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What actually causes Obstructive Sleep Apnea (OSA) and why is it left undiagnosed so often? There are a multitude of reasons, but the most common remains that people are unaware they have a sleep problem. OSA is not always obvious (like a broken bone) and people don’t always know how to address the problem. And despite all of the advancements in the healthcare industry regarding OSA, 70–80% of those affected remain undiagnosed.
Dentists and Orthodontists are usually the first to notice the signs and symptoms of OSA (wear of tooth enamel, scalloped tongue, limited airway based on tonsil size, and small palates). Secondary to the dental field would be an ENT specialist or your PCP. Once the symptoms are noticed, referral to a sleep specialist is the proper course of action.
Let’s talk about the causes of OSA. There are 2 types of causes, direct and indirect.
1. Body Weight – Obesity is determined by calculating BMI (Body mass index), which is a measurement of body fat. BMI is your weight (in kilograms) over your height squared (in centimeters). A BMI greater than 30 = obese, while a BMI of 25-29.9 = overweight. Obesity is present in more than 60% of people diagnosed with OSA, and overweight people have a 6 times higher risk of developing moderate to severe obstructive sleep apnea (compared to normal BMI). If you are overweight, your windpipe may become narrow from the extra soft fat tissue, making it harder for it to stay open overnight.
2. Age – As we age, sleep-related disorders become more common (difficulty falling asleep and staying asleep, night-time awakenings, amount of quality sleep obtained, etc.). Studies show that more than 50% of adults over the age of 65 have a sleep-related disorder. Age-related loss of muscle tone in the throat muscles and increased fat deposits in the oropharyngeal area can cause your airway to become narrow or weak, creating tendency to collapse. Lengthening of the soft palate and structural changes in the area around the pharynx can also occur. Additionally, the aging process impairs your brain’s ability to keep your throat muscles stiff during sleep, also leading to airway collapse.
3. Sex – Studies have shown that men are more susceptible to developing OSA than women. The average ratio of male patients vs. female patients referred for clinical evaluation is between 5-8:1. The male predisposition for OSA can be attributed to both anatomical and functional traits of the upper airway, hormonal influences and respiratory responses to arousals. While women also suffer from OSA, they tend to report different symptoms than men. Rather than the typical loud snoring and gasping for breath (stereotype of a man’s sleep profile), women usually report fatigue and lack of energy during the day (things men do not typically want to admit). Furthermore, female bed partners of men with undiagnosed OSA tend to report the symptoms more often than male bed partners of females with undiagnosed OSA.
4. Anatomy – A deviated septum, enlarged nasal turbinates, thickened soft palate, enlarged uvula, large tongue, tonsillar hypertrophy, retrognathia, inferiorly positioned hyoid bone, or maxillary and/or mandibular retroposition can all cause airway restriction. Additionally, your risk of OSA increases if your neck circumference is larger than 17” for males and 15” for females. If your airway is blocked, then your lungs won’t get enough airflow, which results in loud snoring and a drop in blood oxygen levels. When your oxygen drops to an unsafe level, your brain is triggered to disrupt your sleep. This disruption opens up your windpipe again and allows normal breathing to restart (often accompanied by a choking noise).
1. Use of alcohol or sedatives – Sedation can interfere with the ability to awaken from sleep. It can also lengthen periods of apnea (no breathing), with potentially fatal consequences. Alcohol can tamper with hormones you can consume manlig.nu/testosteronbrist/ supplements to help keep your health in the best shape. Alcohol and sedatives can cause the throat muscles to become too relaxed, resulting in OSA.
2. Smoking – Smokers are 3 times more likely to have OSA than non-smokers. Smoking irritates the upper airway tissues, leading to inflammation. The inflammation then reduces the space for airflow, causing eventual obstruction. Smoking has been linked to frequent awakenings and sleep deprivation, contributing to poor sleep quality. Smoking has also been associated with longer apneic episodes and greater levels of oxygen deprivation.
3. Asthma – Studies have shown that people with asthma have a significantly higher risk of developing OSA. This link is even higher for people who were diagnosed with asthma as children. People with asthma suffer from breathlessness, nighttime coughing and wheezing, which disrupts the sleep cycle. The airway becomes inflamed, constricting the airflow and therefore breathing becomes difficult.
4. Nasal congestion – Whether you are suffering from seasonal allergies, a cold or a sinus infection, nasal congestion increases your risk of developing OSA. Your body naturally tries to breathe through your nose while you sleep, so when that isn’t possible, it forces mouth breathing. Mouth breathing then creates a negative pressure behind the uvula, causing noise and vibration between the uvula and soft palate. This sound is known more commonly as snoring.
5. Sleep position – Typically, OSA is worse when you sleep on your back (supine position). OSA can occur in other positions, but the most common complaints from bed partners are when their partner is supine. Additionally, you are more likely to snore while supine, as the tissues in your upper airway can crowd the back of the throat and block airflow. If you phase into REM sleep while supine, apnea may worsen, as your upper airway has no muscle tone during this stage of sleep.
At Michigan Head & Neck Institute, we exclusively offer treatment of sleep apnea that consists of creating a custom-fit oral appliance (mouthpiece) which is comfortable and can be adjusted to meet the requirements of each patient. Even though males who are overweight are at higher risk for OSA, females who are not overweight are also at risk. Each patient is treated with a customized oral appliance that is specific to his or her needs. Dr. Klein works with each patient to provide the best options for their specific treatment.
Please contact our office at (586) 573-0438 if you would like to learn more about the causes of OSA and possible treatment options.
References
Punjabi, N.M. The Epidemiology of Adult Obstructive Sleep Apnea. Proceedings of the American Thoracic Society. 2008; 5(2), 136 -143.
Tishler PV, Larkin EK, Schluchter MD, Redline S. Incidence of sleep-disordered breathing in an urban adult population: the relative importance of risk factors in the development of sleep-disordered breathing. JAMA. 2003 May 7; 289(17): 2230-7.
Redline S, Schluchter MD, Larkin EK, Tishler PV. Predictors of longitudinal change in sleep-disordered breathing in a nonclinic population. Sleep. 2003 Sep; 26(6): 703-9.
Young T, Shahar E, Nieto FJ, Redline S, Newman AB, Gottlieb DJ, Walsleben JA, Finn L, Enright P, Samet JM. Predictors of sleep-disordered breathing in community-dwelling adults: the Sleep Heart Health Study. Sleep Heart Health Study Research Group. Arch Intern Med. 2002 Apr 22; 162(8): 893-900.
Strohl KP, Redline S. Recognition of obstructive sleep apnea. Amer Jour Respir Crit Care Med. 1996 Aug; 154:279-89.
Durmer, Jeffrey. (2016, October). Addressing Sleep: An Umbrella Strategy to Reducing the Impact of Chronic Diseases. Retrieved from www.fusionhealth.com.
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Let’s face it – most of us aren’t thinking about the position we sleep in when our head hits the pillow after a long workday. Nevertheless, the correct sleeping position and sleep quality can have an incredible impact on chronic pain (back, head, neck, shoulder, etc.). A good night’s sleep allows your body to repair/heal itself and prepare for the next day. If you are repeatedly waking up with aches and pain, consider altering your sleep position to get the most effective rest.
The correct sleeping position has an effect on a number of things including how the head and neck are supported, and how your jaw and neck are affected by this support or lack of support. Position also affects how the muscles in the head, neck and shoulders are stretched and strained. Waking up with daily headaches indicates that you may be sleeping in a poor position. The likelihood of clenching and grinding your teeth increases in certain positions, which is a main contributing factor to daily headaches. Any strain on the face (head, neck, jaw, shoulders) can cause TMJ-related disorders, or worsen any conditions that may already exist.
For people who are experiencing TMJ symptoms, sleeping on your back is the correct sleeping position for you. Your pillow should cradle your head and support the proper curve of your neck. Benefits to sleeping on your back include:
If you are waking up with shoulder pain, it’s your neck that’s most likely the underlying source of the pain. Because the muscles of the upper body are working together, the shoulder muscles will have to work harder to support the neck if you are in a disadvantageous position. Some people benefit from a rolled up towel placed under their neck for added support. This is usually the best sleeping position for shoulder pain.
Sleeping on your stomach is the worst position to be in, followed by sleeping on one side with an arm under your head. The stomach and side positions cause your body to be out of alignment, and in turn worsen any TMJ symptoms. Side sleeping can put lateral pressure on your jaw, causing a possible increase in bruxism. If you are going to sleep on your side, try not to curl up too much so that your spine remains in a neutral position. Additionally, you can place a pillow in between your knees to keep your spine and pelvis aligned properly.
Again, sleeping on your back (supine position) is recommended. It is very hard to adapt to sleeping on your back, however. For a lot of people it just does not seem comfortable (only about 14% of people sleep on their back). Here are some tips to help you get in the habit of sleeping on your back:
There are several different types of pillows out there (polyester, foam regular, foam contour, feather and latex), so just make sure that you choose one that won’t cause any adverse effects. Pillows are intended to support the head and neck in a neutral position and minimize stress on cervical structures. Memory foam pillows conform to the contour of your head/neck and many claim to provide proper spine alignment. Try to avoid a pillow that is too stiff, or too high. These can cause the neck to stay flexed overnight and not allow your muscles to relax, leading to stiffness and possible pain the next morning. If you are sleeping on your side, make sure that the pillow is higher under your neck than your head for ultimate support. During travel (plane, train, or car), a u-shaped pillow can be used which prevents your head from dropping to the side.
For more information on the correct sleeping position for you, please contact our office at (586) 573-0438.
References
Hibi H, Ueda M. Body posture during sleep and disc displacement in the temporomandibular joint: a pilot study. J Oral Rehabil. 2005 Feb; 32(2): 85-9.
Minagi S, Akamatsu Y, Matsunaga T, Sato T. Relationship between mandibular position and the coordination of masseter muscle activity during sleep in humans. J Oral Rehabil. 1998 Dec; 25(12): 902-7.
Gordon SJ, Grimmer-Somers KA, Trott PH. Pillow use: the behavior of cervical stiffness, headache and scapular/arm pain. J Pain Res. 2010 Aug; 11(3): 137-45.
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For most people today, the typical workday no longer consists of a “9 to 5” schedule. Nurses, for example, typically work a 12-hour shift (7am – 7pm or vice-versa). People working the night shift may begin at 11pm or midnight, and they are getting ready for bed at 9am. Our internal clocks are geared for nighttime sleep and daytime activity, so by working through the night or working overtime, our sleep schedules naturally become disrupted. A sleep schedule for working nights is difficult to pin down.
A study conducted by the Pennsylvania Patient Safety Reporting System (PA-PSRS) showed working a 12-hour shift or working overtime was related to having trouble staying awake during the shift, reduced sleep times and nearly three times the risk of making an error. The study also indicated the “most significant” error risk seen was when the nurses worked 12.5 hours or longer (See Rachael Zimlich, “Reconsidering The 12-Hour Shift For Nurses” 2014, Healthcare Traveler at.)
Many people work long hours out of necessity because there are staffing issues. When businesses are short-staffed, employees become burnt out, fatigued, and unhappy (with their job and life in general). Hospital employees especially are at risk for on-the-job accidents, and patients may face compromised care. The most common errors made in the healthcare field due to fatigue are medication errors (wrong dose, extra dose, etc.)
Fact: Approximately 75% of nurses work 12-hour shifts.
The American Nurses Association (ANA) recommends that nurses who work a 12-hour shift be allowed to leave on time instead of staying over for staff meetings or educational requirements. ANA also urges hospitals to offer support to nurses in a position to experience fatigue by offering breaks away from patients during their shifts.
Unfortunately in many cases, employees are told that overtime is mandatory. Especially in understaffed hospital settings, nurses can be intimidated by their superiors and told that they will be fired or reported to the Board for non-compliance.
Fact: On average, nurses work 8.5 weeks of overtime per year.
In addition to the physically draining nature of a nursing job, including exposure/health risks, there is also an overwhelming amount of paperwork and administrative duties that follow. The American Hospital Association found that for every hour of patient care, 30-60 minutes were spent on the subsequent paperwork & follow-up protocols.
According to a Peter D. Hart Research Associates study (April 2001), the top reason why nurses leave patient care, besides retirement, is to seek a job that is less stressful and less physically demanding (56%). The Hart study also found that a significant number, 22 percent, are seeking more regular hours; 18 percent desire more money; and 14 percent want better advancement opportunities. When asked what the biggest problem with nursing is, respondents who were in active nursing practice cited understaffing (39%) and the stress and physical demands of the job (38%).
Because non-traditional work schedules are becoming more common and more accepted, we need to make sure that we take care of ourselves and get enough sleep. Otherwise, we run the risk of sleep disorders, autoimmune dysfunction, diabetes, cardiovascular disease, high blood pressure, obesity, and a domino effect of other chronic health problems. For tips on getting enough sleep, please check out our FaceBook page (click here)
References
The Institute for Nursing Healthcare Leadership, “Work force challenges in the 21st century: Implications for health-care and nursing,” April 2001: 15.
“Reconsidering the 12-hour shift for nurses” July 2014.
https://www.jointcommission.org/assets/1/18/health_care_at_the_crossroads.pdf
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Accounting for about 50% of headaches, tension-type headaches are the most common type. You will sometimes hear these referred to as “muscle contraction headaches”. Although women are more likely than men to get these, pretty much everyone will have at least one tension headache at some point in their life.
The pain reported is usually mild-to-moderate in intensity, with a continual pressing/tightening feeling. Some people state that it feels like their head is being squeezed. Head tension is typically not accompanied by nausea and/or vomiting.
Four types of tension headaches:
Symptoms of tension-type headaches include a tight feeling around the head, shoulder pain, neck pain, and sometimes even light or noise sensitivity. The pain is typically steady, not throbbing or pulsing.
Tension-type headaches and migraines have some similar characteristics, so people tend to think they have migraines when they actually don’t. Some key differences are:
Head tension episodes are rarely disabling and do not usually require emergency treatment. Chronic headaches, however, can have a negative impact on your quality of life. For many suffering from chronic tension-type headaches, depression and anxiety also come into play. Stress can trigger or aggravate these headaches as well.
Common triggers for head tension include:
Tension-type headaches can usually be treated and prevented. It is more likely that patients who experience head tension ONLY will not have them for more than 1-2 years. Patients who experience migraines in addition to tension-headaches are up against much greater challenges. Over-the-counter pain relievers like Advil or Ibuprofen are the most popular choices (NSAIDs), followed by Aleve (naproxen). Many patients also report that caffeine helps as well as massage therapy. More aggressive treatments include things like stress management therapy, drug treatment with antidepressants, and relaxation training.
For more information on tension-type headaches, or if you are currently suffering from head tension, please contact our office at (586) 573-0438.
References:
Medical News Today. (16 May 2006). Study suggests tension-type headaches may actually be TMJD.
Temporal change in headache and its contribution to the risk of developing first-onset temporomandibular disorder in the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) study
Pain: January 2017 – Volume 158 – Issue 1 – p 120–129
Sanders AE, Ohrbach R. General health status and incidence of first-onset temporomandibular disorder: OPPERA prospective cohort study. J Pain.
Macfarlane TV, Glenny AM, Worthington HV. Systematic Review of Population-based Epidemiological Studies of Orofacial Pain. J Dent. 2001; 29:451–46.
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Do you work the night shift or know someone who does? Approximately 20% of the US workforce is engaged in some type of shift work. To clarify, shift work means having a work schedule outside of the typical “9 to 5” day. This can mean a 12-hour shift, a night shift, or something like 6am – 2pm.
Shift Work Sleep Disorder (SWSD) is a type of sleep disorder that usually occurs in people who work between 10pm – 6am. Because these kinds of schedule are outside of the norm, the sleep schedule is outside of the body’s circadian rhythm. People usually have great difficulty adjusting to this type of sleep schedule, especially if you are transitioning from regular working hours to the night shift.
Characteristics of SWSD include:
This disorder occurs because the individual cannot synchronize their internal clock with their work schedule (i.e. staying awake when it is dark outside and sleeping when it is light). As a result, many people fall asleep on the job, have accidents during their shifts, become injured themselves or cause injury to others, or fall asleep during their commutes to/from work.
The 2005 International Classification of Sleep Disorders estimates that a shift work sleep disorder can be found in 2-5% of workers.
Consequences and health risks associated with SWSD:
For people who are transitioning from a regular work schedule to a night schedule, physicians recommend getting a minimum of 7 hours of sleep per every 24-hour period. This would be the best sleep schedule for night shift workers. It is also suggested that you start the sleep cycle directly after work has ended. Additionally, you can take a 20-30 minute nap during your shift to maintain alertness.
Some preventative measures that can be taken to decrease the effects of SWSD would include things like maintaining a sleep journal to monitor your sleep schedules, avoiding long commutes, limiting caffeine and alcohol, and getting adequate sleep on your days off. Sleep aides can be used, but proceed with caution as they can have their own list of side effects.
It would also be beneficial to try and limit the number of nights worked in a row. You are more likely to recover from sleep deprivation with days off in between. If you work 4 consecutive night shifts, then your body will need at least a 48-hour recovery period afterwards. Try to avoid overtime at all costs – you want to make sure that you still have time for regular activities of daily life and socialization.
Another extremely important aspect of shift work is to make sure you are getting enough light exposure. Light exposure improves alertness and overall mood.
For individuals working indoors overnight, there are different types of light boxes (light therapy) that is recommended so that you still have exposure to “daylight”. This can help synchronize the body’s circadian rhythm.
The bottom line for those shift worker out there is to make sure that you get enough sleep! If you think you may have a night shift sleep disorder, please contact our office for more information at (586) 573-0438.
References
Reid K, Abbott S. Jet Lag and Shift Work Disorder. Sleep Med Clin. 2015 Dec; 10(4): 523-35.
Bolvin D, Boudreau P. Impacts of Shift Work on Sleep and Circadian Rhythms. Pathol Biol (Paris). 2014 Oct; 62(5): 292-301.
Roth, T. Shift Work Disorder: Overview and Diagnosis. J Clin Psychiatry. 2012 Mar; 73(3).
Wright K, Bogan, R, Wyatt J. Shift Work and the Assessment and Management of Shift Work Disorder (SWD). Sleep Med Rev. 2013 Feb; 17(1): 41-54.
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For those of you who have been following my blog, you will recall that TMJ stands for your Temporomandibular Joints (jaw joints). Each person has a left and right TMJ and can experience a problem or dysfunction in one side or both. A TMJ Dysfunction is typically referred to as TMD. The TMJ has many ligaments that are often overlooked by many medical providers. These ligaments are the sphenomandibular, stylomandibular, and capsular ligaments.
These ligaments pictured above are responsible for limiting excessive openings of the jaw. They stabilize the jaw joint and act like a piece of tape would, by preventing movements that are not supposed to occur. You can think of the jaw joint in the same regard as your knee, hip, shoulder or elbow. All of these joints belong to the same group called synovial joints, which are the most common and most movable type of joint in the body. Similar to other fibrocartilages such as the knee meniscus, the TMJ disc contains a mixed population of cells. There are between 20 and 50 million cells per gram of tissue.
Stem cells are cells of the body, which have the ability to divide and differentiate themselves for a particular use. The stem cells function is very specific. Because they possess a regenerative purpose, they offer new potentials for treating certain ailments and diseases.
In recent years, more and more studies have been done with stem cells, suggesting that they can have a significant role in regenerating and/or repairing the temporomandibular joints (TMJs). The most common TMJ disorder is the displacement of the articular disc/s (eventually leading to degenerative changes in the joint). By injecting stem cells into the joint space, diseased tissue can be repaired, the joints can be regenerated, osteoarthritis can be reduced, and new condylar cartilage can be produced.
One TMJ treatment, albeit lesser-known, is stem cell therapy for jaw issues. Repair begins with injection – the cells are introduced into the TMJ, the affected cells tell the new cells what they need, and thus the regeneration process begins.
Ideally, you want to use stem cells that are already present in your body to increase the chance of acceptance. These cells are collected through a minimally invasive procedure (similar to liposuction). The cells are then separated from the fat and can be injected into the TMJ. These cells can also be given by IV to reach the joint via the bloodstream.
If you cannot use your own cells, then you would use donor cells. With donor stem cells, however, there is a high risk of rejection by the recipient. Even if the donor cells are accepted, they could possibly introduce pathogens into the implantation area.
More and more research is being performed so that these patients suffering from TMJ disorders may finally have a solution that doesn’t involve surgery. With advances in stem cell research, these patients could be pain-free after just a few injections. I will keep you updated on any additional studies that come out in 2017.
References:
Zhang, S, Yap, A.U.J. & Toh, W.S. Stem Cell Rev and Rep (2015) 11: 728. doi:10.1007/s12015-015-9604
Johns, D. E., Wong, M. E., & Athanasiou, K. A. (2008). Clinically relevant cell sources for TMJ disc engineering. Journal of Dental Research, 87(6), 548–552.
BioMed Research International
Volume 2014 (2014), Article ID 454021, 10 pages
http://dx.doi.org/10.1155/2014/454021
Yang Wu,1 Zhongcheng Gong,2 Jian Li,1 Qinggong Meng,1 Wei Fang,1 and Xing Long. The Pilot Study of Fibrin with Temporomandibular Joint Derived Synovial Stem Cells in Repairing TMJ Disc Perforation.
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As you may recall from other blogs you have read here on my website, TMJ dysfunction (TMD) is known as “The Great Impostor” because its symptoms mimic those of many other conditions. One that we will focus on this week is Vertigo, which is a sensation of dizziness that can cause postural imbalances. In other words, your surroundings seem to be moving even though you are standing still. Read on to find out what the connection is between TMJ and dizziness; in some cases, vertigo. These spells are also known as TMJ dizzy spells.
Balance comes from the brain integrating data from the inner ears (vestibular system) and eyes (visual system). The vestibular system also includes nerves and joints. The inner ear contains the labyrinth, which is a small structure, which is a crucial to the body’s balance. The labyrinth has fluid, which moves around as you move, and that sends messages to the brain about balance. When any of this gets disrupted, the brain can misinterpret the signals and that gives off the feeling of vertigo or dizziness.
An interesting fact about the labyrinth is that it is located in your temporal bone in your head. Your TMJ (temporomandibular joint) also attaches to the skull at the temporal bone. The TMJ may move the temporal bone just enough to move the labyrinth housed inside to be moved out of position as well. So, whenever any misalignment or inflammation occurs in the TMJ, this is how the fluid gets disrupted.
Alternatively, if any hyperactivity in the masticatory muscles (chewing muscles) is present, this can cause dysfunction of the Eustachian tube, also leading to imbalance, dizziness and vertigo. The Eustachian tube is a part of the middle ear that equalizes pressure.
The following are some of the many symptoms associated with vertigo:
1. Dizziness/Lightheadedness
2. Confusion
3. Nausea/Vomiting
4. Pain in the eyes
5. Perception that objects are moving
6. Imbalance
7. Feeling of being pulled down towards the floor
8. Hot flashes
9. Light sensitivity
10. Headache/Migraine
If you have ever experienced a ride at an amusement park that goes round and round in a circle, then you are most likely familiar with this feeling. It seems like you are still moving when you get off the ride, because there is still movement within your semi-circular canals. But, your visual cues alert the body that you are standing still. This very disconnect between the signals gives your body that feeling of nausea and dizziness.
When your lower jaw (mandible) is not properly aligned to your upper jaw (maxilla), then there are certain pressures exerted on the jaw joint (TMJ). These pressures are transmitted, and in that process, the balance organs are moved out of alignment. Once misaligned, balance is naturally thrown off.
Take your pinky finger and put it inside your ear canal, and then move the jaw by opening and closing. You will be able to feel the movement of the mandible and realize how close it is to your inner ear.
Aligning (normalizing) the jaw joint often corrects the balance organs and equilibrium. Unfortunately, many people are placed on medications such as Antivert or Zofran to treat the symptoms of vertigo rather than treat the underlying problem (joint dislocation). While these medications can provide temporary relief, they will never provide a permanent solution to a joint problem.
If you or someone you know is experiencing any of the symptoms listed above, please call our office at 586-573-0438 to talk to Dr. Klein about a possible TMJ disorder.
References
Marchiori, Luciana Lozza de Moraes et al. “Probable Correlation between Temporomandibular Dysfunction and Vertigo in the Elderly.” International Archives of Otorhinolaryngology. 18.1 (2014): 49–53.
Chole RA, Parker WS. Tinnitus and Vertigo in Patients With Temporomandibular Disorder. Arch Otolaryngol Head Neck Surg. 1992;118(8):817-821. doi:10.1001/archotol.1992.01880080039010
Weber, PC. Vertigo and disequilibrium: a practical guide to diagnosis and management. 1961.
Parker WS, Chole RA. Tinnitus, vertigo, and temporomandibular disorders. Am J Orthod Dentofacial Orthop. 1995 Feb;107(2):153-8.
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