Bridging Dentistry, TMJ, and Sleep
Interview with Dr. David Shirazi
I’ve explored the topic of sleep a few times, and it was a pleasure to connect with Dr. David Shirazi as a result. I’m delighted we had the opportunity to collaborate on this informative interview.
With thanks to Dr. David Shirazi.
TMJ and Sleep Therapy Centre of Los Angeles and Conejo Valley
Sleep Series so far:
1. David, you hold multiple certifications as a dentist, acupuncturist, and sleep technologist. What led you to pursue this unique combination of specialties?
Thank you for the question! My mom is a dentist and of course I was inspired by her, I also love working with my hands and I love helping people. In dentistry, it’s one of the very few professions where you look at people in the eye and connect with them on their medical needs. Outside of being a psychologist or an osteopath, every other profession seems very deliberately to distance the patient and practitioner.
Immediately after dental school while taking ridiculous amounts of continuing education, I was getting a Masters in Chinese Medicine with the main intention of when I have my own family I can take care of them as holistically as possible. Western Medicine is great for emergencies, i.e. steroids and antibiotics when you need it, but how do you prevent an illness or extend life? How do you treat a medium grade problem? I opened my first practice after completing that degree and seeing how I could combine the two to be very effective with my patients.
Immediately after that I pursued a Masters in Spiritual Psychology, again with the intention on working on myself so I could be the best dad/husband/doctor/man I could be (I’ll always be working on this btw). And after practicing in functional orthodontics, TMJ disorders (orofacial pain) and sleep apnea, and I had taken so many courses outside of dentistry, Chinese Medicine and Sleep Technology, at a Sleep Tech conference someone asked me if I wanted to become one and open up my own sleep lab.
I was so shocked by the question, as it never really called to me as there’s so many that have sleep labs around me. But on the flight home I was thinking about it in earnest, and since I was moving my practice one block away to much bigger space, it seemed very possible! I never renewed that license after 5 years, as there’s just not enough time to do all the CEs for three licenses and have a busy practice and a family.
2. Can you walk us through your journey to becoming board-certified in Cranio-Facial Pain? What inspired your focus on TMJ (jaw joint) and sleep disorders?
I first started by performing functional orthodontics on the growing child. Back then, sleep apnea was not in the mainstream consciousness but all the symptoms of it were well known: ADD/ADHD, bet wetting, bruxing (grinding the teeth at night) difficulty in school and sibling housing settings. And we did see huge improvements in their lives and their family's lives after successful treatment.
We were often focused on achieving a "Class I Skeletal" relationship, i.e. the ideal norm of facial and dental development, and the results were so profound that even their parents asked me to help them, which then let me to go and do more training to help adults. As I got more and more skilled with it, I could see that many patients can be helped without the need of orthodontics though many absolutely still need it.
Back then there was no speciality for TMJ or Orofacial pain, so the only thing you could do would be to be Board Certified in either Cranio-Facial Pain, or Orofacial Pain. These were the only two Boards that had Diplomate status that had Psychometric exams and even an oral "defend" exam that you could prove you really knew what you were talking about.
3. Your practice combines traditional dental approaches with alternative medicine like acupuncture and cold lasers. How did you develop this integrated treatment philosophy?
I am very privileged to say that I stand on the shoulders of giants. I could not have asked for better mentors in my lifetime; it seemed they were all extremely expert for their niche(s) and more so than anything they emphasized on diagnosing first and treating second and to always be thinking of what’s going on.
We see our patients through a course in their timeline, we have to discern if its an easy, moderate or severe case, and how they got to where they are, and why they're in your office. I never understood why anyone should have a problem with doing/trying a conservative approach as long as there are studies that show their effectiveness (short and long term) and their safety. Wouldn't you want that for yourself? I know I would want it for me and my loved ones.
4. You've treated numerous TMJ patients. What are the most common misconceptions about TMJ disorders that you encounter?
Probably the most pervasive one is that they're all crazy. And that’s not to say that mental illness doesn't overlap with pain, but we know that the #1 cause of insomnia is pain, so these patients are in pain AND can't sleep properly, how do you expect them to be in the world? If I go one night without sleep I’m quite grouchy myself (I should add that that doesn't mean we tolerate abuse to our staff based on their pain, they are still responsible for their behavior).
Probably the next most common belief is that TMJ disorders can never be fixed, only "managed" with lifelong drugs or surgery or both. Though it’s true that sometimes we need traditional interventions, and sometimes prescribing a drug temporarily can tell us what the correct diagnosis is, based on how it works or doesn't work, but in my experience the majority can be treated without lifelong drugs or surgery.
5. Could you explain the connection you've observed between jaw issues and Forward Head Posture? How does this impact overall health?
In my eyes, I see the TMJ as the next cervical vertebrae above C1, what I call C0. If someone can't breathe out of their nose properly and are mouth breathing, and/or they have a swallow that elicits pain as their teeth are coming together, this can drive patients to keep their heads forward, which puts further strain on the neck, which can further add to a phenomenon called Central Sensitization. This is the mechanism of how Migraines are formed, and the cause is chronic peripheral nerve pain.
6. Your research indicates that 18 to 70 million Americans have sleep-disordered breathing. What makes this such a widespread yet often undiagnosed condition?
Mainly because it happens in our sleep, while everyone else is sleeping and we are not at all consciously aware that it’s going on. Even if someone chokes themselves awake, by the time they're awake they often don’t even know that they were gasping/holding their breath. They may realize that their heart is racing, and their mouth is dry, but because they had no idea what was going on 10 seconds before, it can get shrugged off as anxiety.
When you add that as a society we have passed on proper breast feeding over to bottle feeding, which narrows the palate, which is also the floor of the nose, which then compromises the size of the nose and mouth (i.e. teeth crowding), we are getting started on the wrong foot in having enough surface area to breathe. Then factor in how 1/3 of the population is obese, at least, this then further compounds the issue.
7. You've mentioned that cluster headaches are strongly correlated with sleep apnea. Could you elaborate on this connection?
Well we certainly see the overlap between patients with OSA and chronic jaw, head and neck pain with over 2000 articles showing this overlap, here is one: (Rains JC, Poceta JS. Headache and sleep disorders: review and clinical implications for headache management. Headache 2006; 46:1344–1363). It’s well established during overnight sleep studies, and in real time, that when the airflow slows in our sleep, even if there’s no lack of oxygen, the masseters are engaged to clench very hard, which then restores the neuromuscular tone in the tissue of the oropharynx, which then restores normal airflow and then bruxing ends (we see this at least 50% of the time associated with bruxing).
Now, what would this chronic bruxing all night do the TMJ? And when do we ever get a break from using our jaws? We eat, chew, talk and sometimes clench during the day (though at a much much lower compressive force than at night). This comes back to where we were discussing Central Sensitization, when you have a chronic peripheral nerve injury like jaw pain, like neck pain and etc, that is going on for so long that it causes these plastic changes to the Pons of the brainstem, in the trigeminal nucleus, causing disorders like migraines and cluster headaches and many other disorders.
In my POV, the mechanism with Cluster headaches and OSA goes deeper than that, but that is more than I can write in one essay. Most central sensitization pain syndromes, also called chronic regional pain syndrome, deal with pain but because the trigeminal nerves have both sensory AND motor functions, that is where we get blood vessel dilation and contraction on the MCA and STA arteries.
8. Your center offers NightLase® treatment. What made you decide to adopt this European technology, and how has it transformed your approach to treating sleep apnea?
We have a funny saying in my industry: the term WNL usually stands for Within Normal Limits. In my field it usually stands for We Never Looked. So in our initial evaluation we look to see what are the areas and tissues that are collapsing that need attention that are causing the snoring and/or sleep apnea.
If the cause appears to be in the oropharyngeal space and if the apnea is mild enough, we use a laser technique called NightLase on at least 3 visits to tighten the tissues back there, to make them what we call "less collapsable." Being focused on using techniques that are more conservative is what drew me to this technique. It didn't hurt that I already had the $100K laser required for it in my office already!
9. Women make up 90% of TMJ treatment seekers. What factors contribute to this gender disparity?
We see TMJ disorders split evenly among men and women, however women of child bearing age have much higher levels of estrogen which again through research we know exacerbates or sensitizes the pain. This makes the pain so much worse that they seek treatment at higher rates.
10. How do you approach treatment for patients who have both TMJ issues and sleep apnea, given the potential connection between these conditions?
This is where it gets technical, and I think truly sets me apart from other providers of TMD or OSA treatment. Before I became expert on sleep disordered breathing I was expert in TMJ disorders and because of that, I know where and where NOT to put the jaw.
The vast majority that treat OSA with oral appliances, as far as I’m able to see and I admit I am N of 1, have truly no concept of what to do with the jaw itself, either in the treatment of a disorder or in not causing a new problem when making an oral appliance for OSA. This in my POV is very very important for solid treatment outcomes. But to answer to your question more directly, I would treat jaw issue first and then if successful move into OSA treatment.
11. How has your understanding of the relationship between airway issues and TMJ disorders evolved throughout your career?
At first I had no idea there was a correlation, this was over 20 years ago! It just seemed that all these things, bruxing, TMJ disorders and patients that couldn’t tolerate CPAP with apnea all seemed to be in one lump group. It was a curious oddity at first and now I find it enlightening and it makes me so excited for the new discoveries we have yet to have! It has come very far but it has more to go, for sure.
12. What are the key warning signs that someone should look out for regarding TMJ or sleep disorders?
For sleep apnea, we see it related to every inflammatory condition that we know of; Type II diabetes, depression and anxiety, headaches (all kinds including tension headaches), heart disease, Parkinson’s and hypertension. If someone has these conditions one of the first things they should do, is to do a sleep study.
For TMJ disorders, its similarly causative of issues like facial pain, trapezius syndrome, tension headaches and especially ear issues like congestion/pain/itching and tinnitus. But most that suffer from those symptoms would be hard pressed to even think that it could be related to their TMJ.
13. You utilize both Western and Eastern medicine approaches. Could you share specific examples of how these different modalities complement each other in treating TMJ or sleep disorders?
Absolutely! A common treatment approach in my practice for chronic pain might be the use of oral appliances and cold lasers with the addition of using acupuncture (or even magnets on acupuncture points) to treat the symptomatic needs of the patient.
14. For those interested in learning more about your work or seeking treatment, what's the best way to stay updated on your research and practice developments?
And thank you for ALL your questions! The best way to find us and learn more is to Google: TMJLA.com. We discuss much of what we do on our website.
TMJ and Sleep Therapy Centre of Los Angeles and Conejo Valley
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This article is being forwarded to my son as he has been the recipient of many from Unbekoming. Starting his work history in a dental office he has learned much and appears to be invaluable to dentists. He allowed too many years to transpire and never fulfilled his dream of being a dentist. So now he assists, efficiently runs an office, makes house calls to friends and family and directs all to dentists with what he sees as specific problems.
My son reconnected a previous fall-out of a implant installed badly by a dentist and it's still in, sturdy as a rock. He took my sister into his dentist to repair serious damage at a cost 1000's less than her dentist charged. But he's deeply into sleep apnea with children.
My son knows my feeling about dentists and many other fields of "expertise", are at ground zero so I have refused treatment in many instances because of the ridiculously high level of xrays required that I do not comply with. I'm sure this article will reignite his lost memories of what I did for myself and my dog when all was lost, using accupuncture, homeopathy and Chinese medicine. I'm still here and my dog lived 7 years past a vets expiration date.
I wonder if people are aware of how important this is...? If you look at a diagram of the nerves in the skull, around the jaw, and the neck, it's an amazing network. The CRANIAL nerves control activities of the eyes, ears, nose, throat, swallowing, etc..
When the CERVICAL vertebrae are out of alignment, the jaw is out of alignment, and the tailbone area is out of alignment. Newsflash! The neck is connected to the tailbone. It's all one piece with lots of connections.
This can cause a lot of what people perceive as psychiatric symptoms. They're caused by miscommunication along the nervous system. The messages are jumbled. Psychiatrist not needed.
I think the concept of sleep-disordered breathing is backwards. It's disordered breathing that factors into the sleep disorder. Disordered breathing is caused I believe, primarily by the vagus nerve being out of tone. When it's out of tone, the autonomic nervous system is out of balance, and a truckload of things are affected including breathing, heart rate, digestion, etc. When tone is restored to the vagus nerve, the sympathetic NS calms down, and breathing becomes regular and deep, not shallow with too many breaths per minute. If we are breathing deeply and relaxed, we sleep well.
I think Roman Shapoval mentioned the harm that EMFs do to the jaw... We're holding cell phones or sitting at the computer being radiated with EMFs from the devices. This wreaks havoc on the head and neck - eyes, mouth, jaw, throat, thyroid. I think it's an unrecognized cause of jaw issues and what is referred to as "burning mouth syndrome," which appears to be everywhere.