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Large leak issues, TMJ problems...feeling helpless
#1
Large leak issues, TMJ problems...feeling helpless
Having issues getting my mask leaks under control.  Using F&P Simplus full face mask with large cushion.  I have developed some severe TMJ problems (disc displacement confirmed via MRI) ever since beginning CPAP therapy, and I believe the mask has been contributing to and/or causing my TMJ problems.  The F&P Simplus came after trying many other masks, but having difficulty getting leaks under control.  I have facial hair.  The Simplus was, for a time, minimizing my leak issues.

However the mask has also been leaving red marks on my face around my nose where silicone touches the skin.  So I began using a fabric pad, which has eliminated the red marks but seems to be causing more leak problems.

Of course, tightening the straps of the mask to eliminate the leaks puts pressure on my TMJ which results in severe pain when eating, and probably caused the disc displacement in the first place.  I'm really struggling to find a good balance of controlling leaks vs allowing my jaw joint to not be in pain....

Does anyone have any ideas??

Attached last nights data for reference.... (Edit: wrong image uploaded initially)

   
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#2
RE: Large leak issues, TMJ problems...feeling helpless
Hmm, sounds like you have a fairly complex problem. Maybe my experience might help.

I also have a loose TMJ, but get minimal pain even with dislocating unless it gets stuck. For me it is more an issue of airway obstruction that occurs when the mandible slides back. So without a TMJ splint I am an obligate mouth breather when the jaw relaxes in sleep. I presently do well with a hybrid FF mask (ResMed F30i), but it sounds like your jaw is not tolerating the pressure against your chin a FFM causes.

An alternative, which I have tried, is to get a TMJ night splint which should help your pain and also act as a gentle mandibular advancement device. With a night splint I can use a nasal mask since my jaw stays forward enough to keep a solid nasal airway under pressure. (You could get an honest-to-goodness mandibular advancement device, but they are tricker to fit and force the mandible to close into a static position, which it sounds like your jaw will not tolerate) The only issue with the splint approach is learning to keep your mouth closed with a nasal mask and your tolerance of mouth taping if that is needed.

For me, I still use a FFM rather than the night splint plus a nasal mask because I find it most comfortable (and I just can’t unlearn mouth breathing it seems). But for you the calculus may be the opposite.
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#3
RE: Large leak issues, TMJ problems...feeling helpless
I had same issue when I used to use F30. The bottom straps pushes the bottom of the mask that's on the chin, thus pushes your jaw back depending on how tight the straps are. You don't run into this issue with Nasal masks. I recommend the N20 if you are not a mouth breather. If you are, you can try tape in combination. You got to be careful with tape. You have to take into consideration of possible blackouts that wills stop the machine and cause air to not flow, and you will not get oxygen.

Also, cervical collar can make you clinch hard. I had issue with this.
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#4
RE: Large leak issues, TMJ problems...feeling helpless
Thanks for your input, apologies I didnt see this response sooner.

I've since gotten a full time TMJ splint which has helped tremendously with my jaw pain.  My dentist says this is not meant to be a permanent solution, however, and is now discussing more permanent options with me (2-3 yrs braces or porcelain crowns basically) while also recommending a sleep apnea night guard type thing to use instead of the sleep apnea machine which is putting pressure on my jaw.

I'm not quite sold on my dentist's recommendations yet and would love to hear if you have any thoughts on this since you mention you also have TMJ issues (although probably different from mine.

In the meantime, I've also switched my mask to a Resmed Airtouch F20, which has allowed me to get a good seal while reducing the strapping pressure on my chin somewhat.  Unfortunately, most days I find myself still waking up quite tired, mouth bone dry, sometimes headaches, and I have to wonder how much benefit I'm actually getting from my CPAP these days.... A sleep apnea night guard is starting to sound kind of tempting, however I'm sure it has its own issues i'm simply not aware of yet...
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#5
RE: Large leak issues, TMJ problems...feeling helpless
Good to hear from you and that you are making progress!

I would be cautious of "permanent" solutions to the TMJ. People have been recommending I do things for 40 years (pull teeth, cap teeth, get braces, and even a sliding osteotomy to shorten my jaw), and every time I reconnect for treatment (every decade or 2) the provider exclaims on how great it is that I did not do whatever the previous provider said. Though, to be fair, I did a face-plant this winter and chipped a tooth, which subtly changed my bite in a very stabilizing way. But I do not recommend this as a therapy!

When I first got a TMJ brace I wore it all the time. But then cut back to nights only, and that worked very well for me for years. So well, in fact, that I kept stopping using it until my jaw would start dislocating again and then I would dig it out of the drawer. If the splint is working well for you, I suspect that means your jaw naturally "floats" to the best position. Have you tried using a nasal mask (so there is no pressure on the jaw) with your present splint? For me, this makes a tremendous difference as far as nasal obstruction, I just wake up too easily with air leak noises if I use a nasal mask.

For dry mouth, I would advise turning up the APAP humidifier to just under rain-out (manual settings). And check out your numbers on OSCAR and add a recording oximeter, if possible, to see if the headaches signal desaturation (Amazon has the Wellue Ring and others you can read about) vs referred pain from the TMJ.

My experience with a true MAD (mandibular advancement device) is that it will lock your jaw un-naturally forward - after all, that is the point - which is uncomfortable even with my tolerant jaw. You will drool too as swallowing is tougher. Try to swallow with your tongue sticking out and you will get the idea. Its bulk is uncomfortable with a FFM, so it either has to do the trick without a CPAP (this will only be enough for mild purely obstructive apnea) or you still have to use a nasal mask.

I hope this is a help!
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#6
RE: Large leak issues, TMJ problems...feeling helpless
I tried a nasal mask previously but it became very clear that I cannot avoid mouth breathing at night.  I would probably need to try mouth taping with a nasal mask, so that may be next on my agenda.  However I am quite sensitive to air leak noises and sensations, so that may be problematic.

After doing further reading, i'm pretty concerned about my dentist's recommendations for a sleep apnea appliance.... I can't imagine my jaw responding well to being forcibly advanced and locked in one place all night given the disc displacement that has been confirmed via MRI...  I also was tested to be on the threshold of severe OSA given the number of events I was experiencing, so perhaps it wouldn't even be effective anyway...
 
My dry mouth issues are worse now with the appliance I'm wearing... But my issue with the humidifier is that if i turn the humidifier up too high, the tank on my ResMed AirSense 10 is depleted in like 5-6 hours.  I have to set the humidifier to about 4-5 in order for it not to run dry by morning.  Rather frustrating but it seems to be better to have it lower throughout the night than wake up with it bone dry in the morning...

Anyway, lots to consider...thank you for your input.
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