Blog Post

The Relationship Between Sleep Apnea and TMJ Disorder

Dec 04, 2020

Historically, obstructive sleep apnea (OSA) and temporomandibular joint disorder (TMD)  were typically diagnosed and treated separately. Over time, however, a connection began to emerge that begged the question, “Is there a relationship between OSA and TMD and if so, to what extent are they related?” 


Questions such as this, and with TMDs considered the most common cause of facial pain, ultimately led to the OPPERA (Orofacial Pain: Prospective Evaluation and Risk Assessment) prospective cohort study. This large-scale, multi-center study followed adults ages 18 to 44 years at enrollment for a median 2.8 years. The goal was to identify the incidence of first-onset TMD and potential risk factors for development of TMD. Although the findings indicated an overlap between the OSA and TMD, further studies are required to more completely define the relationship.

What are Obstructive Sleep Apnea and Temporomandibular Joint Disorder?

Obstructive sleep apnea, the most common type of sleep apnea, is signified by breathing that stops repeatedly during sleep. It is usually accompanied by observed loud snoring and abrupt awakenings that include gasping or choking. In severe cases, this can occur up to 30 or more times an hour with breathing paused for 10 seconds or greater. 


Breathing is interrupted when throat muscles become too relaxed and block or severely restrict the airway during sleep. When the brain senses this, the central nervous system is aroused to restart breathing. OSA sufferers often awaken momentarily as this occurs, but these awakenings usually happen so quickly they are unaware. The result, lack of restorative sleep, can lead to host of life-altering or potentially life-threatening symptoms.


Temporomandibular joint disorder is an umbrella term referring to pain and dysfunction of the temporomandibular joint (TMJ) and jaw muscles. The pain may also radiate to the face, neck, and ears. The TMJ, which connects the mandible to the skull just below the ear on each side of the head, functions as a sliding hinge, moving back and forth, side to side, and up and down. Working constantly throughout the day, TMJs enable us to talk, chew, yawn, and more.

OPPERA Prospective Cohort Study Indicates OSA and TMD Connection

The OPPERA cohort study identified TMD-free adult subjects at study onset. A component of the study included identifying a subset of subjects with a high likelihood for OSA, and to what extent OSA symptoms preceded the first-onset of TMD. In summary, the study findings indicate a correlation between the two conditions.


Among the 6.1 percent of study subjects with a high likelihood for OSA, the rate of first-onset TMD was two times greater compared to those with a low likelihood for OSA. Study conclusions after statistical analysis indicated a 73 percent higher incidence of TMD among subjects with a high likelihood for OSA than those with a low likelihood of OSA.

Cause and Effect

With a linkage between OSA and TMD identified, a next step is to determine the cause of the connection. We know certain factors apply. For example, patients with OSA can experience increased motor activity in the upper airway muscles as the body attempts to maintain an open airway during sleep and pushes the lower jaw forward.


This can result in bruxism (teeth grinding and clenching). In fact, nearly one in four people also suffer from sleep bruxism, according to the National Sleep Foundation. Bruxism exerts pressure on TMJ and its articular disc, as well as surrounding muscles and tissues. This pressure and overuse can cause inflammation and result in painful TMD. 


In other instances, OSA may share an underlying cause withTMD. For example, malocclusion can play a role in OSA development by causing the airway to become blocked during sleep. Malocclusion also keeps jaw muscles from resting in an optimum position, which in turn puts stress on the TMJ, thus contributing to TMD.

Implications for OSA and TMD Patient Screening and Treatment

Clearly, with a large-scale study documenting a statistically relevant coexistence of OSA and TMD, the approach to screening and optimally treating both conditions needs to reflect this association. When a patient presents with one or the other, best practices should include screening for the both. If one is initially present but not the other after assessment and diagnosis, such as OSA without TMD, periodic screening checks for TMD should be conducted. 

Treatment Options and Patient Management

Treatment plans and the system of care provided depend on whether one or both conditions are present, and the extent of their severity. 


With TMD alone, at-home jaw opening and relaxing exercises and over-the-counter nonsteroidal anti-inflammatory NSAIDs are appropriate first-line treatments in simpler cases. In moderate and more severe cases, splint therapy may also be part of a comprehensive TMD treatment plan that rehabilitates the transmandibular joint for long term success and lasting relief.  Prescription medication may be required to relieve pain and inflammation. Treatments may also include temporary use of an oral appliance to support the retraining of jaw muscles, myofascial massage therapy, and acupuncture. When TMD is thought to be caused by unmanaged stress and anxiety, anti-anxiety medications may be prescribed. 


Patients with OSA and not TMD are usually treated either with a custom oral appliance or a CPAP (continuous positive air pressure) machine. Patients with mild to moderate OSA who find it difficult to tolerate wearing a bulky CPAP device, may be good candidates for treatment with a more comfortable custom oral appliance. Rather than force air through the airway manually like with a CPAP machine, mandibular advancement devices guide your lower jaw forward. This movement prevents the collapse of soft tissues at the back of the throat, which is a primary cause of obstructive sleep apnea. 


Patients with both OSA and TMD can be treated simultaneously.  Since oral appliance therapy for OSA could potentially cause or worsen TMJ symptoms, splint therapy is often combined with the use of CPAP in this scenario.  This provides both short term and long treatment of the TMJ disorder and immediate treatment of OSA.  If the TMJ becomes stable and symptom free, a mandibular advancement device could be considered to replace the splint and CPAP combination at that point.  Most other TMD treatments can be applied as well, with a few exceptions.  For example, muscle relaxants, which may be used to treat TMD, tend to worsen OSA.  The back of the throat is already too relaxed with sleep apnea, and muscle relaxants exacerbate this.  Therefore, careful coordination by an expert is required with the application of both treatments. 

What This Means for Patients and Treatment Providers

There is still much to be studied and learned about the connection between OSA and TMD, but the OPPERA prospective cohort study identified a significant connection that had not been well-documented with a large-scale study. With this knowledge, treatment for both OSA and TMD can be better-coordinated and optimized. As a result, patients may experience fewer symptoms and better treatment outcomes.  Dr. Katherine Phillips has over a decade of experience coordinating patient care with Sleep Physicians and helping patients manage both TMJ disorders and obstructive sleep apnea.  To request a consultation with her, you can do so here.

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Dr. Kathrine Phillips
About The Author
Dr. Katherine Phillips, DDS, MS received her undergraduate degree from the University of Michigan and her dental degree from the University of Detroit Mercy School of Dentistry. She currently serves as the Secretary/Treasurer on the American Board of Dental Sleep Medicine (ABDSM) Board of Directors and treats TMD and sleep disordered breathing at Restore TMJ & Sleep Therapy in the Houston, TX area. 
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Teeth grinding is the most common cause of jaw pain. Grinding your teeth also results in fractured teeth and the destruction of dental work, which can even change how you look. People who grind their teeth during the day can make conscious changes to reduce their teeth grinding for those who grind their teeth at night . Fortunately, with a visit to Dr. Phillips, you can discover how to stop grinding your teeth. What is Teeth Grinding, and What Causes it? Grinding or clenching your teeth, or bruxism , is a common condition affecting millions of people and, if left untreated, can lead to broader health issues. According to the American Dental Association (ADA), a 2020 ADA Health Policy Institute report stated that half of the dentists saw a rise in clients with stress-related dental problems, primarily due to teeth grinding and jaw clenching. It can happen during the day or night and often goes unnoticed until the person is alerted by a partner or family member. Treating bruxism can prevent further damage to the teeth and relieve any symptoms associated with the condition, and there are several steps you can take to stop grinding your teeth and protect your oral health. People grind and clench their teeth for various reasons, including stress and anxiety, misalignment of the teeth and jaw, or an abnormal bite. In adults, teeth grinding is often caused by emotional tension and stress and can become a subconscious habit. In children, teeth grinding is usually due to an immature bite and can be triggered by new teeth erupting or the recent placement of braces. How Do You Know if You're Grinding or Clenching Your Teeth? Grinding or clenching your teeth can be challenging to identify since it usually happens when you are unconscious or sleeping. However, several signs could indicate you are grinding your teeth. Common symptoms of teeth grinding include: Waking up with a sore jaw Frequent headaches Increased sensitivity or pain in your teeth Tired or tight jaw muscles Pain that feels like an earache, but there is nothing wrong with your ear A locked jaw that is difficult to open or close completely Neck or face pain Noticing that your teeth feel different or worn down You or your sleep partner may also notice that you make clenching or grinding sounds during the night. At a dental appointment, your dentist may suspect teeth grinding if you have the following: Teeth that are chipped, loose, flattened, or fractured Worn enamel on your teeth Gum recession Possible Causes of Teeth Grinding Many people grind their teeth and tighten their jaws without realizing it, especially at night. Although stress and anxiety can lead to teeth grinding, other common causes are: Posture. Poor posture is not only horrible for your back; it's also bad for your teeth. When the body's joints aren't in proper alignment, it can result in jaw clenching and grinding. Misaligned teeth. If the upper and lower teeth don't fit together correctly, the misalignment may result in the tendency to grind teeth or clench jaw muscles. Sleep disorders. Sleep habits and sleep disorders can lead to teeth grinding at night. Chronic obstructive sleep disorder , also known as sleep apnea , is a known cause of sleep bruxism. Resolving sleep apnea can help stop teeth grinding. Sleep terrors and insomnia may also result in grinding teeth at night. Joint disorders. The temporomandibular region is around the jaw, mouth, and ears. This area contains the temporomandibular joints and jaw muscles, which allow the jaw to open and close. Disorders in this area can affect teeth grinding and a sore jaw. Stimulants. Stimulants like caffeine, nicotine, and alcohol can trigger teeth grinding. Avoiding these can help prevent teeth grinding. Stress. Stress is a common cause of teeth grinding and clenching. Finding ways to manage and reduce stress can help decrease teeth grinding. These can include relaxation techniques such as progressive muscle relaxation, yoga, deep breathing, meditation, and guided imagery can help relax the jaw muscles and stop teeth grinding. Chewing on Objects. Chewing on objects such as pencils or fingernails can trigger teeth grinding. You may also need to avoid chewing gum, which can exacerbate teeth grinding. Finding out how to stop grinding teeth at night takes getting to the root cause of grinding. Discovering the cause provides clues, pointing to the appropriate solutions. Prevent teeth grinding during the day. It is crucial to identify triggers that cause teeth grinding if you intend to stop grinding them during the day. Pay attention to your habits during the day and see if you notice when and if your grinding or clenching is worse. A TMJ specialist or dentist specializing in bruxism can provide you with exercises or relaxation techniques you can do throughout the day if you notice yourself clenching and, in some cases, offer medical treatment like muscle relaxants or Botox for bruxism. Prevent teeth grinding and clenching at night/in your sleep. You'll have to make changes during the day to stop grinding or clenching your teeth at night or in your sleep. Start by talking to your dentist or doctor to determine if you have underlying medical issues that could be causing the grinding. Additionally, your dentist may suggest you wear a mouthguard, splint, or other oral appliance. At the same time, you sleep to protect your teeth from further damage and keep your mouth in the proper alignment, helping your TMJ to relax. A custom-fitted mouthguard also helps lessen the impact of teeth grinding by covering the teeth to create a physical barrier that reduces damage. How To Stop Child/Baby Grinding Teeth Many children grind their teeth at night, but most grow out of it. If your child or baby grinds their teeth, the first thing to do is identify what might be causing the behavior. Stress, anxiety, or an underlying medical condition can cause your child to grind their teeth. If the grinding is stress-related, identifying and addressing the source of the stress, such as an overly demanding school schedule or peer pressure, may help. If a medical or dental condition causes the grinding, your child's dentist or doctor can help you determine the best action. If the grinding results from a habit, it can help redirect your child's attention when they start to grind and provide them with other activities that may help reduce their stress and anxiety. Side Effects of Teeth Grinding Grinding your teeth may seem like a harmless habit. After all, it's easier to notice this behavior if you're not on the lookout for it. And unless your significant other or family members complain about the noise from your nighttime teeth grinding, it's difficult to find proof of the act. However, long-term grinding of teeth at night can lead to significant side effects like: Pain in the jaw. The pressure and movement from teeth can lead to tenderness in the muscles, causing jaw pain . For some people, the pain may become chronic and severe. Headaches. The constant back-and-forth movement and clenching can impact the muscles around the neck and head, resulting in headaches due to muscle fatigue and tension. Wearing down teeth. Like sandpaper eventually smooths a surface, the repetitive motion from teeth grinding can flatten teeth and wear the enamel down over time. Teeth grinding can change the appearance of your teeth, causing them to look shorter and making chewing more difficult. Damage or fractured teeth. Grinding can destabilize teeth, making them shift and feel wobbly. The force from grinding may also crack teeth, causing pain and affecting oral health. Misalignment and cracked teeth can result in gum disease, cavities, and tooth loss — leading to poor overall health. Chronic ear pain. The temporomandibular area is closely connected. If the muscles around the ear become affected due to teeth grinding, chronic ear pain may occur. Facial muscle changes. Most people need to be aware that teeth grinding can change the shape of your face. Long-term bruxism can cause shorter teeth. Shorter teeth, in turn, change the structure of the face and jaw — leading to a sunken appearance. In addition, other muscles around the face can enlarge to compensate for dental changes. If you're concerned about your appearance, you may want to note that chronic teeth grinding can change the way you look. Remedies for Teeth Grinding The methods for how to stop teeth grinding at night versus teeth grinding when you are awake are typically the same. Although some treatments aren't quite possible when you're asleep, their benefits can last even after you've gone to bed. Reductive coronoplasty. Reductive coronoplasty directly involves changing or leveling the biting surface of teeth. This procedure reshapes crowded or crooked teeth, improving teeth alignment. Conversely, additive coronoplasty can add to the surface of teeth to help treat bruxism. Dental Appliances: Mouthguards, night guards, and splints. A mouthguard does just that — it guards teeth. Typically used for sports, a mouth guard keeps teeth from injuries sustained during activity. A night guard protects teeth from grinding at night. Lastly, a bit splint guides jaw movement, enabling the jaw to land in the appropriate position. These appliances protect teeth differently, and finding the right one for your situation is essential. Biofeedback. Biofeedback allows a person to train themselves by monitoring auditory and visual stimuli from the body. Although biofeedback needs a person to be alert, the technique can still help sleep bruxism by reducing overall stress. Stress reduction techniques. Though implementing stress reduction techniques such as yoga, exercise, and meditation requires a person to be awake, they can also help with nighttime teeth grinding. Allowing muscles to decompress and relieve tension alleviates stress-induced teeth grinding, even at night. Tongue and jaw muscle exercises. Most people don't stop to think about it, but their faces and mouth are a team of tissue, muscles, bones, and joints that closely affect each other. The tongue, for example, affects how the jaw moves. You reduce teeth grinding by exercising the right muscles — like the tongue and jaw. Behavior changes. Behavioral modifications like changing your posture and avoiding environments that cause stress can reduce instances of teeth grinding. Cognitive Behavioral Therapy (CBT) can help change behavior and thought patterns that lead to teeth grinding. Medications. A doctor can prescribe medication to help treat bruxism if all other treatments don't work. When used for short periods, muscle relaxants can relieve tension in the temporomandibular area. In severe cases of teeth grinding, botox injections can alleviate muscle tension. Antidepressants and anti-anxiety medications assist in decreasing anxiety, allowing jaw muscles to relax and reduce bruxism. How Can a TMJ Specialist Help with Teeth Grinding and Clenching? A TMJ specialist is a dentist board-certified in orofacial pain and conditions affecting the TMJ. TMJ specialists have extensive knowledge and experience regarding the structure, function, and pathology of TMJ. In addition to more thorough diagnostic evaluations, they can often provide more effective and long-term solutions for teeth grinding than your doctor or dentist alone. This is because TMJ specialists use a holistic approach to treatment, focusing on the underlying causes of the teeth grinding, such as stress, anxiety, or misaligned teeth, rather than just treating the symptoms. They often work with other medical experts like dentists or sleep physicians for more comprehensive care and treatment. Protecting Your Oral Health Protecting your teeth is critical to taking care of your overall health. Chronic teeth grinding can result in costly dental work, poor oral health, and chronic pain. If you're experiencing a sore jaw, headaches, or cracked teeth, seeking an expert diagnosis to find the cause is the first step to finding a solution. Get the answers you need on how to stop grinding your teeth at night or keep from grinding in the daytime to protect your oral health. As a TMJ and sleep apnea dentist, Dr. Katherine Phillips specializes in diagnosing and treating bruxism. With her Master of Science in Orofacial Pain From USC and extensive experience in TMJ therapy, Dr. Phillips utilizes proven and effective evidence-based medical interventions to identify bruxism and help find the right treatments to suit your needs. Get in touch today for more information.
By manager 16 Dec, 2022
The temporomandibular joint, or TMJ, is an anatomically complex joint, composed of muscles, joints, ligaments, bones, and discs. Proper jaw movement requires a high level of interaction and coordination among all these components, especially the articular disc (which absorbs stress), the adductors (jaw-closing muscles), the abductors (jaw-opening muscles), and jaw ligaments. This makes diagnosing problems or dysfunction with the TMJ extremely difficult. Properly diagnosing disorders of the TMJ—collectively referred to as TMD—requires both clinical examinations and medical imaging in order to develop an accurate assessment of the joint, its function, and its surrounding bone and tissue. If you are experiencing pain, discomfort, or dysfunction in your TMJ, you will first have a clinical evaluation. This is when your doctor or TMJ specialist will discuss your symptoms with you and examine your jaw, pressing on areas around it to identify any sensitivity. He or she will also observe the range of motion of your jaw and listen to and feel around your jaw while you open and close your mouth. In some cases, the doctor’s clinical findings are enough to diagnose a TMD and begin treatment. Other times, additional diagnostic imaging will be necessary to confirm the presence of a TMD.
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