Dr. Demerjian Center For TMJ And Sleep Therapy

The TM joints work in synergy with the facial bones and multiple pairs of muscles to allow opening and closing of the mouth, chewing, swallowing and speech, as well as to enable the forward, backward, rotational, and side-to-side movements of the lower jaw.

Any disturbance to the perfect facial balance can trigger the cycle characteristic of TMJ disorders, which affects muscles and joints on all areas of the face, neck, and back. When muscles and joints are not working together correctly, muscle spasm can result which produces pain and dysfunction. Due to this complex system, a problem in one area can cause symptoms elsewhere.

In a normal joint, the disc, a thin piece of cartilage, acts as a cushion or shock absorber between the condyle and the glenoid fossa. It is held in place and guided by muscles and ligaments. When the lower jaw opens and closes, the disc stays between the condyle and the glenoid fossa at all times.

The following are contributing factors to TMJ disorder: trauma to the head and face, whiplash, uneven bite (malocclusion), bruxism (grinding your teeth), clenching etc. When trauma to the TM joints is prolonged, the body begins to compensate by involving muscles in other areas: the face, neck, throat, upper and lower back, arms, etc.

TMD is often a chronic and degenerative disease. Anyone experiencing headaches, earaches, dizziness and clicking or popping in the jaw joints should schedule an appointment for a thorough examination with a qualified dental professional, before their symptoms become more severe.

TMJ disorders have been called the “Great Impostors” because many of the symptoms have overlapping characteristics, which often mimic other conditions. Indeed, it is quite common for people to seek the care of a medical doctor or medical specialist in search of a cure or answer. Most, however, never think to contact a dentist trained in TMD since the symptoms are primarily medical in nature.

Do you suffer from any of these?

• Headaches	• Jaw joint clicking or popping
• Facial Pain	• Neck pain or stiffness
• Jaw joint pain	• Worn, loose or sensitive teeth
• Limited ability to open and close your mouth	• Difficulty eating, chewing or swallowing
• Dizziness or vertigo	• Pain whenever you talk or smile
• Earaches (or ear congestion)	• Poor posture

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TRAUMA

According to statistics published in the Journal of the American Dental Association in 1990,* 44% to 99% of TMJ problems are caused by trauma. By trauma, we mean an injury as obvious as a blow to the jaw with a fist or something as subtle as a whiplash injury, with or without direct trauma to the head or jaw. (*JADA 1990;120:267) An overwhelming majority of patients who sustain whiplash injuries in motor vehicle accidents (MVA) also dislocated one or both temporomandibular joints at the same time without having impacted their face or head against the steering wheel, door column, windshield or other parts of the car.

Some of the causes of TMD include:

• whiplash injury and automobile accidents
• intubation procedures in hospitals
• trauma to the head, face, or jaw

TMD diagnosis is a complex and often daunting process. This explains why physicians and dentists who are not board-certified orofacial and craniofacial pain specialists may miss a potential TMJ disorder in a patient that is suffering from chronic head, neck and/or facial pain.

How is the diagnosis made?

The usual evaluation of the TMJ involves a physical examination of the muscles of the head, face, neck and shoulder with manual palpation. The doctor feels for muscle spasm and rules out "trigger points" which can refer pain to other areas. Ranges of Motion Studies–measurements of jaw movement when moving side to side and on full opening of the mouth, are assessed. General skeletal alignment is also assessed. Additionally, radiographs allow us to see actual pictures of the joint components and their relative state of health. In many cases, additional tests may be recommended. At our office we also utilize the latest in computer diagnostics to measure and record jaw joint activity and jaw movement.

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Parkinson’s Disease (PD) is a progressive neurological disorder that affects movement. Its symptoms may include tremors, rigidity, and blank faces. Slowing or jerky movements are also characteristic of this disease. Comorbidities of Parkinson’s include difficulty sleeping, forward head posture, problems with balance, and other neurologic problems. Symptoms of the disease usually begin between 50 and 60 years old, although some have experienced earlier symptom onset (WebMD, 2010). Various diagnostic tests are used to determine PD, although there are many disorders that resemble Parkinson’s symptoms.

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Cervical Dystonia (CD), or Spasmodic Torticollis, is characterized by abnormal movement or positioning of the head and neck muscles. These sustained muscle contractions result in abnormal head postures which vary depending on the muscles that are affected. CD is the most common form of focal dystonia (it affects one area of the body) and is found in twice as many women as men (Sims, Stack, & Demerjian, 2012). Symptoms of CD include rotational twisting (laterocollis), backward rotation (retrocollis), or frontal rotation (anterocollis), of the head / neck and/or a combination of these. Pain or head tremor is often associated with those that have sustained contractions and there is often associated dystonia in the upper muscles of the same side (segmental dystonia) (Sims & Demerjian, 2012).

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Fibromyalgia is a chronic disorder characterized by pain and tenderness in the joints and muscles of the entire body. It is accompanied by fatigue, loss of sleep, headaches, and has also been linked to depression and anxiety (A.D.A.M. Medical Encyclopedia, 2012). Fibromyalgia is believed to be the result of amplified pain sensations that affect the way the brain processes pain signals (Mayo Clinic, 2011), although it has also been attributed to physical or emotional stress, repetitive injuries, or illness (NIAMS, 2011). Symptoms of fibromyalgia mainly involve pain. Tender points, or painful areas, can be found in the soft tissue of the neck, shoulders, back, hips, elbows, and knees. From these areas, the pain surges to different parts of the body and may feel like a deep ache or a shooting “burning” pain (A.D.A.M. Medical Encyclopedia, 2012). Fibromyalgia affects more women than men, most commonly occurring around middle-age (NIAMS, 2011). It is also more likely to develop in those who have a family member with the disorder and those that have a rheumatic disease (Mayo Clinic, 2011).

Tourette Syndrome (TS) is a neurological disorder characterized by involuntary movements (tics) and vocalizations. Tics occur frequently and rapidly and can present itself on the face, specific body parts, or the entire body. These uncontrollable motor movements may start as an eye blink or a nose twitch, but can progress to more complicated movements such as kicking or stamping (nTSA, 2012). Verbal tics, such as groaning or throat clearing, usually accompany these involuntary movements. Echolalia, or the spontaneous utterance of sounds, is a well-documented symptom of TS (Sims & Demerjian, 2012), although corpolalia, or involuntary swearing, which is popularly associated with the disorder, is a rare occurrence (nTSA, 2012). Symptoms of TS include either simple or complex tics and often get worse with intense emotions, excitement, or anxiety (NINDS, 2012).

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Complex Regional Pain Syndrome (CRPS), also known as Reflex Sympathetic Dystrophy (RSD), is a nerve disorder that produces chronic pain in an area of the body and is believed to occur as a result of injury or dysfunction to the nervous system (NINDS, 2012). Common features of CRPS include severe skin discoloration and temperature changes over the affected body part, followed by an intense burning sensation, sensitivity to touch, and swelling (NINDS, 2012). CRPS has two forms: CRPS I occurs as a result of a minor injury and CRPS II occurs due to injury to a nerve (A.D.A.M. Medical Encyclopedia, 2012). CRPS affects both men and women of any age, although many experts agree that it is more common among young women (NINDS, 2012).

Sleep problems have many causes:

It could be a problem with your airway and/or your breathing, such as snoring and obstructive sleep apnea. It could be a problem with the way signals travel to and from your brain, such as narcolepsy. It could be a condition that causes uncontrollable leg movements at night – that is, restless legs syndrome. Or it could be one of the many problems that lead to insomnia, such as stress.

Sleep disorders are common among patients who suffer from allergies, ulcers, arthritis, heart disease, asthma, hyperthyroidism, kidney disease, Parkinson's disease, and Alzheimer's disease.

If you or someone you love is suffering from a lack of restful sleep, a smart first step is to discuss your concerns with a dentist who is trained in dental sleep medicine. He or she will review your dental and medical history, evaluate your airway and nasal passages using state-of-the-art technology and, if warranted, recommend treatment or refer you to the right kind of sleep specialist.

• Snoring
• Upper Airway Resistance Syndrome (UARS)
• Obstructive Sleep Apnea (OSA)
• Central Sleep Apnea
• Sleep Bruxism
• Excessive Daytime Sleepiness

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According to the American Sleep Apnea Foundation, more than 12 million Americans suffer from sleep apnea, and it is estimated, conservatively, that 10 million Americans remain undiagnosed. Are you one of them?

When the muscles of the jaws, soft palate and the tongue become too relaxed during sleep, they can sag and partially or completely block your airway. As you struggle to breathe, your body becomes distressed and you become partially awake, nearly every time this event occurs. These episodes can occur hundreds of times each night, keeping you from reaching the deep, restorative sleep your body requires and putting a great deal of stress on your heart. Since this can have serious consequences, we urge anyone who is concerned about the quality of their sleep to contact their physician or a dental professional with advanced training in dental sleep medicine.

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After a thorough examination of the airway and nasal passages, if the problem is found to be in the nasal passages or adenoids and tonsils a referral will be given to an otolaryngologist (ENT) with the testing results for the ENT to be able to determine the degree of obstruction and necessity for surgery.

However if SDB is due to a malformation of the teeth and jaw then we will be able to evaluate the child for oral appliance therapy. With oral appliance therapy we can correct structural problems such as recessed jaw, narrow arches that may be leading to airway narrowing or collapsing.

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CPAP is an extremely effective therapy; however, nationally only 45% of patients using CPAP machines continue to use them.

The American Sleep Disorders Association is recommending dental appliance treatment for patients with severe OSA who are intolerant of, or refuse treatment with, CPAP.

A CPAP (continuous positive airway pressure) is a machine that delivers lightly pressurized air through a hose to a small nose mask. The flow of the air acts like an “air splint” to keep the upper airway open and prevent apnea (i.e., shortness of breath). CPAP machines have 99% efficiency in restoring normal breathing during sleep. They have also undergone many improvements since an Australian invented the first one from a vacuum cleaner and a length of hose. However, the rate of patient compliance with CPAP is less than 50%.

Thanks to advances in dental sleep medicine, qualified dentists can effectively treat many patients who suffer from snoring, obstructive sleep apnea, upper airway resistance syndrome and other sleep-disordered breathing problems using oral appliance therapy.

An oral sleep appliance is similar in appearance to an athletic mouthguard, and it is worn during sleep to maintain airway patency. Oral sleep appliances are safe, less expensive vs. CPAP or surgery, and easy to use.

There are also few, if any, side effects. However, one size does not fit all. There are currently six (6) different FDA-approved oral appliances we can use to treat sleep-disordered breathing. Regardless of the appliance selected, to be effective, it must be properly customized and precision fit for each patient. For some patients, an oral sleep appliance can eliminate the need for CPAP or surgery. For patients with more severe sleep problems, an oral appliance can be an effective and convenient adjunct therapy.

Children can also snore and suffer from obstructive sleep apnea. Often they are highly allergic and their airway is blocked due to enlarged adenoids, tonsils or swollen nasal mucosa. The snoring or labored breathing can also be due to structural problems of the jaw and teeth. Sleep Disordered Breathing ranges in severity, from snoring to different digrees of airway obstruction. This is why it is important to have a dentist trained in SDB to evaluate the situation.

Some of the things to pay attention to at home are:

THE FACTS!

Abnormal sleep position Restless sleep Difficulty waking up Bed-wetting Headaches during the day Stop breathing during the night Irritability Difficulty in concentrating at school Hyperactivity

81% of snoring children with ADHD could have their ADHD eliminated if their habitual snoring were effectively treated. (Chervin, R.D., et.al., Symptoms of Sleep Disorders, Inattention and Hyperactivity in Children, 1997, Sleep 20(12): 1185-1192). Using a dental sleep appliance can eliminate the need for surgical removal of the tonsils in some cases. Nighttime bedwetting ceased in 10 cases studied when oral therapies were used to reduce nasal constriction. (Timms, D., Rapid Maxillary Expansion in the Treatment of Nocturnal Enuresis. The Angle Orthodontist, 1990, 60(3).

Unlike adults, children who suffer from  sleep-disordered breathing are often likely to exhibit  hyperactivity during the day.

Restful sleep is essential to your child's health

Undiagnosed and untreated pediatric sleep disorders have been linked to a spectrum of health and behavioral issues, including

• Attention Hyperactivity Deficit Disorder (ADHD)
• Nocturnal Enurosis (Nighttime Bed Wetting)
• Weight Gain or Obesity
• Nightmares

• Why should I consult a dentist about my sleep concerns?
• If I snore, does that mean I have obstructive sleep apnea?
• Can a dental appliance stop snoring?
• Can a dental sleep appliance replace my CPAP machine?

Orthopedics simply put is changing the size, shape, and relationship of the bones of the face and jaws to create symmetry and balance. The simple concept of Orthopedics suggests that dental overcrowding is not due to there being too many teeth, but to the fact that facial growth has not reached its full genetic and growth potential. It takes into consideration airway issues, upper and lower jaw relationship and proper tongue position. Orthodontics simply put is the movement and correct alignment of the teeth.

Both disciplines deal with malocclusion or “bad bite”

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ORTHOPEDICS... CHANGING THE SIZE, SHAPE AND RELATIONSHIP OF THE BONES TO THE FACE AND JAW…IN MOST CASES THIS CORRECTION CAN BE ACCOMPLISHED WITH FUNCTIONAL APPLIANCES AS OPPOSED TO SURGERY

Orthopedics looks at the whole person and as such can be applied to all age groups. Our team will be looking for all aspects of dental, facial, cranial and skeletal structural imbalances. As the baby develops into an infant, external factors (mouth breathing, thumb sucking, ear, nose and throat (ENT) problems etc) effect normal growth. When the baby molars and first permanent molars erupt into contact it locates and locks in the early skeletal development. The teeth will make contact regardless of the size and position of the upper and lower jaws and at this stage, the dental interface becomes essential for the first time. It is possible to interpret the extent of the bony discrepancy for each individual. This is achieved by clinical examination by the Dentist, followed by the taking of study models and cephlometric radiographs.

What caused the problem in the first place?

No one knows the exact cause of every orthodontic problem. Some causes are very evident, such as thumb sucking. Most are much more complex, However, the old cliche' that the patient inherited daddy's teeth and mother's jaw is simply not correct. You are never too old to be evaluated for craniofacial or dental orthopedic problems. You are never too old to correct a problem non- surgically.

 

MALOCCLUSION

Malocclusions are usually inherited or acquired.

Acquired malocclusions can be caused by accidents (called "trauma"), sucking of the thumb, finger or pacifiers, tonsils and adenoids that obstruct the airway, and disease or premature loss of primary or permanent teeth.

Inherited malocclusions that determined how well your teeth fit together are largely determined by such attributes as tooth and jaw size. For example, people can inherit large teeth and small dental arches, or the reverse. A "poor bite" is often caused by teeth that have too much or too little room in the jaw. Other common causes of crooked teeth are factors that move the teeth out of place, including oral habits and early tooth loss, which leads to tooth shifting.

Regardless of whether malocclusions are inherited or acquired, many of these problems affect not only alignment of the teeth but also facial development and appearance as well.

SKELETAL DISCREPANCIES On assessing the face it is possible to see many features that might be construed as not normal, such as:	SYMPTOMS Teeth that do not meet normally will lead to the following symptoms
Narrow palate with a high arch Mouth breathing and poor lip seal Lower jaw well behind upper jaw Lower jaw well in front of upper jaw Lower jaw deviating to one side Temperomandibular joint dysfunction Overcrowded teeth	ENT problems Facial disharmony Problems with biting the cheek or roof of the mouth Over crowded teeth-permanent teeth erupting out of their normal position Poor function of the teeth Headaches and various facial pains Speech difficulties Self- consciousness

FUNCTIONAL HABITS

Functional habits include thumb sucking, mouth breathing or a tongue thrust habit which can contribute to the unfavorable growth of the jaws. Oral habits can commonly cause the upper front teeth to stick out and can contribute to speech problems. The best way to intercept a habit is to first make certain that the child has a proper size airway and can breath through the nose. In cases where there are serious allergies, swollen adenoids or tonsils, a referral to an Ear, Nose & Throat Specialist must be done.

These are all signs that your child may need early intervention!

Dental Orthopedics works with your child's growth and development to guide the jaws to their proper size.

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  Open Bite

  Do the upper and lower teeth not meet in the front when your child bites together?

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  Deep Bite

  Do the upper teeth completely hide the lower teeth when you bite down, or does your child bite on the roof of their mouth?

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  Overjet

  Do the upper front teeth seem to be more noticeable and stick out quite a bit, compared to the lower front teeth?

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  Crossbite

  When you look into your child's mouth are the upper teeth on the inside of the lower teeth? If you think of the upper jaw as the garage and the lower jaw as the car?the garage should be bigger than the car!

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  Crowding

  Are the permanent teeth starting to come in crowded?

• Facial Asymmetry

  When looking at your child from the front does it appear that their face, or chin are shifted to one side. Are they growing crooked?

• Earaches

  Sometimes a bad bite or a deep bite can cause undue pressure on the small membranes of the ear, contributing to earaches.

Early Treatment

Early orthopedic treatment usually starts before the eruption of the permanent teeth or when the child has very few permanent teeth present. Our goal is to guide the growth of the upper and/or lower jaw to make adequate space for the eruption of all the permanent teeth. We feel that children should be evaluated by the age of four to see if there is a bone problem (orthopedic) or a tooth problem (orthodontic).

It is always less expensive to correct a problem when the patient is younger rather than wait for the problem to become more serious in the future.

Dr. Demerjian has taken over 2000 hours of postgraduate education courses, in the area of TMJ, Craniofacial Pain, Sleep Disorders and Orthodontics. He is also a graduate of Las Vegas Institute for advanced Dental Studies –a renowned center for Neuromuscular Dentistry. He is knowledgeable in neuro-anatomy, pain patterns, trigger points, the trigeminal branch/nerve and how it correlates to neurologic disorders.

Since 2004, he has limited his practice to the treatment of TMJ Disorders, Headaches, Facial Pain, Sleep Apnea, Movement Disorders and Orthodontics. Along with two busy practices, Dr. Demerjian also lectures on topics in Temporomandibular Joint Disorders and its correlates on neurologic disorders.

Dr. Demerjian currently treats adolescents and adults with tmj/mpd-mayofascial pain disorders using custom fabricated orthotic appliances, myriad of therapeutic techniques and orthodontics. His sleep-disordered breathing treatments utilize using multiple dental sleep appliances and therapeutic techniques. He also treats patients suffering from neurologic disorderswith dental management of the disorder through his TMJ treatments. He has published several articles and research papers including how the trigeminal system correlates to neurologic disorders.

Bonita High School, La Verne, California 1980-1984

University of La Verne, La Verne, California 1984-1985

Loma Linda University, Loma Linda, California 1985-1987

University of the Pacific School of Dentistry, San Francisco, California 1987-1990

Las Vegas Institute for Advanced Dental Studies, Las Vegas, Nevada 1998-2003

Diplomate/Master - American Board of Craniofacial Pain

Fellow - American Academy of Craniofacial Pain

Diplomate - American Board of Pain Management

Fellow - International College of Craniomandibular Orthopedics

Diplomate – American Board of Forensic Dentistry

Diplomate – American College of Forensic Examiners

Master – Electro-Diagnostic Modalities – Bio-Research Institute

Certified Forensic Consultant

Certified - Academy of Laser Dentistry

American Academy of Craniofacial Pain

American Academy of Pain Management

International College of Craniomandibular Orthopedics

American Academy of Orofacial Pain

American Academy of Dental Sleep Medicine

American Academy of Sleep Medicine

American Association for the Advancement of Science

American College of Forensic Examiners International

International Association of Orthodontics

American Academy of Functional Orthopedics*

American Dental Association

California Dental Association

San Gabriel Valley Dental Society

American Academy of Cosmetic Dentistry*

Academy of Laser Dentistry*

Advanced Cosmetic Interdisciplinary Study Club

Dr. Demerjian grew up in Pasadena and his family moved to La Verne in 1981. He has been practicing dentistry in the city of Glendora since 1990 and in the San Fernando Valley since 2001. He is an avid Martial Arts practitioner, holding several Black Belts in numerous styles. He serves as the head instructor for Marquez School of Hope, teaching karate to all students including to the specially challenged. He is on the Dental Advisory Committee at Citrus College and the Sleep Panel at the Pomona Valley Hospital. He maintains active membership in numerous scientific organizations.