Hamidreza Nassery , DMD, FICOI, FAGD, FICCMO  
Male, 54
Miami Beach, FL

Interests: My family, Dentistry, all sports, Travel
Miami Beach, FL
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TMD & SLEEP APNEA - So What's the Connection?

Apr 21, 2009 - 4 comments

After the last two blogs, a number of people had asked me about the connection of TMD and Sleep Apnea, and even the origins of these issues.  I am sure that many more had the same question in mind but did not ask.  After all what is a dentist doing speaking about sleep apnea and snoring.
In my previous blogs, you may have noticed how I have mentioned the fact that our dental arches (Upper and Lower Teeth) have been moving back.  We have obseved this phenomenae now for  the past 250-300 years, and it is well documented in orthodontic research.
Dr. Weston Price, a dentist in the 1930's from Cleveland, Ohio, noticed these issues first, some 70 years ago.  He was a true genius.  You see, unlike most who will immediately go into fixup mode, he asked the question, "What is the underlying cuase of all the malocclusion and dengeneration?"  A question that to this day has not been addressed properly.  Unfortunately, the bulk of his work and research has gone unnoticed for the most part. As a dentist, I can tell you that his work or name were never mentioned at all in dental school.  A true travesty.
Whether it is blaten ignorance or systematic cover up  the results are the same.  We have turned into a culture of quick fixes.  The direction of modern medicine and dentistry has been mostly in dealing and hiding symptoms rather than dealing with the source of ailments.  There is a fill for everything, from blood pressure and cholesterol to headaches.  If we break a tooth we just cover it or if one grinds we make them a nightguard, never asking the right question.  Why things go to where they got??
Dr Price asked the right question.  He set out on a journey that took him to several countries where he studied some fourteen different indigenous populations.  From Africian tribes to Eskimos in Alaska, to Polynesian Islands and Swiss Alps.
The first thing he noticed was that the farther he got from civilization the less decay he encountered.  However, he also observed well developed facial features such as nostrils, straight teeth, well developed wide dental arches, healthy bodies and resistance to diseases.  The depth of his findings are much too deep to be explained in a in a simple blog.  I highly recommend reading his book "Nutrition and Physical Degeneration."  It is Timeless.
So, what is the connection of his findings to our subject specifically?  Well, it turns out that those well developed nostrils he noted in his writings have everything to do with what we see today.  Our bodies reaction what he termed "Western Diet" alongside an arguably good dose of environmental pollution, has made it very difficult for most of us to be nose breathers.  We all have differing degrees of histaminic reactions to these substances, which make us more of a mouth breather.
How does this effect our development??  To properly develop our dental arch form, there must be a balance between muscles. Muscles of facial expression from the outside and our tongue from the inside.  However, when one breathes more from the mouth than nose, we effectively take the tongue out of this equation and create the imbalance during our developmental years between ages 2-9, when most facial development is happening this lack of nasal breathing, or upper airway problem will tip the balance off and the only effective force on one upper dental arch is the external forces of muscles of facial expression which will push the upper arch back and narrows it.    In response to this, our lower arch will have to take a more posteriorized position and match the narrow upper arch.  All of these will result in encroachment on the tongue space, which by now has pushed into our pharyngeal airway, also our muscles of masticiation will end up working a different trajectory of function.  This latter is perhaps responsible for most recurrent headaches and sysmtoms.
So now you should have a picture in your mind of what we are dealing with.  I hope that in some small way I have been able to shed some light on the possible origins of these conditions.  This, by no means, is to indicate that these are the only reasons, as there are several other factors that can be at work concurrently.
What seems to be the constant , is the role of our diet in all these ailments.

To your health.

Best Treatment for TMJ

Feb 25, 2009 - 818 comments

For the past few weeks I have been throwing around ideas as to the best way to respond to this matter. You see a recent article ( Feb.3 , 2009 NY times) titled "Best treatment for TMJ May be Nothing" nearly made me clench my jaw to pieces.
While well written, I found that the author, Ms. Brody, relied heavily on out dated and narrow perspective supplied to her by a small group of dentists. The information provided to her would lead one to believe that TMD ( or "TMJ' as it is wrongly called by many) is easy to treat and self-manage or that it may all be in the patient's mind. The sources in the article stated that, "TMJ problems were originally thought to be caused by dental Malocclusion but that this was an infrequent cause of the problem".

The American Academy of General Dentistry (AGD), an organization of some 40,000 of the nation's leading dentist, recognizes the relationship between maloclussion and headaches. Their website states " The average person swallows 2000 times a day, causing the upper and lower teeth to come together and push against the skull. People who have a poorly aligned bite or missing teeth can have related problems, such as frequent headaches or Sleep disorders, because their Jaw muscles must work harder to bring the teeth together, straining the surrounding muscles."

a simple Google search for TMD would have provided this author with a wealth of informative sources regarding her subject.

I, as most responsible medical professionals, believe in using the most conservative successful form of treatment. As one who treats patients with most severe TMD symptoms, I can assure you that my patients are unable to manage the pain associated with these conditions by simply receiving counseling on their habits. What's more is  that I find that dental malocclusion is frequently one of the principle causes of the TMD.

The article went on commenting that MRI and CAT scans are among the biggest advances in diagnosis of TMD, that is just ludicrous.While those are valuable diagnostic tools they do not show what is the underlying cause of the misalignment. I frequently find that to be the malocclusion.

Another statement that I found very irritating was " 80-90 % of the needed information can be obtained just by talking to the patient". Now we all know the importance of a thorough and complete history, it is a vital part of diagnosis. However, when objective evaluation tools such as Electromyography to study the muscle condition, computerized jaw tracking to record and document functional abnormalities, x-rays and MRIs to study the structure are available and yet ignored, it is like saying " lets just do away with the EKG, just ask the patient if they have chest pain".

Dentistry has traditionally been a profession guided largely by mechanical concept. It does not have to that way anymore. It is time for the profession to recognize that occlusion and jaw function are governed by physiological processes and diagnose and treat them accordingly.


Feb 25, 2009 - 13 comments

For many years we have known that heavy snoring causes major increase in risk of carotid Atherosclerosis and stroke. This has been widely established through published research. One such reasearch published in "Sleep" the journal of sleep disorders shows that this risk in independednt of the risk for sleep apnea and nocturnal hypoxia. Carotid Atherosclerosis( hardening or clogging)  is a major cause of storkes.

In a recent published study in Sleep, it was shown that heavy snoring in abscence of sleep apnea also seriously added to the risk for carotid Atherosclerosis and stroke. In this study a group of 110 volunteers were broken down into three groups based on the severity of their snoring. Mild snorers , snored less than 25% of the time, moderates snorers, snored 25-50% of the time and severe snorers snored more than 50% of the time. The prevalence of carotid artery hardening increased along with the severity of the snoring. Non of the volunteers showed oxygen desaturation.

A previously published article in JAMA, reported that snorers have a 300% increase in motor vehicle accidents. Both  snoring and sleep apnea are associated with increased daytime sleepiness and reduced mental abilities in both adults and children. Further more, snoring in children has been associated with poor performance in school and ADHD. Sleep apnea has been shown to permanently affect brain development in children. It is well known that emotional , hormonal, cognitive and autonomic nervous system changes occur in patients with OSA. A recent study in July issue of Sleep, showed that many of these problems remain even after successful treatment of the sleep apnea.

It is estimated that 15-54% of middle aged adults snore. Snoring is a major warning sign for sleep apnea, a much more serious and life treathening  disroder that affects 4% of middle aged males and 2% of middle aged females.
While the gold standard of treatment for this problem is CPAP, or continous Positive Air Pressure machines , it also remains one of traetments with the poorest complaince rates. A properly trained Sleep Apnea dentist who is also trained in the treatment of TMJ can provide these patients with another alternative treatment. Patients generally preferre Oral applainces to CPAP machines.