Posts by: Momentum

Our Precautions on the COVID-19 Virus

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Dear Patients, fellow Colleagues, and Friends,


At Michigan Head & Neck Institute, it has always been our goal to protect the health and safety of our patients and staff.

As the coronavirus (COVID-19) situation evolves, we remain committed to this goal. We continually check for updates from the most credible sources such as the CDC (Center for Disease Control and Prevention) and we promise to share with you what we believe warrants caution and what is not worthy of unwarranted fear.

Coronavirus Concerns & Precautions

The novel coronavirus is known to cause a respiratory illness (COVID-19), with symptoms of fever, coughing and difficulty breathing. There is currently no vaccination to protect against COVID-19, nor are there drugs to specifically treat the virus.

According to the latest information, the Centers for Disease Control and Prevention (CDC) believes at this time that symptoms may appear two days to fourteen days (median time is five days) after exposure.

The emergence of a new infectious disease re-emphasizes the importance of vigilance relative to all aspects of infection control for patients and for Dental Healthcare Personnel (DHCP).

At Michigan Head & Neck Institute, as appointments are now being made and/or confirmed, we will be gathering information about the well-being and recent travel history of every patient.

If it is determined that a patient may have an acute illness or was exposed to one, elective treatment at our office should and will be deferred until the patient has recovered.

As a general reminder, health care experts claim that the best prevention against respiratory illness is the following:

  • Wash hands frequently with soap and water for at least 20 seconds. If soap and water are not available, use alcohol-based hand sanitizer with at least 60% alcohol.
  • Avoid touching your eyes, nose and mouth, especially with unwashed hands.
  • Cover your cough or sneeze with a tissue, then throw the tissue in the trash. If no tissue is available, use your elbow or sleeve.
  • Make sure that you are no immuno-compromised, ensure that you build your immunity with opioid detox treatment.
  • Avoid close contact with people who are sick.
  • Stay home if you are sick.

Michigan Had & Neck Institute Uses Standard Precautions and Transmission-Based Precautions


Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of the suspected or confirmed infection status of the patient, in any setting where health care is delivered.

Transmission-Based Precautions include Contact Precautions, Droplet Precautions and Airborne Precautions, and are based on the likely routes of transmission of specific infectious agents.

Our office protocols are designed to protect both Dental Healthcare Personnel (DHCP) and you, our patients. These precautions include:

  • Hand hygiene
  • Use of personal protective equipment (e.g., gloves, masks, eyewear)
  • Respiratory hygiene / cough etiquette
  • Sharps Safety (engineering and work practice controls)
  • Safe injection practices (i.e., aseptic technique for parenteral medications)
  • Sterilization of instruments and devices. All instruments are sterilized or used once and disposed of.
  • All surfaces of our treatment rooms are cleaned and disinfected after every patient. The materials and methods used have been shown to be effective for viruses.

As with flu outbreaks that came before it, we believe the current coronavirus situation will pass. At present, however, keeping aware of the latest information can lead to the proper balance of caution with reduced fear.

We remain committed to keeping you informed, as well as protecting your health and safety. If you would like to find out more on your own, we highly recommend The Centers for Disease Control and Prevention at

Please feel free to share any questions or concerns you may have with us.

Call Michigan Head & Neck Institute at 586-573-0438.


Thank you!


Michigan Head & Neck Institute
















How Behavior Patterns Affects Sleep

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How Behavior Patterns Affects Sleep

Getting a good night’s sleep is essential, but still ends up at the bottom of the list and is elusive for many.  Why?  The number one excuse is “I don’t have enough time to sleep”.  Sleep is one of the most important components in our everyday lives and should not be considered just another “activity”.  Too many of us alter our bedtime to pursue personal or professional goals, or social obligations.  We need to find a balance.

Sleep, diet and exercise are essential parts to your health and longevity.  Simultaneously, sleep, diet and exercise affect your mood, and vice-versa.

Improved Sleep = Improved Mood = Improved Sleep

We need to view sleep as an interconnected piece of the puzzle, along with other functions, so that we consciously make changes in certain behaviors that can lead to improvements in sleep.  Problems that occur during sleep are typically found in individuals undergoing stress or are managing chronic health conditions.  Who doesn’t have stress?  This is a great question, and the answer is that most people DO have stress, but what matters is how you manage the stress.  Do you let it completely affect your existence, or are you still performing the normal activities and functions of everyday life?


Bedtime Behaviors chart












The relationship between waking behavior and sleep quality has been investigated for years.  For example, post-menopausal women are at risk for disturbed sleep.  One thought behind this is because women at that age are less active than when they were younger, which in turn affects their mood by increasing chance of depression/anxiety, leading to sleep disorders.

Both sleep quality and sleep quantity have significant impacts on mental and physical health.

Mental impacts – anxiety, depression, disorientation, performance issues, substance abuse problems.

Physical impacts – circadian rhythm disruption, weakened immune system, high blood pressure, cardiovascular disease, body temperature, hormone release.

Sleep Deprivation Symptoms illustration






Poor sleep negatively impacts the restorative stages of the sleep cycle, and if you are not spending as much time in those stages as necessary, then you will not function to your full potential during the next day.  Brain activity is altered, as well as self-awareness.  You become unproductive at work, which I think we can all relate to in some way or another.  You don’t feel good when your thinking is impaired, your reaction time slowed, and ability to handle day-to-day life, or work situations, becomes overwhelming.

If you find that you are feeling depressed or anxious, an important thing to notate is your sleep duration.  How long are you actually resting every night?

Sleep duration categories:

Short – 6 hours or less per day

Long – 10 hours or more

Recommended – 7-9 hours is considered “normal”

Data suggests that “long” sleep may have decreased from 11.6% reported in 1977 to 7.8% in 2009.

Quantity and quality of sleep are also related to physical activity and sedentary time.  Typically, people who are active and spend time outside experience more pleasant moods, and therefore better sleep.

Measuring Sleep Quality:

Restful (normal)

Average (less than restful

Restless – insomnia

Wide eyes illustration









Physical activity doesn’t mean that you must spend 2 hours in the gym training vigorously.  It can include walking, dancing, cleaning the house, yardwork, etc.  Sedentary time, meaning time sitting or lying down, will significantly increase the likelihood of impaired sleep.  Those with sedentary time in excess of 6 hours – are the people at the greatest risk (likelihood of restless sleep by 38-85%).  Be mindful of consistent physical activity (walk, take the stairs, stretch at work or consider a standing desk).  Another behavioral habit for a healthier life would be to only use your bed for sleep or sex, rather than lying in bed to watch movies or play video games during waking hours.  This will help promote good sleep habits and make you more aware that the bed should be for sleeping only.

For more information on behavior and sleep, or to schedule a consultation with Dr. Klein, please contact our office at (586) 573-0438.


Creasy SA, Crane TE, Garcia DO, Thomson CA, Kohler LN, Wertheim BC, Baker L, Coday M, Hale L, Womack CR, Wright KP, Melanson EL. (2019). Higher amounts of Sedentary Time are Associated with Short Sleep Duration and Poor Sleep Quality in Postmenopausal Women, Sleep.

Krueger PM, Friedman EM. Sleep duration in the United States: a cross-sectional population-based study. Am J Epidemiol. 2009; 169:1052–1063. doi: 10.1093/aje/kwp023

Littlewood DL, Kyle SD, Carter LA, Peters S, Pratt D, Gooding P. Short sleep duration and poor sleep quality predict next-day suicidal ideation: an ecological momentary assessment study. Psychol Med. 2019;49(3):403–411. doi:10.1017/S0033291718001009

Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev. 2002; 6:97–111. doi:

Ohayon MM. Difficulty in resuming or inability to resume sleep and the links to daytime impairment: definition, prevalence and comorbidity. J Psychiatr Res. 2009; 43:934–940. doi: 10.1016/j.jpsychires.2009.01.011

Roth T. Insomnia: definition, prevalence, etiology, and consequences. J Clin Sleep Med. 2007; 3 (suppl):S7–S10.

St-Onge MP. The role of sleep duration in the regulation of energy balance: effects on energy intakes and expenditure. J Clin Sleep Med. 2013; 9:73–80. doi: 10.5664/jcsm.2348

Swanson LM, Arnedt J, Rosekind MR, Belenky G, Balkin TJ, Drake C. Sleep disorders and work performance: findings from the 2008 National Sleep Foundation Sleep in America


Are Women Affected More Than Men?

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There are countless symptoms and dysfunctions associated with the TNS (trigeminal nervous system), and unfortunately women are more prone to them than men.  As medical professionals, a thorough examination should be performed on each and every patient to assure that nothing is being overlooked.

The list associated with the CSNB (chief sensory nerve of the brain) is extensive and includes migraines, headaches (tension, sinus and morning), sinusitis, fibromyalgia, chronic pain, insomnia, chronic fatigue, anxiety, panic attacks, trigeminal neuralgia, irritable bowel syndrome, stabbing ‘ice pick’ pain in the eye, vision problems (auras, blurred vision, light sensitivity, and glaucoma), Sjögren’s syndrome, vertigo, Lupus, multiple sclerosis, adult scoliosis, osteoarthritis, rheumatoid arthritis, depression, dementia, and Alzheimer’s.

Skull diagram









Men also experience these problems, but the CSNB is four times more likely to be under attack in women (who are also more four times more likely to have TMJ dysfunction). Women fall victim to these symptoms and dysfunctions because they face physical abuse more than men and their ligaments are more elastic.  The NIH and the Michigan Medical School research prove that women feel more pain than men.

Physicians, and dentists in particular, have a huge advantage in the treatment and prevention of TMJ disorders. Dentists are trained to use teeth as a vertical support system to avoid a lifetime of irritation to the CSNB.

Dentist working on a woman's teeth








When you have a malocclusion, meaning that your teeth and jaws are positioned incorrectly, your body becomes accustomed to functioning at an insufficient level.  This, in turn, triggers TMJ dysfunction along with numerous concomitant symptoms and dysfunctions that linger throughout the majority of some people’s lives.  Structures in the head and neck transmit continual impulses through the brain, eyes, ears, sinuses, and the trigeminal nucleus in the brainstem.

Malocclusions Teeth Diagram








This causes the bones of the TMJ to rub against the auriculotemporal branch of the TNS, prompting referred pain and muscle spasms associated with the joint dislocation.  Malocclusion also causes gum disease, tooth loss, enamel wear, and arthritis.  Studies indicate that when the teeth and jaw joints do not align properly during the early stages of life, then the CSNB is over-stimulated, leading to pain, poor sleep, fatigue, and other symptoms.

Dentists that use a customized mandibular repositioning device are able to reestablish balance and support by correcting the malocclusion to a stable jaw joint position (and therefore stable occlusion).  By doing so, joint space is created, thus lessening, and eventually eliminating, chronic lifelong pain and dysfunction.  Physical therapy, physical medicine techniques and protocols such as trigger point or entrapment neuropathy injections can relieve the muscle pressure on the Trigeminal or Greater Occipital nerves.

Teeth mold






For all the women out there suffering from chronic pain associated with these symptoms, the next time you are told by a physician that your pain is “all in your head”, ask them why they didn’t take ROM (range of motion) measurements or palpate the muscles of your head and neck.  Dr. Stack always used to say “How do they know what’s wrong with the patient if they don’t touch the patient.”


Richard T. Seymour (2016) Why women? CRANIO®, 34:6, 353-355. DOI:10.1080/08869634.2016.1235536



Newly Known Dangers of Snoring

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Aside from keeping you awake at night, many individuals who snore heavily are at risk for damaging their upper airways in their sleep.  This, in turn, can lead to a plethora of medical problems including dysphagia, or trouble swallowing.  Researchers at the University of Sweden have been focusing on airway damage and the healing process (healing the damaged tissue).  Neurophysiological assessments have shown evidence of denervation in the pharyngeal muscles.  OSA patients will have lesions on the muscles in their upper airway, which are trauma induced, and lead to the collapse of the airway.  An OSA sufferer’s airway muscles are overly relaxed during sleep, making the respiratory efforts increasingly stronger (to combat the blockage).  This is the point that your bed partner will hear a loud gasp or be woken up from a loud snore.  People who snore regularly have a loss of nerves and muscle mass in the soft palate, so as the body tries to heal the muscles, they end up forming in an abnormal arrangement.  This becomes a cycle – the body is trying to heal, but the constant disruptions make it impossible.  This research focuses on growing muscles and nerve cells, which will hopefully be able to treat the airway damage and regenerate the nerves and muscles.  My good friend Dr. Alan Moses has also researched the future potential problems of snoring.

Please click here to read the full article online.

How To Relieve TMJ Pain

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As a person suffering from a TMJ disorder, you know how distressing it can be to try to relieve TMJ pain. Like many others, you probably contend with pain in your jaw, neck and face, along with common symptoms like blurred vision, ear pain, muffled hearing, dizziness, ringing of ears, light and sound sensitivity, eye pain, excessive tears and a clicking jaw. You want relief, but more to the point, you need a permanent solution. Learning more about TMJ and your therapeutic options can help you make informed decisions about your treatment.

What Is TMJ Disorder?

You may know that TMJ is short for the temporomandibular joint. There are two of these joints connecting your jaw to the rest of your skull on its left and right sides. Acting like hinges, they allow you to move your jaw vertically and horizontally. These movements allow you to speak, chew, drink, kiss and yawn.

TMD, or temporomandibular disorders, affect these joints and the muscles controlling them. There’s no single common type of TMD that all sufferers have because a wide range of things can cause them. Injuries to the jaw or head and neck muscles, such as whiplash from a car accident, can result in TMD.  Pre-existing bite problems, jaw imbalances, muscle strain, arthritis, stress or even grinding your teeth may lead to a TMJ dysfunction.

Common TMJ Symptoms

TM joints connect the jaw to the temporal bones that comprise the sides and base of the skull. That’s why TMDs can cause pain and discomfort in your face, jaw, ears, eyes and surrounding areas. However, many symptoms of temporomandibular disorders can mimic those of other conditions like sinus problems, chronic migraines or tooth pain. Rather than assume what’s causing your problem, it’s a good idea to seek medical advice from your doctor or schedule a consultation with us.

How your TMJ dysfunction affects you can be different from another person with a similar TM issue. Many people experience a wide range of symptoms:

  • Pain, tenderness or stiffness in the jaw, neck, face or shoulders
  • Headaches that don’t get better with medication
  • Clicking or popping noises with jaw movement
  • Difficulty swallowing or opening the mouth wide
  • Blurred vision or dizziness
  • Pain behind the eyes
  • Light or sound sensitivity
  • A tired feeling in the face, neck or jaw
  • Excessive tear production
  • Ear congestion or hearing loss
  • Ringing or buzzing in the ears
  • Ear pain

Relieve TMJ Pain

Because temporomandibular disorders can be caused by different things, any treatment plan must be personalized for the best results. Therapies focus on the root causes of the problem as well as pain relief. Surgery may be the last resort in some cases, but other less invasive therapies can target the problem and ease symptoms. Dr. Klein will recommend treatment methods based on your specific diagnoses.

TMJ Treatments:

  • Adjustable corrective orthotic mouthpieces
  • Transcutaneous electrical nerve stimulation, or TENS unit usage
  • Physical massage of the TM joint and surrounding muscles
  • Application of heat
  • Pain relieving injections
  • Non-invasive pain relief

We also educate to help you better understand your condition. Certain harmful habits may exacerbate TM dysfunction, so we show you how to avoid these habits. Many of these treatments could be covered by your insurer. Our administrative staff can help confirm your coverage, so don’t hesitate to contact them if you have any questions.

Contact Your Head and Neck Specialist

For over 25 years, Michigan Head & Neck Institute has provided compassionate high-quality care to clients in Warren and surrounding communities. As a trusted TMJ doctor, Dr. Richard Klein along with our experienced staff treat TMJ disorders, sleep apnea and related conditions. We want to help restore your health and quality of life, and we’d love to hear from you! Visit our contact page and enter your info to schedule a consultation. You can also call our practice at (586) 588-9444.

Why Do Some People Need Less Sleep?

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If someone told you that there was a pill you could take to get by on less sleep, chances are that 99% of us would take it.  Especially if it was proven that no health consequences would be suffered.   Researchers at the University of California, San Francisco, have identified a genetic mutation showing that mice needed less sleep, remembered better and suffered no other ill effects.  The test subjects are a father and son who have been feeling fully rested on 4-6 hours of sleep, as opposed to the traditional 7-9 hours.

The professor in charge of the study has stated she is more interested in understanding healthy sleep and preventing diseases (like Alzheimer’s) but noted that the test subjects are sleeping efficiently.  We need to take that knowledge, the “why”, and figure out how to make everyone sleep efficiently.

The notion that many people have is that they can get by on 4-5 hours per night during the workweek because of their busy schedule, and then “make up” for it on the weekends by sleeping more.  This actually does not work, and ends up impairing overall performance.  If you sleep a lot more on the weekends, it is indicative that you do, in fact, need more sleep on a daily basis.

We do have to keep in mind that there are social implications and trade-offs associated with this process, even if a pill were to become available in the future. There may be pressure to work more and take less time to unwind and relax.  People still need down time, even if that means they aren’t actually sleeping.

Studies on the genes involved in sleep will continue, with researchers hoping to discover more pieces of the “genetic puzzle”.

Please click here to read the full article.

New Year – New You

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It is that time of year when everyone is busy with the holidays and family and friends.  We must make sure that we are taking care of ourselves during this time, especially when it comes to maintaining our sleep schedules. Between parties, shopping and family get-togethers, we sometimes barely have time to rest.  January is a perfect time to start making some resolutions!

While all of the activities are fun, they can definitely throw you out of your routine pretty quickly.  And if you have kids, then their excitement may leave you with little energy left.  Try to keep them in a routine as well, maintaining their usual bedtimes during the school breaks.

If you go to bed and wake up at the same time each day, then you will keep your body’s sleep-wake cycle consistent. This will allow for better quality sleep. Sleeping in sounds like a good idea, but this can backfire, making us feel even more jet-lagged.  Try taking a 30-minute nap in the afternoon to recharge as opposed to sleeping in for an extra hour in the morning.

Plan to stick with your regular routine and keep your body’s circadian rhythm on track.  There is an old saying, “When you fail to plan, you plan to fail.”

Daytime vs Nighttime Illustration

Practice eating dinner a little earlier and try not to drink any alcohol late at night.  Going to bed on a full stomach is our worst enemy. Being full leads to tossing and turning, which means bad quality sleep.  This is a snowball effect, as many of us know well.  If you are feeling hungry before you go to bed, try eating a piece of fruit or a handful of nuts or granola.  Even a glass of milk (or soymilk) can suffice for some.

Another great resolution is to start exercising more.  Not only does exercise reduce stress, but it will raise your body temperature and also tire you out, helping you sleep better.  The rise and fall of the body’s temperature leads to sleepiness.  Just don’t try and run 10 miles right before you go to bed.  This strenuous of an activity will keep you awake.

Remember to take time to decompress and unwind.  We are always “on the go” leaving us little time to calm down after a long day.

If we think about the way we care for our electronic devices, we should take care of ourselves in a similar way by “powering down” and prepping for a good night’s rest, rather than worrying about all of the chores we have to do.  Reading, deep-breathing exercises, or a bath are a few examples of things that may aid this process.

Woman in yoga pose

Now, following through is the most difficult part.  The reason why so many resolutions fail is because they simply aren’t enjoyable or sustainable. Quick fixes do not work.  We need to focus on converting our unhealthy habits into healthy habits.  And make sure that the approach you are using is something you can actually maintain and still enjoy life.

Educate yourself and surround yourself with positive people that make it easier to make good choices. People that care about you will also hold you accountable. Create an environment that you feel comfortable in.  If you want to stop eating junk food late at night, step one would be to stop buying junk food and keeping it in your house.

Junk food crossed out

A great method to help with follow-through is the SMART system:

S – Specific

M – Measurable

A – Achievable

R – Relevant

T – Timeline

Specific – clearly defined, smaller attainable goals adding up to a larger goal

Measurable – make sure you have a way to track your progress

Achievable – make sure your goals are realistic; within reason

Relevant – are you passionate about this, or do you just want to set a goal

Timeline – there must be specific deadlines to achieve your goals

If you need help starting 2020 off right, contact Dr. Klein at 586-573-0438, or visit our website at


Han, KS, Kim, L, & Shim, I. (2012). Stress and sleep disorder. Experimental neurobiology, 21(4), 141-50.

Kitamura, S, Katayose, Y, Nakazaki, K, Motomura, Y, Oba, K, Katsunuma, R, Terasawa, Y, Enomoto, M, Moriguchi, Y, Hida, A, Mishima, K. (2016). Estimating individual optimal sleep duration and potential sleep debt. Scientific reports, 6, 35812. doi:10.1038/srep35812

Aghera, A., Emery, M., Bounds, R., Bush, C., Stansfield, R. B., Gillett, B., & Santen, S. A. (2017). A Randomized Trial of SMART Goal Enhanced Debriefing after Simulation to Promote Educational Actions. The western journal of emergency medicine, 19(1), 112-120.

Can TMJ Be Cured?

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Can TMJ Be Cured

Temporomandibular joint disorder is a condition where the joint responsible for operating the jaw sustains damage. As a result, it hurts to chew and yawn, and some patients experience chronic headaches and ear pain. You need to see a healthcare professional immediately to deal with TMJ pain  and its multiple systems of ear congestion, subjective loss of hearing, dizziness, sensitivity to sound, itchy ear, ear pain, eye pain, blurred vision, excessive tears and neck pain.  The condition cannot necessarily be cured, but it can be reversed with proper action.


Professional Treatments

Many people develop TMJ symptoms due to clenching or grinding their teeth at night. Therefore, it may be prudent for some people to wear a mouthguard at night to protect their molars from such actions and to protect the lower jaw from banging into the skull in the TM Joints. Your TMJ doctor will need to look at your teeth to determine whether you grind at night. Your dental office can create a custom mouthguard that fits perfectly in your mouth.

You may also need to go through physical therapy. In many cases, TMJ pain is a result of excessive stress. People feel anxiety through work or familial obligations, and they manifest that stress by grinding their teeth. You can apply a heating pad on your own, but you may also want to book massage appointments to help you unwind.  Pharmaceuticals such as muscle relaxers, anti-inflammatory and pain reduction pills are also helpful in the beginning of treatment.

Your doctor may also recommend pain-relieving injections to help you deal with the pain. In extreme cases, the only way to deal with TMJ dysfunctions is to undergo surgery. These invasive methods are typically reserved as a last resort, and you should go through everything else first before bringing up surgery to your doctor.


At-Home Remedies

As you pursue professional treatments for your TMJ pain, you should also make lifestyle changes at home to relieve your symptoms. For the time being, you should stick with softer foods. Yogurt, applesauce and mashed potatoes are good options because they will not aggravate your jaw as much. During this time, you want to avoid sticky foods, such as gum, because they can overwork your jaw and create more problems.

Stress management is critical for all people. You can incorporate various stress management techniques at home, such as practicing yoga and meditation regularly with the help of Marianne Wells Yoga Instructor. It is natural to feel stress at various points in life. However, you need to be aware of when your stress levels are out of control. It may be a good idea to take on fewer responsibilities at work so that you can focus more on your personal health.

Another way to relieve stress is to practice exercises including those for the jaws. There are various stretches and movements you can do with your face to help relax your jaw muscles. For additional advice, you want to talk to your doctor to see if he or she would recommend anything. Your doctor may also be able to pinpoint the exact area where the TMJ pain is localized so that you can better target that area.


Holistic Approaches

When you decide to incorporate relaxation exercises into your routine, you should consider adding essential oils into the mix. While they may not work for everyone, some people insist they help remedy chronic pain. Some of the best oils to use in this endeavor include peppermint, frankincense and lavender oil.  In particular, lavender oil has been shown to help relax jaw muscles. All you have to do is add a single drop to a quarter teaspoon of coconut oil and massage it into the affected area. However, this should be used as a supplement to other techniques, and you should always consult with your TMJ doctor before altering your oral healthcare regimen.  Women react to essential oils at a higher rate of success than do men.


Managing TMJ Pain With Ease

Millions of Americans suffer from TMJ pain at one point or another. With prompt action, you can limit your symptoms and completely cure yourself of the condition. For residents of Warren, the Michigan Head & Neck Institute is here to lend a helping hand and help you overcome your condition. Reach out to us as soon as you notice the symptoms so that we can help you comprehensively.

Oral Appliance Therapy/Titration

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As we know, TMJ/TMD patients frequently present with overlapping signs and symptoms of OSA/sleep disorder patients.  TMD affects approximately 5% to 15% of the population, predominantly women.

Many patients exhibit sleep dysfunction associated with persistent pain and inability to sleep on their side, but sleeping supine in most people increases the risk for sleep disordered breathing, since gravity pulls the tongue down when we sleep on our back.

Myofacial pain and arthralgia are the most common symptoms of TMD.  Retrognathia, a condition that can result from TMJ arthritis, also constitutes a risk factor for SDB (sleep disordered breathing).  In addition, several different craniofacial configurations such as a more caudally positioned hyoid and smaller anteroposterior dimensions of the lower face have been associated with a greater prevalence of OSA/SDB.

Women who just woke up from alarm clock

Patients with SDB have frequent arousals from sleep and suffer from sleep deprivation.  They have frequent and repetitive episodes of oxygen desaturation.  The most common clinical symptoms are loud snoring, apneas witnessed by bed partners and excessive daytime sleepiness.  In addition, the condition has been linked to delayed reaction times, difficulty concentrating, and is linked to cardiovascular disease.

Treatment with a mandibular repositioning device is now frequently used in the treatment of mild-to-moderate OSA, and severe OSA may be treated with a combination oral appliance to reduce the AHI and thus reduce CPAP pressure.  An intraoral appliance is easier to travel with, that’s for sure, and more socially acceptable.

Appliance vs CPAP

Patient compliance is much better with the oral appliances as well. Most patients, as multiple peer reviewed articles document, who use their CPAP only do so for 4-6 months and then it ends up in the closet.

A few names you may have heard before include the following:

  • The Silencer
  • HAP
  • Herbst
  • PM Positioner
  • SUAD
  • TAP
  • Silent Night
  • NAPA
  • Moses

At Michigan Head & Neck Institute, we exclusively offer treatment for obstructive 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. Each patient that chooses an oral appliance (OA) as their treatment, will receive follow up sleep studies (either at-home or a in a sleep lab) which will ensure the OA is positioned accordingly.

Resultant Muscle Force

We must always remember to reference Centric Relation.  Centric Relation is a concept where dentists manipulate the jaw to find a hinge axis position and then use that position to establish the bite, this is normally done before using a whitening teeth blue light to make sure it will reach all your teeth.  The proper relations of the jaws are determined when the muscles are at their healthiest.  The most important function of the jaw, jaw muscles, tongue and entire trigeminal neuromuscular complex is to maintain the airway.

Oral Appliances can cause bite changes (and can exacerbate jaw problems). If the jaw problems pre-exist the oral appliance therapy, then we must be sure to address both.  Bite changes that take place with the use of oral appliance therapy is actually a healing mechanism that occurs when the temporomandibular joint is unloaded and the retrodiscal lamina in the posterior portion of the joint compartment rehydrates and acts to mechanically change the bite.

So, how are these appliances adjusted correctly?  At what interval is appropriate to make adjustments?  There are several titration protocols designed to eliminate problems. Over a period of several weeks/months, the mandible can be advanced in 1mm increments.  These appliances are then adjusted in the same way a CPAP is titrated.  The mandible is advanced until respiratory events are eliminated (confirmed by follow-up sleep test with PSG).

Teeth model Teeth 2







For more information on oral appliance therapy, or to schedule a consultation with Dr. Klein, please contact our office at (586) 573-0438.


Cunali PA, Almeida FR, Santos CD, Valdrighi NY, Nascimento LS, Dal’fabbro C, Tufik S, Bittencourt LR. Aims: To evaluate the prevalence of pain associated with temporomandibular disorders (TMD) in obstructive sleep apnea syndrome (OSAS) patients referred for oral appliance therapy. J OROFAC PAIN 2009; 23:339-344.

Sutherland K, Vanderveken OM, Tsuda H, et al. Oral Appliance Treatment for Obstructive Sleep Apnea: An Update. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine. 2014;10(2):215-227. doi:10.5664/jcsm.3460

Doff MHHoekema AWijkstra PJvan der Hoeven JHHuddleston Slater JJde Bont LGStegenga B. Oral appliance versus continuous positive airway pressure in obstructive sleep apnea syndrome: a 2-year follow-up. Sleep. 2013 Sep 1;36(9):1289-96. doi: 10.5665/sleep.2948

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Are Mood Swings Related to Headaches?

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Emotions often play a part in headaches.  Sometimes, the emotions are suppressed, while other times they are apparent at the surface.  A headache is one of the most widespread disorders in the world.  Depression and anxiety, similarly, also have a dominant presence.  Numerous studies have established that mood disorders are comorbid with headaches.  In fact, people suffering from headaches/cephalgia are 4-5 times more likely to have anxiety.

Anxiety and mood disorders coexist in headache patients, and physical symptoms result from both.  Anxiety produces excessive worry, irritability, agitation and concentration problems, while depression causes a lack of energy, fatigue, decreased motivation, weight gain or loss, trouble sleeping and increased overall sadness.

Depression is a psychological response to pain and can disable physical and social activity levels.  It can induce chronic pain by increasing susceptibility to the pain itself (tolerance reducing effect).

Several studies conducted by a rehabilitation centre, legacy healing miami, have shown evidence that anger is related to pain, level of severity, addiction and emotional distress.  Anger can be internalized (suppressed) or externalized (aggressive lashing out).  It has been found that headache patients suppress their anger more than non-headache patients.  Patients that experience headaches struggle with anxiety and/or guilt after expressing anger.  Typically, the intensity level of the headache/cephalgia is dependent on the level of depression, emotional distress and reduced quality of life.

Headache/cephalgia sufferers have been known to possess personality traits such as:

-being overambitious

-having a Type-A personality

-appearing inflexible in their mindset


-short tempered

Cephalgia “attacks” or onsets can be related to psychological stress.  In fact, sometimes they occur after the initial stress period is over.  For example, sometimes when people get massages, they get a headache immediately afterward.  It follows in the relaxation phase.  Another example of this would be soldiers during the war who got cephalgia attacks not while fighting, but when they were done fighting.  Some experienced chronic head and neck pain after retirement from the service.

Further to add to this “relaxation hypothesis” would be people who get headaches on the weekends, once they have had a stressful week at work.  This has been called the “weekend headache” in the past.

Moderate stresses of everyday life are also affected by the individual’s level of activity/exercise.  States of increased activity followed by relaxation can sometimes trigger headaches/cephalgia.

Headaches/cephalgia should prompt the treating physician to proactively search for mood disorders (and vice-versa).  Untreated depression is a proven risk factor for low-frequency episodic cephalgia to chronic cephalgia.  Comorbid depression and anxiety also are associated with higher health insurance costs and healthcare costs in general, as well as increased disability rate (related to headache).

Sometimes even when a person appears relaxed, they are actually suppressing their anger and internalizing it, which then causes a delayed headache.

One last factor that can affect mood and therefore headaches/cephalgia is either menopause and/or menstruation cycles.  For all the husbands out there, who think their wives hate them, you are not alone.  This is one of the great stressors on a marriage – women who suffer from headaches and their husbands who take care of them.  When estrogen levels and hormone levels are going up and down, headaches and cephalgia can be the result.  Luckily, these are not permanent situations!

Remember that getting adequate sleep and exercising routinely can help a great deal.  And also as discussed previously, eating the right foods can help with your mood (and therefore headache prevention) as well.  If you would like more information on headaches, cephalgia, and chronic head/neck pain, or to schedule a consult with Dr. Klein, please contact our office at (586) 573-0438.


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