure of the thumb (or fingers) behind the upper front teeth can pull not only the teeth, but also the bone forward. The roof of the mouth, or palate, gets pushed up and becomes narrower. The airway space through the nose gets smaller and smaller. Eventually it can become difficult for the child to breathe through the nose and his or her mouth must stay open to breathe better (note: normal breathing occurs with your lips together and a clear nasal airway). This causes the lower jaw to grow in a downward direction so that the teeth will never match up properly.

By 6 years old it is time to do what ever is necessary to stop the thumb sucking habit. An orthodontist, who will eventually straighten the crooked teeth, can make an appliance that cements behind the upper front teeth. This appliance has beads on it (instead of the old spikes). The beads keep the patients fingers and tongue away from the front teeth and help to allow normal development. The appliance usually remains in the child's mouth for a couple of months. After the 'thumb sucking' has stopped it may be necessary to place other types of appliances to help correct the damage that has already occurred.

I see pacifiers and thumb sucking as normal childhood development. However, by age 3, it's a good idea to start mentioning that these habits can't go on forever so that by age 4 it will be easier to stop.