Is There a Connection Between Sleep Apnoea, TMD and Orofacial Pain?

Is There a Connection Between Sleep Apnoea, TMD & Orofacial Pain?

The connection between sleep apnoea, TMD and orofacial pain is more common than one would think. Cases are predicted to rise globally, yet many patients go undiagnosed or misdiagnosed. In this post, we share more about these disorders and how they may be connected.

*Disclaimer: The term ‘Orofacial Pain Specialist’ is made within the context of the USA and not Singapore. The designation of ‘qualified sleep dentist’ is only used in the sole context of the European Academy of Dental Sleep Medicine, an organisation founded and governed by university and hospital-based practitioners which sets the standards of competency in the practice of Dental Sleep Medicine across Europe; dental sleep medicine is not an established dental specialty in Singapore. Please refer to our Disclaimers and FAQ pages for more information.

Definitions of Sleep Apnoea, TMD and Orofacial Pain

There are three different types of sleep apnoea, namely: Obstructive Sleep Apnoea (OSA), Central Sleep Apnoea (CSA) and Complex Sleep Apnoea Syndrome (CompSAS). This article will focus on Obstructive Sleep Apnoea, which consists of about 90% of all sleep apnoea cases, and is the most common sleep-related breathing disorder (Lee, 2022).

In Obstructive Sleep Apnoea, the individual stops breathing for periods of time due to collapse of the upper airway. The scary thing is that such episodes can last for up to 10 seconds, and the person is often unaware that the problem exists. Often it is their partner who informs them about the problem, and more than 80% of people with Obstructive Sleep Apnoea go undiagnosed (Lobbezoo, 2020). TMD (Temporomandibular Joint Disorders) and orofacial pain are also more prevalent in patients with Obstructive Sleep Apnoea (Alessandri et al., 2024), with about 50% of TMD patients living with OSA (Lee, 2022).

There are seven main classifications of orofacial pain, and they can be of a systemic, neuropathic or neurovascular nature, which includes headaches, sleep disorders, TMJ and jaw movement disorders and more, where each is also an umbrella term for yet more specific disorders. For example, there are more than 30 different types of disorders within the category of TMJ-related pain in itself.

Orofacial pain can be difficult to diagnose due to overlap in symptoms, and they can occur anywhere around the orofacial region, including the jaw, mouth cavity, face, head, neck, temporomandibular joints, ears and all surrounding areas. Sometimes, the area where the pain is felt does not correspond with the root cause as well, leading to misdiagnoses.

Whilst sleep apnoea, TMD and orofacial pain can be independent conditions, in many cases one condition triggers the other to cause a cycle of pain, discomfort and/or poor quality sleep. It is best to seek treatment early, so that these issues do not compound.

Risk Factors for Obstructive Sleep Apnoea

One of the biggest risk factors for Obstructive Sleep Apnoea is obesity, which is considered a chronic disease that is becoming epidemic. In fact, about 70% of obese individuals suffer from Obstructive Sleep Apnoea, and obesity in itself can worsen OSA as well (Goyal and Johnson, 2017). With advanced age as another risk factor and in combination with the obesity epidemic, cases of Obstructive Sleep Apnoea are predicted to rise globally.

Other factors that contribute to Obstructive Sleep Apnoea include, but are not limited to: smoking, craniofacial morphology, nasal obstruction, genetic factors, endocrine disorders and menopausal status. Males are also more prone to OSA in general (Shah and Roux, 2009).

If left untreated, Obstructive Sleep Apnoea can lead to health issues both in the short and long-term. Apart from sleep fragmentation and daytime sleepiness, blood pressure, heart rate fluctuations and hormonal imbalances are some of the short-term effects of OSA.

In the long-term, Obstructive Sleep Apnoea can lead to cardiovascular diseases such as hypertension, stroke and heart failure. It can also lead to neurocognitive impairment, metabolic syndrome, and other comorbid medical conditions such as chronic pain and depression (Lee, 2022). Not every patient with OSA manifests TMD or orofacial pain as a sequela, but when they do, it is important to address all conditions simultaneously.

You can learn more about the signs and symptoms on our Sleep Apnoea Treatment page.

Risk Factors for TMD & Orofacial Pain

TMD / TMJ Disorders can affect anyone regardless of age or sex, although it is more commonly seen in women, and those between 20 – 40 years of age. Other risk factors for TMD include: bruxism (grinding of teeth), poor posture, genetics, use of orthodontic braces, excessive gum chewing, jaw injuries, poorly positioned teeth, comorbidities such as arthritis and musculoskeletal disorders, and more.

Orofacial pain covers a wide range of disorders that can be acute or chronic in nature. The most common manifestations of orofacial pain are temporomandibular joint (TMJ) pain, headaches and neuropathic pain. Patients are often misdiagnosed as having a toothache (Renton, 2020), but might be suffering from something else such as Trigeminal Neuralgia or Facial Migraine.

Women are twice as likely to experience orofacial pain as compared to men, and it can occur in children as well. Other risk factors for orofacial pain include, but are not limited to: smoking, psychological factors and comorbidities (Van Deun, 2020).

You can learn more about the signs and symptoms of TMD and Orofacial Pain on our TMJ Disorder Treatment page and Orofacial Pain Treatment page.

The Vicious Cycle of Sleep Apnoea, TMD and Orofacial Pain

Many patients with TMD or orofacial pain suffer from Obstructive Sleep Apnoea concomitantly. According to a systematic review done by Kang and Lee (2022), “Sleep disorders are among the well-known comorbidities of TMD, particularly painful TMDs”.

Some studies have also shown that TMD developed after a patient had Obstructive Sleep Apnoea in almost 73% of the cases (Zwiri et al., 2020), and that OSA can be an independent risk factor for the development of subsequent TMD as well (Wu et al., 2020).

Patients with orofacial pain such as TMD / TMJ disorders are also more prone to Obstructive Sleep Apnoea, so the relationship goes both ways. Studies have shown that about 28% of those with TMD also had OSA, and even if they did not, there may be other forms of sleep-related breathing disorders as well (Lavigne and Sessle, 2016).

In addition, moderate to severe Obstructive Sleep Apnoea can also lead to teeth and TMJ wear and tear, and aggravate existing orofacial pain further (Ning et al, 2023). All combined, this can trigger a vicious loop of chronic sleep deprivation, chronic fatigue and chronic pain that feed into each other.

Sleep Apnoea, TMD and Orofacial Pain Can Also Co-Exist Independently

Having said that, there have also been studies which found no statistical significance between Obstructive Sleep Apnoea, TMD and orofacial pain, as well as Sleep Bruxism. This makes sense as these are conditions are of multiple aetiologies.

The studies that found no appreciable association may have involved cohorts of TMD patients whose causes of pain involved other factors apart from OSA, such as genetic susceptibility to pain, mental stress, etc.

It is therefore advisable and logical to treat Obstructive Sleep Apnoea, TMD and Orofacial Pain simultaneously from a clinical point of view, if these conditions coexist. Apart from the holistic health benefits, treatment may also determine the nature of relationship between these disorders.

Diagnosis & Treatment for Sleep Apnoea, TMD and Orofacial Pain

According to Lobbezoo et al. (2020), “Dental sleep medicine is an up and coming discipline focused on the study of the oral and maxillofacial causes and consequences of sleep-related problems”. The diagnosis, treatment and management of Obstructive Sleep Apnoea, TMD and orofacial pain needs to be approached from a biopsychosocial model, as these conditions interact dynamically over time. A trained dental sleep and Orofacial Pain specialist should be on your primary health care team, as well as other medical professionals such as neurologists and cardiologists, depending on what your diagnosis is.

The gold standard for the diagnosis of Obstructive Sleep Apnoea is polysomnography (sleep study). On top of this, the dental sleep specialist should also take into account the patient’s medical history, and other lifestyle factors that may affect the results. This applies as well to the diagnosis of TMD / TMJ Disorders and orofacial pain, as these often have a multifactorial aetiology with overlapping symptoms. Misdiagnosis not only leads to more pain for the patient, but also incurs unnecessary costs. At times, patients undergo unnecessary dental treatments where the damage is irreversible as well.

Sleep apnoea is primarily managed with the use of a continuous positive airway pressure (CPAP) machine, but many patients find this uncomfortable and the compliance rate may be low. Mandibular advancement appliances (MAD) are also used to manage Obstructive Sleep Apnoea, although your dental sleep specialist will first need to do a clinical examination and carry out the necessary diagnostic tests to see if you are a suitable candidate to use these oral appliances. If suitable, they will then make models of your teeth to craft a customised mandibular advancement appliance for you. Customisation is important, as each person’s oral cavity can differ widely. Surgery is also an option, although conservative management should be approached first.

How Nourish Dental Sleep & TMJ Care, Singapore, Can Help with Sleep Apnoea, TMD and Orofacial Pain

Dr. Eric Chionh runs the practice at Nourish Dental Sleep & TMJ Care in Singapore, together with a committed team. He is formally trained in Oral Medicine and Orofacial Pain, and holds a Singapore Dental Council approved qualification in these areas. He also focuses on Pain and Sleep Dentistry, including Sleep Apnoea.

He has over 20 years of hands-on experience, and is a recognised specialist in Orofacial Pain/TMD on the American Board of Dental Specialties (ABDS), American Dental Association (ADA), and a *qualified sleep dentist under the European Academy of Dental Sleep Medicine (EADSM).

Dr Chionh is passionate about improving his patients’ quality of life using the latest evidence-based medicine and guidelines. He treats each patient as an individual and takes into account their unique medical history, lifestyle, symptoms, pain experience and pain threshold. Our clinic also uses suitable technology to assist with the proper diagnosis and management of sleep apnoea, TMD and orofacial pain.

Visit our About page to learn more about Dr. Eric Chionh and his credentials, and our Services page to view all services provided at Nourish Dental Sleep & TMJ Care.

References:
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  • Goyal, M., & Johnson, J. (2017). Obstructive sleep apnea diagnosis and management. Missouri medicine, 114(2), 120. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140019/
  • Kang, J. H., & Lee, J. K. (2022). Associations between obstructive sleep apnea and painful temporomandibular disorder: a systematic review. Journal of the Korean Association of Oral and Maxillofacial Surgeons, 48(5), 259. https://doi.org/10.5125/jkaoms.2022.48.5.259
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