Tag: Dr Donald Tanenbaum

An Implant for Obstructive Sleep Apnea?

There has been a lot in the news lately about implants as a way to treat sleep apnea. As a dentist involved in helping patients with their snoring and obstructive sleep apnea, my biggest challenge has been figuring out strategies to keep the tongue from falling back into the oropharyngeal region. Once this happens, airflow is compromised, leading to diminished levels of oxygen in the blood and frequent arousals while sleeping.

As a result, these patients never feel rested, experience daytime sleepiness, and often underperform at school or in the workplace. Others develop significant heart-related problems or even fall asleep behind the wheel with tragic outcomes. Moreover, for patients who have small lower jaw, large tonsils, fat uvulas, and long sloping and floppy soft palates: nighttime airway compromise is a big problem (even if tongue size is normal!). For obese patients with large necks, fat tongues, and weak tongue muscle strength, the problem is further compounded.

Treatment over the years has included weight loss, airway surgery, CPAP (essentially blowing air through the obstruction), and oral oral devices to prevent the tongue from falling backwards while sleeping (tongue retaining devices) or designed to actively keep the jaw forward, carrying the tongue in the process (mandibular positioning devices). Tongue retaining devices that pull the tongue forward past the lips have also been used with variable levels of success.

On the horizon, however, is a new kind of implant that may be an alternative treatment option for those with obstructive sleep apnea. As reported in the January 9th issue of the New England Journal of Medicine this implant will serve as a pacemaker of sorts, delivering electrical impulses to the nerve that is responsible for maintaining tone in the muscles that keep the tongue in a forward posture.

Tests conducted to date found that “these impulses reduced nightly sleep apnea events by about 68 percent, according to the results of the one year clinical trial. The technology also decreased by 70 percent the number of times that a person’s blood oxygen level dropped due to sleep apnea. Not surprisingly, patients reported a 40 percent improvement in their ability to stay awake during the day.”

According to new reports that reference the Journal article “the device operates by having an electrode run from the pacemaker to the hypoglossal nerve located under the tongue. Another lead wire runs down to the muscles between the ribs of the chest and keeps track of the person’s breathing. As the patient breathes in and out, the pacemaker sends electrical impulses to the nerve, which causes the person’s tongue to move slightly forward and their upper airway to contract open. Both movements keep the airway from collapsing.”

“It’s a unique and promising new treatment,” said study co-author Dr. Ryan Soose, director of the division of sleep surgery of Pittsburg Medical Center. The surgery is minimally invasive, and patients typically were back to regular activity within in a day or two.”

Though more research is needed, this new option will be a welcome addition to the treatment options that are currently available.

Dr. Donald Tanenbaum is a specialist with offices in New York City and Long Island, NY. He is uniquely qualified to diagnose and treat facial pain associated with jaw problems, TMJ, referred pain, nerve pain, and migraines. Find out more at www.nytmj.com.

Tags Dr Donald Tanenbaum, implant for obstructive sleep apnea, implants for sleep apnea

Facial Pain

Facial Pain & Diabetes – The Connection

Recently I had the opportunity to evaluate a 55-year old woman who complained of right side facial pain that by its description seemingly had a nerve-related origin. Her pain was daily and was most intense during the first few bites of a meal. In addition, as she brought food to her lips, (which initiates salivation), her pain greatly intensified. The pain was described as bright, sharp, and debilitating during eating and lingered even after the meal was over.

Prior to her consultation in my office she had seen a number of ENT doctors whose evaluation did not lead to a diagnosis or an effective course of treatment. All dental exams and X-rays were also negative. What then could be causing this pain problem characterized by nerves that were firing abnormally essentially sparking when stimulated? Trauma and disease had been ruled out as the source of the pain based on the patient’s pain history and complete MRI scanning.

How did I approach this mystery? There was a risk factor that needed consideration: the patient was diabetic! While many patients with diabetes experience no nerve symptoms, others have pain, tingling, and even numbness. This condition is called diabetic neuropathy. Diabetic neuropathy in fact can impact every organ in the body. Some studies have shown that 60% to 70% of patients with diabetes have some form of neuropathy and the highest rates are in those who have had diabetes for more than 25 years.

The causes of diabetic neuropathy are multiple and researchers are now studying how prolonged exposure to high blood glucose causes nerve damage. Nerve damage, however, is likely due to a combination of factors:

Metabolic factors: high blood glucose levels, and possibly low levels of insulin
Neurovascular factors: lead to damage of the blood vessels that carry oxygen and nutrients to nerves
Autoimmune factors: can cause inflammation in nerves
Lifestyle factors: smoking or alcohol use (in this case, the patient also smoked!)

So my patient’s intense facial pain was most likely glossopharyngeal neuralgia, a type of neuropathy that individuals with diabetes may develop, particularly when aggravated by chronic smoking! Glossopharyngeal neuralgia causes sudden, intense pain in the throat, mouth, tongue, jaw, ear, and neck and may be brought on by swallowing, sneezing, chewing, clearing the throat, eating spicy foods, drinking cold liquids, speaking, laughing, or coughing.

As with other neuralgic pain, the course of treatment has been to use medications to reduce the spontaneous firing of nerves in the presence of normal stimuli, in this case eating. Though glossopharyngeal neuralgias are often quite receptive to medications, my patient’s history of diabetes and long-term smoking will likely be complicating factors that will influence her ability to respond to treatment.

For more information about neuropathy and diabetes, link here.

Live or work in New York City or on Long Island? You can schedule a consultation with me here or call 212-265-0110

Tags diabetes risk factors for tmj, diabetic neuropathy, Dr Donald Tanenbaum, Facial Pain, facial pain and diabetes

TMJ

Are Anti-Inflammatory Medications Safe for TMJ?

Though it is common for many TMJ sufferers to take anti-inflammatory medications called NSAIDs, which are available without a prescription in local pharmacies and in super-sized containers in big box stores, they are not as safe as presumed.

The most common of these over the counter medications are Advil and Aleve and many of my patients down them as if they are sugar-coated candies. Even when the medications are not working, patients continue to use them, wrongly assuming that since they are available without a prescription that they are safe in any quantity.

For the most part, short-term use of these medications for a period less than ten days should not pose any health concerns. Unfortunately, many TMJ problems may require weeks of use in order for muscle and joint inflammation to be controlled. As a result, these medications can pose cardiovascular, kidney, and gastrointestinal risk.

In particular, patients with a previous history of a heart attack are more at-risk for another episode when taking this class of medication. Medications for high blood pressure and so-called ‘water pills’ (anti-diuretics) may also not work as well when NSAIDs are taken at the same time. Kidney performance can suffer as well when taking these medications in an uncontrolled manner over an extended period of time.

Though these medications are commonly associated with stomach upset prompting patients to discontinue their use after a short period of time, many patients tolerate these drugs for long periods before the side effects of upset stomach and bloody stools are experienced. By this time, damage may have already occurred to the stomach and other parts of the digestive system. So here are some suggestions:

Using NSAIDs Safely

Don’t take these medications for more than two weeks without professional guidance.
Make sure you take these medications with at least twelve ounces of water or after a meal.
Take these medications at the recommended time interval between doses and not before, even if pain begins to increase.
Don’t rely on these medications to ease symptoms. Use other strategies at the same time to help decrease inflammation. These other efforts can include following a soft diet, using ice/heat, self or professional massage, stretching your jaw muscles; the list goes on.
If while taking these medications you begin to bruise easily, discontinue use immediately and consult with your physician.
If you have a history of hypertension, routinely take your blood pressure when on these medications.
If your stomach begins to hurt or your stools darken, discontinue these medications and consult with your doctor immediately.

In summary, NSAIDs are tremendously helpful medications, but benefit and risk should always be weighed. If you are not sure, whether to use or continue using these medications, professional consultation is always advised.

There are more treatment options available to help alleviate TMJ pain:

Tags Dr Donald Tanenbaum, NSAIDs and TMJ pain

Sleep Apnea Snoring

Snorers! Now A Sleep Study Can Be Done in Your Own Home

Snoring, long considered to be no more than a social nuisance, is now seen by the medical community as a possible sign of more serious health conditions. In order, however, to determine whether a patient’s snoring indicates a more serious disorder, like obstructive sleep apnea, overnight sleep studies are critical to obtain. The problem of course is that many patients are resistant to spending the night at a Sleep Clinic, and after hearing nightmare stories from friends and family that have spent restless nights lying awake in a sleep lab, refuse to schedule an appointment.

It is not uncommon therefore to be confronted by this familiar story. The patient, a man in his mid-thirties or forties, married, with children has a history of snoring. With some gain of weight his nightly snoring has become so disruptive that his wife routinely leaves the bedroom halfway through the night. On vacations, it’s necessary to reserve two rooms instead of one just because of the snoring. Basically, dad disturbs the sleep of the entire family.

Upset and exhausted, the wife finally convinces her husband to see his physician, which he does, though reluctantly. The physician then suggests a Sleep Study, which involves a night away from home at a Sleep Center. This is where the problems really start as men often refuse to spend the night away from home, particularly since they don’t even think they have a problem and deny that they snore in the first place. So, the snoring goes on, the family suffers and more importantly the snorer may be at risk for health consequences down the road.

But, there is good news for snorers and their families. In the past 10 years advances in technology have brought sleep testing equipment to the bedroom. At-home Sleep Study equipment has been proven to provide reliable data and is currently a service that has been embraced by medical insurance carriers. In fact home studies are often being required prior to the more formal and traditional study done in a sleep lab. Although physicians have traditionally been thought of as the primary health care provider to advise patients with snoring and more serious airway problems (like apnea), dentists have begun to play a critical role in terms of assessment, and more importantly in motivating patients to pursue comprehensive evaluations inclusive of overnight sleep testing.

What then would indicate that a home study is needed?

In order for your doctor to ascertain if you are a candidate for a Sleep Study, he or she will ask you questions about your health, and how you routinely feel during the day and on arising in the morning. Pen and pencil questionnaires may also be given to you which ask questions about:

Daytime sleepiness
General fatigue levels
Frequency of sleep arousal
Morning headaches
Irritability in the morning or daytime moodiness
Problems concentrating during the day
GERD
Hypertension

If your answers indicate that a Sleep Study is recommended, your doctor will set in motion a process to pre-certify the home study through your insurance company.

The testing equipment will either be obtained at a local sleep center or it will be shipped directly to your home. The equipment is easy to use and very self -explanatory. You will need to use it for only one night, then return it so that the data can be read and interpreted by a board-certified sleep physician. A report is then sent to your doctor who will then be able to make a recommendation based upon the findings.

In my practice, depending on what the Sleep Study indicates, recommendations for additional consultation or treatment will follow. Snoring that does not carry with it other health concerns can be treated with an oral appliance. Apnea if present can be treated in a number of ways depending on the severity identified on the overnight study. Oral appliances certainly are one option that can be explored.

The goal: Healthy airways and maybe save a few marriages along the way!

To learn more about Oral Appliances for Sleep Apena Treatment, consider reading some of my other recent blogs:

Tags Dr Donald Tanenbaum, Sleep Apnea, sleep apnea treament, sleep studies at home, sleep study, sleep study at home, Snoring, snoring treatment

Facial Pain TMJ

Chronic Facial Pain More Debilitating Than Back Pain

A lot of times people deal with aches and pains by simply ignoring it, or taking an aspirin in the morning before heading out to work. In many cases aches and pains are the unfortunate byproducts of getting older or working hard. For some patients, they look at having a TMJ problem in a similar fashion. They’ll take a couple aspirin, massage their jaw muscles or maybe switch to soup for a day, and then try to ignore it. But did you know that TMJ disorders can be among the most debilitating forms of pain people can suffer?

According to a recent study by University College in London, orofacial pain is any type of pain that occurs in the region of the face, including the mouth, jaw (TMJ), nose, ears, eyes, neck, and head are considered more debilitating to its sufferers than those suffering with chronic back pain or headaches. When compared, those who suffered from facial pain reported higher levels of disability and limitation than those who suffered from backaches or headaches by a margin of more than 19%.

Dr. Leeson, a member of the pain study, said. “These initial results suggest that chronic orofacial pain can have a significant impact on patient’s lives, affecting their normal daily activities, ability to work and causing marked disability.”

Though creating high levels of suffering, help is available for these problems. Rather than suffer through the pain and jeopardize your ability to perform at your job, or to have a fulfilling life, consulting with an orofacial pain specialist is the first step in getting relief. It is not uncommon for patients who have been suffering for months or even years to find considerable relief from the nonsurgical therapies that are commonly employed. If, however, care is not provided, these problems can become rather complex and challenging to manage.

Tags Dr Donald Tanenbaum, Facial Pain, Orofacial Pain, TMJ, TMJ Dentist, TMJ Doctor

Facial Pain TMJ

Get to the Source of Your Facial Pain

Quite often patients come to our office stating that they have been diagnosed with a TMJ problem due to the location of their facial pain and jaw pain complaints. Though statistically other than toothache pain, the most common facial pain problem is due to the jaw muscles (part of the TMJ system), there are a number of other pain problems that we see routinely. These problems are in fact distinguishable from TMJ problems in a number of ways.

Remembering that a TMJ problem is an orthopedic problem, similar to those in the knees, elbows or ankles, the complaints and findings should be familiar and predictable. For instance if you have a knee problem, there is a good chance that going for a jog or using the knee repetitively during exercise would increase the pain, noise in the knee, or the experience of joint instability. The same should happen in the TM Joint during chewing or keeping the mouth open such as during frequent yawning or sitting in the dental chair.

If a patient says that she* can open and close her mouth, chew whatever she wants, and maintains jaw opening without predictably increasing pain and or making it worse, it is likely that she does not have a TMJ problem. In addition, the pain of a TMJ problem is like that in an elbow that has been overused or strained overtime. The pain has an aching quality that typically is not gone completely during some hours of a day and miserable during other hours for no apparent reason. So, if it’s not a TMJ problem, what can it be?

3 types of Facial Pain that are NOT related to TMJ:

Facial Pain referred from the neck and shoulders
Facial Pain of nerve origin
Facial Pain due to migraines

Pain From The Neck And Shoulders: These problems are related typically to muscles in the neck and shoulders that are in a state of tension. These tense muscles have the ability to refer pain to the face (pain location is frequently not the same place as the pain origin). The pain is often felt in the lowest part of the jaw and does not typically increase with chewing…even with bagels!!!! Examination of these muscles reveals tenderness and often can reproduce the pain in the face. These muscles often refer pain to the ear and teeth prompting medical and dental investigations.

Pain Of Nerve Origin: Though often labeled Trigeminal Neuralgia (which may be the diagnosis), there are a number of variations. The most important thing to remember is that these pains can often be present for seconds or minutes and then totally go away for no apparent reason or time frame. The pain is often sharp and described as excruciating (which, in contrast, is a word never used by a TMJ sufferer). The onset of the pain is often unprovoked but in the words of many patients, “it just comes out of nowhere.” Other nerve pain problems that may be more constant often having a burning quality.

Pain Due To Migraines: Facial pain, including toothache complaints, can be due to migraine problems. This pain often has an odd character, which may include a sense of numbness in the face, and again often do not relate to jaw use. The pain may be preceded by light and noise sensitivity and or a headache across the forehead or in the mid-face region. At times a sense of nausea may accompany these symptoms. Typically these pain complaints are not accompanied by limited jaw motion, jaw noises, or eating challenges.

*Note: facial pain can affect anyone, but the majority of sufferers are female

Tags Dr Donald Tanenbaum, Facial Pain, Migraines and Facial Pain, Nerve Origin Facial Pain, Referred Facial Pain, TMJ and Facial Pain, Types of Facial Pain

Facial Pain Referred Pain

Causes of Facial Pain: The Psycho-Muscle Connection

The Muscle Connection is Key

In my book, Doctor, Why Does My Face Still Ache?,” we explore puzzling questions that do not have simple or anticipated answers:
• Why would a person experience a constant toothache when the tooth that hurts is completely fine?
• How does someone gradually lose the ability to open his or her mouth or talk when there hasn’t been a direct injury to the area, or medical disease diagnosed?
• Why does someone experience non-stop aches or pains in their face when a medical evaluation suggests that nothing is wrong?

Unfortunately in the search for answers, many practitioners tend to overlook the muscle connection when it comes to the cause of facial pain. But considering how much of the face is made up of muscles, it’s beneficial to know how muscles can be affected by factors such as emotional issues and the stress of life-challenges. In the book, I call this state a “Brain Under Siege.”

Facial Pain and Emotions

A brain is under siege when it is faced with many challenges, which may include but not limited to:
• Economic uncertainty
• Loss of control relating to illness, aging parents, work relationships, etc.
• Inability to express fear and anger
• Pressure to “Keep Up with the Joneses”
• Marital and or relationship turmoil

For patients experiencing one or more (or perhaps all) of these stressors, the toll it can take on jaw and neck muscles could directly cause facial pain. I realize that many people might want to reject this theory. Our culture is such that we often look for external or structural causes of facial pain. Even medical professionals are tempted to ignore these connections to muscle pain, perhaps because they’re uncomfortable posing sensitive questions to their patients. But this doesn’t mean that a connection doesn’t exist.

Of course there are many causes of facial pain, and in many cases traditional methods of relieving this pain works fine. But each patient needs to be evaluated individually, and all aspects of what causes facial pain need to be taken into account. Most facial muscle pain sufferers can be helped, and it often requires patient insight and participation so the proper treatment can be applied.

Though we often wish it were so, sometimes facial muscle pain can’t be solved by the patient simply walking into the office and saying, ‘Doctor, fix me.’

Dr. Donald Tanenbaum is a co-founder of New York TMJ & Orofacial Pain. We have four locations in the NYC metropolitan area: Manhattan, White Plains, Long Island, and Springfield NJ. Each location is staffed with board-certified Orofacial Pain specialists who are qualified to diagnose and treat symptoms associated with TMJ problems. Find out more at www.NYTMJ.com

Tags Causes of Facial Pain, Doctor Why Does My Face Still Ache, Dr Donald Tanenbaum, Facial Pain