Not All Nightguards Are The Same

There are many different philosophies when it comes to constructing a nightguard. In its simplest form, the primary function of a nightguard is to protect the teeth from the destructive actions of clenching and grinding during sleep. Upper nightguards with a flat surface are a popular and simple solution to to this problem. However, after more than 30 years of studying and treating bites, joints, and airway issues, I have found that while many upper nightguards may protect the teeth from tooth-on-tooth damage, they often disregard important elements of a balanced bite and an open airway.

Traditional upper nightguards are generally made by taking a single impression of the top teeth and palate, and then sending that single impression to a laboratory to have a simple nightguard made. Little attention is given to the physiology of the joints and muscles, resulting in many upper nightguards that actually shove the lower jaw backwards, causing pain and compression in the joint space. Many of these nightguards are also constructed with a flat biting surface for the bottom teeth to slide against. The idea is that the teeth are grinding around anyway, so why not give them full freedom to do so?

The problem with that concept is based on a fundamental misunderstanding of why people clench and grind in the first place. Stress can certainly play a role, but nighttime clenching and grinding can also be a physiological effort to open the airway or to find a more comfortable resting place for the teeth that better supports the joints and muscles. A flat plane that the teeth literally skate around on can actually causing grinding to increase as the muscles and joints struggle to find any resting place at all.

Upper nightguards can also exacerbate breathing problems, especially for those people who already snore, suffer from allergies, or have any form of sleep apnea. Most upper nightguards are fairly thick across the palate. This construction crowds the tongue further back into the throat, constricting the airway. When this happens, patients will often stop wearing the nightguard even if they don’t know why because it feels claustrophobic or simply “too big”.

In my practice, I always recommend and construct lower nightguards for my patients. Even if a patient has no known joint or breathing issues, my goal as a neuromuscular dentist is to always protect the balance that already exists. A lower nightguard allows more room for the tongue and, when constructed properly, holds the lower jaw in a neutral, relaxed position to support the joints and muscles.

When we make a lower nightguard, impressions of both the upper and lower jaw are taken, and a bite registration is used to determine the ideal relationship between the upper and lower teeth when the joints and muscles are at rest. A bite, or resting place, is carefully constructed into the surface of the nightguard. This bite is not a locked position, but rather a subtle suggestion to the teeth to settle into a more relaxed position when not engaged in a grinding activity. Full freedom of movement is still possible and careful attention is paid to potential interferences when the jaw moves forward and side-to-side during the final fittings.

A nightguard is a simple device in theory, but like any other treatment or device that introduces a change in the body, great care must always be taken to reduce or eliminate any unnecessary and unwanted changes to other systems. If you are considering a nightguard, or you have questions about the construction and efficacy of your current nightguard, I encourage you to seek out an opinion from a neuromuscular dentist. Current patients or individuals who would like to become patients within my practice are always encouraged to call or schedule and appointment to further discuss my approach to nightguard construction and to determine if a nightguard is the correct appliance to address all your functional needs.

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What Your Child’s Sleeping Habits May Be Telling You

It’s easy to misinterpret certain types of sleep behavior in children as simple signs of deep sleep or dreaming. A little snoring or minor limb movement on occasion are certainly nothing to worry about, but when your child begins to snore chronically, breathe irregularly, or thrash physically during sleep, it may be time to consider whether or not he or she might have some form of sleep disordered breathing.

Obstructive Sleep Apnea (OSA) is one of the most common forms of sleep disordered breathing in adults, but children can also suffer from it – especially when there are other contributing factors present like excessive weight, chronic allergies, or specific jaw and bite alignment issues. Unfortunately all of these conditions can be intricately interrelated, sometimes making it difficult for a parent and a medical provider to successfully treat the OSA completely without addressing multiple factors at once.

What makes OSA so serious for both children and adults is that in its most severe form, it can be fatal. Thankfully, those cases are still extremely rare. However, medical research is now demonstrating that OSA and other types of sleep disorders in children and adults can manifest daytime symptoms that mimic mild to moderate forms of ADD and ADHD. Mistreating these cases with ADHD medication (typically stimulants) is dangerous on two levels: Your child could potentially be taking medication he or she does not need; and he or she could still have an underlying sleep disorder that remains unaddressed and potentially even exacerbated by the medication. 1

This month, I’ve added a new resource to The Airway Series that expands and explains these important issues in discovering and treating breathing and airway development issues in children. It is my hope that eventually all children will be screened for the underlying conditions that can lead to OSA, and that preventive measures like functional orthodontic treatment, healthy eating, and plenty of exercise are pursued before the pathological conditions related to OSA ever have a chance to develop.

As always, I encourage you to share this material as much as possible with your friends and family, and to bring any questions you may have about your own children with you to your next regularly scheduled appointment.

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Clenching and Grinding

In my 31 years of dental practice, I have seen all kinds of wear and damage to the teeth from a variety of accidents and oral habits. But the most common – and the most damaging – activities seem to be the ones that people are the least aware of. I’m talking about clenching and grinding your teeth, and many people clench and grind far more often than they think they do.

The exact causes for these habits are not known, but we do know that stress is often a contributing factor, and there is some evidence that airway problems and severely misaligned bites may also play a role. But many people who have none of these problems still clench and grind regularly either out of habit or some other cause we don’t yet understand.

The muscles that control your bite can generate huge amounts of force – more force, in fact, than any other muscle system in the body. Certainly, teeth can crack and break under that kind of pressure, and the muscles will often go into spasm and cause all kinds of facial pain. But these immediate symptoms can also be compounded by the slow wearing of the teeth caused by years of unconscious grinding. As the teeth are ground shorter and flatter, the bite collapses. The space that those teeth once held open for the joints and muscles to function properly closes, and chronic pain can set in for many people.

It is always sad for me when I see a new patient who has obviously worn away several millimeters of tooth structure through some kind of long-term grinding habit and seems to be completely unaware of it. “Why didn’t anyone ever tell me this was happening?” is such a common question from new patients in this situation, that I find myself asking the same question: Why aren’t we communicating the importance of this information to our patients more clearly?

Protecting your teeth, muscles, and joints from the wear and tear of an unconscious clenching or grinding habit can be as simple as wearing a nightguard appliance during sleep and becoming more aware of whether or not your teeth are pressed together during the day. Stretching during the day – especially when you notice yourself clenching or grinding – can alleviate muscle spasms, headaches, and help break daytime habits.

If you suspect that you may have a habit of clenching or grinding during the day, or at night – and certainly if you suddenly notice in recent photographs that your teeth just don’t seem to be as tall as they used to be – I encourage you to speak with your dentist about what you can do to protect your teeth from further damage.

There is no question that the best teeth you can have for the rest of your life are the ones you were born with. Anything you can do to protect them from damage and avoid the need to replace them with implants, partials, or dentures will always be worth it for the long-term health of your mouth and your body.

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Publication Announcement

This summer, I had the honor of seeing some of my original research published in the International Journal of Orthodontics. The peer-reviewed article, entitled Masseter Muscle Bite Force in First Bicuspid and Collapsed Occlusion Cases, outlines the fundamental relationships between masseter muscle function and a well-supported bite based on the information I gathered over several years of treating chronic pain and malocclusion cases.

Many of you who have seen me for dental treatment may have experienced the direct application of this research in my everyday clinical practices. The muscle tests and palpations that I perform during routine exams – or any time a change to the bite is being considered or performed – have been specifically developed out of my extensive studies on the interrelationships between tooth position, muscle strength, and TMJ function.

This research and experience has formed the backbone of my functional approach to dentistry over the years, and I am thrilled to be able to share a piece of it with the greater dental community. It is my hope that more dentists and orthodontists will begin to consider the importance of muscle function whenever changes to the bite are being considered.

I invite you to take a closer look at the article if you are interested by linking here, and I hope that you will always feel welcome to ask me more about how these concepts apply to your treatment whenever you come in for a visit.

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chewing is not optional

For many years before I attended dental school, I worked to support myself and my family as a dental assistant. During that time, I was often fascinated not only with the techniques used to heal disease and repair damage in the mouth, but also with the overall function of the teeth and mouth in general. What made it easy for some people to chew and why was it so painful for others, even when their teeth seemed to fit together?

The dentist I worked for did not treat TMJ disorders, but we certainly saw patients who suffered from the consequences of an unbalanced bite. When the time came for me to go to dental school myself, I was excited to finally learn more about TMJ disorders and the science of occlusion (the bite), in addition to the study of dental technique. I assumed that all three areas of study were a standard part of the dental curriculum. I was wrong.

At school, while I did receive some instruction on occlusion, the majority of my education in that area focused primarily on tooth position with little or no regard for the joints and muscles responsible for the action of chewing. Teeth were teeth. As long as they fit together, everything else was supposed to be fine. But it wasn’t long after I graduated that I encountered my first challenge to this idea.

Shortly after I started in practice, a young woman appeared in my office, crying in pain about her horrible headaches and jaw problems. She could chew, but the pain was greatly exacerbated by the activity. Her doctor’s solution? Stop chewing.

Stop chewing at 28 years old? For how long? The rest of her life? It was ridiculous advice, and even though I didn’t know exactly how to help this young woman at the time, her situation set me on a quest to better understand three-dimensional jaw function that still continues to this day.

There are many often conflicting lines of thought about how the teeth should be aligned, how long the cuspids should be, how sharp the cusps of the teeth should be, and where the “balls” of the lower jaw should fit into the bony concavity in front of the ear. In the more than 30 years since I graduated dental school, I’ve spent countless hours in classes, reading textbooks and journals, and observing the mouth movements and function of my patients. I was, and still am, somewhat obsessed – watching how people move their mouths in movies, in restaurants, and in everyday conversation. I still watch the way the front teeth fit together, study the wear patterns on the teeth, observe the development of crowding – all in an attempt to understand how the entire system functions both in health and in disease.

Early in my quest to understand, and to help this young woman who was now my patient, I came upon the work of Dr. Bernard Jankelson. A noted prosthodontist, Dr. Jankelson had also struggled with the success of bite reconstruction based purely on the mechanics of the teeth. His work, considered by most to be the foundation of neuromuscular dentistry, finally created a system of analyzing jaw movements and bites that also respected muscle function. And I discovered through my study with his son, Dr. Robert Jankelson (a noted prosthodontist himself, and the leading contributor to the promotion and continuation of his father’s work), that the pain my patient was experiencing as a headache was coming from the muscles that couldn’t function correctly while chewing in their current three-dimensional relationship to the teeth.

That young woman I saw so many years ago is still my patient today. And guess what? She’s still chewing. So well, in fact, that sometimes I have to warn her about chewing a little too much gum! The idea of chewing gum when she first came to see me would have been excruciating to her. Today, we’re both grateful that she didn’t just accept the ridiculous advice her doctor initially gave her to simply stop chewing altogether. I wish I could say this is the only time I have heard this advice, but unfortunately the recommendation to stop chewing is still too common. A lifetime of a liquid diet isn’t just boring, it is nutritionally insufficient. In all but the most extreme cases, chewing should never be considered an optional activity.

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