None of us want to see a doctor unless absolutely necessary. One of the most compelling symptoms prompting us to call or see our doctor is pain. Patients suffering from craniofacial pain and temporomandibular disorders (TMJ), unfortunately have few effective self-care options for the chronic pain usually associated with these conditions and therefore must seek professional care. Acute jaw joint or muscle pain is a common problem. Self-care can often be very helpful. I recommend soft diet, limiting opening movements, anti-inflammatory medication, and warm moist compress to the affected area. In other words, rest your jaw. For jaw pain, studies indicate the best over the counter medication is Aleve (sodium naproxen). This medication is well tolerated and requires only one dose every 12 hours to be effective. I strongly recommend the gel capsules over the tablets. Gel capsules act faster and do not irritate the stomach lining, which can occur with significant side effects when taking the tablet form. Of course should your pain and/or limitation of movement persist for more than 7-10 days or become worse you should seek care from a professional trained in the diagnosis and treatment of craniofacial pain and temporomandibular disorders
Have you been told your child’s teeth are too big for their mouth? How about “your child has too many teeth for their mouth” or “your child has dad’s teeth and mom’s jaws”. These types of comments are commonly used by both lay people and professionals to explain obviously crowded and crooked teeth. The problem is easy to see, right? The next question is “what should be done to solve this problem?” Logically two main approaches present themselves:
1) Too many teeth….remove some
2) too little mouth….make it bigger
The next question is “which is right for my child?” The answer to that question requires evaluation by a dentist trained in orthodontics and dental orthopedics. Keep in mind that there is not a consensus among dentists as to how a particular problem should be treated or what the underlying causes may be. My view is that most children are not born with a genetic predisposition to develop crowded and crooked teeth or jaw growth deficiencies regardless of their family heritage. The causes of these problems arise in the very early years of development and when left untreated until the teenage years result in crowded teeth, upper and lower jaw bone discrepancies, loss of permanent teeth and less attractive faces. Improper breathing, lip posture and tongue function are believed to be the underlying causes of 90% of malocclusions in children. The good news is that these underlying causes of most malocclusions can be successfully treated in children without braces or other extensive dental procedures.
I am frequently asked about the indications for use of “nightguards” and what type of nightguard I recommend. A few years ago I was asked this question during a presentation I was making at the Washington State Dental Hygiene Association annual meeting. My tongue and cheek response was that in most cases the #1 indication for any nightguard is that the patient does not have one and #2 is that the patient’s insurance would pay for it. Although my attempt at humor was not the response they expected, the truth of my statement was acknowledged by most in the room.
In most dental offices when a nightguard is recommended the patient assumes this follows a careful evaluation and diagnosis of the problem which the nightguard is designed to address. For example, night guards are frequently recommended to prevent excessive enamel wear due to nighttime tooth grinding (bruxism). Bruxism is typically diagnosed by observing wear on the chewing surfaces of patient’s teeth at the time of examination. Bruxism may be confirmed as a current activity by the patient’s bed partner or a parent observing a sleeping child. However, tooth wear alone is not an indication for a nightguard because it could have occurred in the past and the patient may not presently be actively bruxing. Wear on the teeth may also be due to dental erosion, a chemical process which is unaffected by nightguard wear. Confirmation that a patient is currently bruxing requires direct observation either in the home setting or overnight sleep study at a medical sleep center. Therefore, as always, proper diagnosis is an important key factor prior to recommending any treatment, including a nightguard.
Nightguards can adversely affect your health. Be sure you understand why a nightguard is being recommended for you and what adverse effects to look out for. Even when clearly indicated, prescriptions for nightguard designs are rarely based upon objective evaluations of patients individualized jaw muscle physiology and how the proposed nightguard will ultimately affect jaw function. Will it be a good effect or a bad effect? Improperly designed nightguards may result in increased tooth grinding and clenching, inadvertent tooth movement, tooth pain, jaw muscle pain, temporomandibular joint pain and dysfunction; and neck pain. Patients often seek treatment for these conditions from other providers without realizing the nightguard is actually causing or exacerbating the new complaint.
Accepting the recommendation for nightguard wear should not be a casual decision. If a nightguard is recommended for you, ask your dentist to explain why they believe it will benefit you. Also, be sure you have a thorough understanding of the benefits you may expect and what the possible adverse side effects could be.
This is a great question and one we often hear. The first point to understand is that TMJ is not a diagnosis at all. TMJ is an acronym for the TemporoMandibular Joints or simply your jaw joints. All normal healthy people have a pair, one on each side of your head. However, you may have pain or dysfunction (example, limited opening) of your TM joints and therefore your dentist has suggested a diagnosis of “TMJ”. Historically health care professionals, and therefore the general public, have used “TMJ” to refer to a broad range of disorders affecting not only the TM joints, but also associated structures of the head and neck. In order for you to better understand what your health providers are telling you (or not telling you) it may be helpful to take a stroll down nomenclature lane. Currently, painful disorders of dental structures, jaws, head and neck areas are collectively referred to as craniofacial pain disorders. Within this broad category lie the various temporomandibular disorders which refer specifically to problems within the jaw joints themselves.
In his text “Oralfacial Pain, Classification, Diagnosis, Management”, Dr. W. E. Bell described the field of craniofacial pain as follows:
The diagnoses and management of complex acute and chronic craniofacial pain disorders including neuropathic craniofacial pain disorders, muscular craniofacial pain disorders, chronic regional pain syndrome, complex masticatory and interrelated cervical neuromuscular pain disorders, headache disorders, temporomandibular disorders, craniofacial dyskenesias and dystonias, craniofacial sleep disorders and other disorders causing persistent pain and dysfunction of the craniofacial structures.
So, the proper generalized terms for these types of conditions are Craniofacial Pain (CFP) and Temporomandibular Disorder (TMD) and the potential combinations of conditions which may affect a given patient are seemingly endless.
We are now back where this discussion began, “I have TMJ. What does that mean?” Considering there are over 200 different diagnoses under the craniofacial pain umbrella, and different treatments apply to each diagnostic entity, it should be clear that the correct diagnosis initially is the key to successful treatment. The lesson summary is, if a healthcare provider tells you or a family member that you have “TMJ”, ask for more specific information. If their response is inadequate or uncertain, ask for a referral to a Dentist who is specially trained and experienced in the area of craniofacial pain and temporomandibular disorders.
Remember TMJ is NOT a diagnosis.
October 25-27, 2012 found me in Tempe, Arizona attending the International College of Craniomandibular Orthopedics’ 23rd B. Jankelson Memorial Lecture Forum and it happens this is the 23rd that I have attended. It has been over 40 years now since Dr. Bernard Jankelson introduced the fundamental concepts of Neuromuscular Dentistry to the scientific community and the concepts being introduced continue to gain worldwide acknowledgement. The theme of this year’s Forum was “Occlusion: the Basis of Neuromuscular Dentistry”. The presenters were all experienced neuromuscular dentists, but reflected a range of specialized interest. For example, Dr. Rex Eatman, an oral surgeon from Dallas, Texas, demonstrated how relatively minor alterations in head posture can dramatically affect the patients’ dentition. Drs. Doug and Peter Chase from San Francisco, California, followed up this topic with a presentation of head posture related to the radiographic and anatomic analysis of cranial planes. There were also several presentations for dentist and their staff who are new to neuromuscular dentistry.
I was honored to be included among the presenters at this Forum. I presented a portion of a new systematic protocol I have been developing to improve diagnostic information collection. As I have often stated in previous presentations, it is my contention that the diagnostic process is 95% of case management. It is very difficult to be successful in treatment of craniofacial pain and dysfunction disorders when one begins with insufficient or inaccurate diagnostic information. None the less, I continue to see many patients who were previously diagnosed as having “TMJ” prior to initiating some kind of treatment (further detail in my next blog). Those of you reading this who are potential patients should keep this in mind when choosing a practitioner. DO NOT be afraid to ask questions!
It was a wonderful opportunity to come together with colleagues of many years as well as meet new enthusiastic ICCMO members. Tracy, ICCMO executive secretary, has told me that the overwhelming majority of program evaluations submitted by members was very positive and all are looking forward to this years 24th Lecture Forum in Scottsdale, Arizona, October 31 thru November 2, 2013.
Earlier this summer my wife, Anna and I went to New York City to visit my colleague, Dr. Peter Ferro. I met Dr. Ferro some years ago when he became a member of the International Congress of Craniomandibular Orthopedics and then attended the annual scientific meeting. Over the years, Dr. Ferro and I have spent time together at ICCMO meetings followed by interim phone calls. I have come to know Dr. Ferro as a conscientious dentist with a passion for learning. Just the kind of person I want to know more about. As some of my readers will know, my wife Anna works with me every day as my office manager. Dr. Ferro’s wife, Camille, also works with him in the same capacity. We share so much in common; it was about time to visit them in their practice to see what we could learn. They have a very attractive and comfortable (the Germans would say gemutlich) office on Madison Avenue. As it happens, several other of my old dental colleagues practice in the same building. I visited with several of Dr. Ferro’s patients who declared he was the best dentist ever! Well, maybe on the east coast.
There was not much time for sight seeing, however, since we were already on Madison Avenue, I had to drag Anna with me for a visit to the Ralph Lauren Mansion. If you are ever in NYC this store should be on your list of things to see. The building, built in the 1880s as a private residence, covers about one quarter of a city block. During the renovation as the Ralph Lauren Men’s Store, no detail was overlooked and no expense spared. We easily spent an hour touring the several floors and I came away with a few sale items. Across the street are the Ralph Lauren Women and Home stores, so we naturally had to see that as well. Later, we walked back to Dr. Ferro’s office passing up numerous tasty shops for wonderful lunch with Peter and Camille and then off to the airport.
If you have need of a neuromuscular dentist in the greater NYC area, I can enthusiastically recommend Dr. Ferro! You will not be disappointed!
I recently attended the 27th Annual International Clinical Symposium sponsored by the American Academy of Craniofacial Pain (AACP). The meeting was held in Fort Worth, TX on July 27-28 201. The theme for the conference was “Perspectives of Related Professions”.
The AACP was founded in 1985. Membership in this international organization consists of dentists, oral surgeons, physicians, psychologists, chiropractic practitioners, physical therapists, and other related health care practitioners.
The purpose of the AACP is to foster education among the medical and dental professions and to promote the understanding of multidisciplinary treatment of people suffering from craniofacial pain and temporomandibular joint disorders.
The AACP conducts a clinical symposium once a year, in different cities across the United States. Speakers and topics differ at each conference. As it seems with all conferences some of the information was new and very relevant, some was interesting and some was of virtually no value. But knowledge gained was worth the trip.
One of the best aspects of these conferences for me is the opportunity to spend time with old friends and colleagues. It probably will not surprise anyone that some of the best new information comes from the small group interaction in the evening after the scientific programs have ended.
I arrived at Dallas-Fort Worth airport the day before the scientific session and was graciously hosted by my good friend Dr. Rex Eatmon. Dr. Eatmon, an oral surgeon from Dallas, was waiting for me at the baggage claim and we immediately set off to the Fort Worth Stockyards for a late lunch at his favorite Mexican restaurant, Joe T Garcias, Joe T’s as it is locally known has been in continuous operation for decades. We ordered two dinners and a pitcher of ice cold margaritas. The food is served family style and there is plenty of it. I’m not quite sure how we managed to eat enough to feed an entire family but I suspect the very refreshing margaritas had a certain influence on our appetites. If you are ever in Fort Worth do not miss Joe T’s. The Stockyard neighborhood is actually quite interesting. There are numerous shops featuring western wear, art and western furniture, as well as, a great variety of restaurants. It is a very nice area with friendly people and lots of families with small children (not a host of inebriated people as for example Bourbon Street, N. O.) At midday every day there is also a genuine recreation of an olde time cattle drive through the streets to the Stockyard pens. Something you and your children may never see anywhere else.
In summary, the AACP conference was great and Fort Worth was fun. I recommend these both for future professional development or a holiday.
I recently attended the International Association for Orthodontics Annual Meeting in San Juan, Puerto Rico. As a full-time staff member and my office manager, my wife Anna attended as well. I must confess the lure of a tropical vacation enticed her to go along and we spent a wonderful week prior to the conference touring the island. Most Americans know very little about Puerto Rico even though it has been a United States Territory since 1898 when we “liberated” it from the Spanish Crown. We spent the week out in the country making an effort to learn something about the culture and people. I don’t want to bore you with all the fun experiences we had, but I will say the people are friendly and helpful, the food tasty and plentiful and the rum available everywhere. When we returned to San Juan for the conference we were only a short bus or cab ride from the beautiful old city. Spanish forts, colorful Caribbean streets and great restaurants as well as other tourists awaited us there. Should you be tempted to consider Puerto Rico for a tropical Caribbean holiday keep in mind you are in U.S. territory, no passport is required and U.S. currency is used.
The orthodontic conference was one of the best I have attended in recent years. Approximately 300 dentists from all over the world were there to get the latest information on orthodontic diagnosis and treatment. Among the many lectures and seminars I attended were two all-day seminars, one given by Dr. Derek Mahoney from Australia and the other given by my friend, Dr. Duane Grummons from Spokane, Washington. Both of these practicing orthodontists are internationally recognized as leaders in their field.
Dr. Mahoney’s presentation focused entirely on current treatment of what is known as Class II, division 2 malocclusion. Patients with this common problem present with a short lower jaw and lower incisor teeth that seem to disappear behind the upper front teeth when they bite down. Dr. Mahoney covered current concepts such as early orthopedic arch expansion, airway improvement (often in collaboration with ENT specialist), enhancement of lower jaw growth using the MORA appliance technique and new techniques of distraction osteogenesis to lengthen the lower jaw in patients who are no longer growing.
Dr. Grummons’ presentation focused on applying orthodontics to improve restorative and TMJ-TMD outcomes. His perspectives on how to create functional comfort, smile symmetry, facial balance and TMJ stability consistent with individualized facial morphology are very exciting and I might add congruent with my own philosophy and training. I also appreciated his research and fact-based approach to decision making regarding treatment methods and appliances. In my opinion there are too many treatment decisions being made today that are driven by marketing, NOT science. Dr. Grummons left the audience with no question regarding his feeling in this regard and I applaud him for his professionalism and commitment to learning and teaching others. Thank you Dr. Grummons!
Other highlights from the meetings included a presentation by my dear friend Dr. Terrance Spahl. Dr. Spahl gave an interesting presentation on the current understanding of the neurophysiology of craniofacial pain and the orthodontic options available to assist in treating patients suffering from chronic headache pain. Dr. Steve Galella gave a presentation on the “controlled arch system” of orthodontic treatment he has been developing for over 20 years. Dr. Galella was a classmate of mine at the University Of Tennessee College Of Dentistry. Although we have followed each other’s careers over the years, we had not seen each other since graduation. A couple of years ago we reunited at an IAO Annual Meeting and we are once again collaborating in learning. I am very proud of Dr. Galella’s achievements and honored to say he is my friend, classmate and colleague.
This year was the 50th anniversary of the International Association for Orthodontics. At the awards banquet some time was allotted to reviewing the history of the organization and I was surprised to learn how many of the founders and early leaders were still active. One of my heroes, a founder and a past president of the IAO, gave a great presentation on what the IAO has meant to him both professionally and personally. At 89 years-old, he has never missed an annual meeting. When I ask the oft repeated question “do you have any plans to retire?” he said he hadn’t thought about it and indeed had just signed up for a 2 year training program in orthodontic diagnoses and treatment. I know it may sound crazy to many of you, including my wife, but I hope to be so fortunate. Time will tell.
In summary, the Puerto Rico IAO meeting was a great success and I am looking forward to the next meeting in 2013 in Los Angeles, California. It will be even more exciting because I have been asked to speak on the TMD-TMJ-Orthodontic connection.
Coming up next, a visit with my friend and fellow dentist, Dr. Peter Ferro at his office in Manhattan where we will review current neuromuscular treatment and management techniques.
I recently attended the ICCMO 16th International Congress in Vancouver, Canada. The International Congress is held every two years and rotates among the various international chapters of the ICCMO and is scheduled for 2013 in Munich, Germany. I continue to serve on the Board of Directors of the ICCMO and therefore it was necessary for me to attend a full day of business meetings which for me are always tedious, but nevertheless an important part of the work of continuing the growth of Neuromuscular Dentistry around the world. This year attendees included neuromuscular dentists from the United States, Canada, Germany, Italy, Japan, France, Argentina and India. Many of the scientific presentations were presented in the presenters native language through interpreters which required absolute focus. Therefore, I welcomed breaks and lunches. I gave a brief presentation entitled “Iatrogenic Dentistry and the Case for Neuromuscular Dentistry” reviewing some of the common dental conditions caused by misdiagnosis resulting in misdirected treatment. I also used this opportunity to implore our members to increase their efforts to educate our colleagues as to the benefits of Neuromuscular Dentistry for their patients and themselves. Many other presenters demonstrated excellent treatment results with the aid of Neuromuscular concepts. I returned to my practice with new perspectives and renewed enthusiasm thanks to these great dentists.
Fortunately, there were opportunities to visit casually with many dear colleagues I only have the opportunity to see once every year or two. As I found the German presentation regarding dental occlusal rehabilitation particularly interesting, I sought out several members of the German section to discuss their upcoming annual meeting agenda. They very kindly invited me to attend their next conference in Nuremberg, Germany in February 2012. After a very brief consideration I have decided to go and see first hand what interesting ideas my German friends are working on now. They have told me this will be the first visit of a USA section member to their annual conference.
For now, Auf weidersehen!
In June of this year I organized the second Chelan Neuromuscular Seminar for dentists who belong to the International College of Cranio-Mandibular Orthopedics. For those of you not familiar with Chelan, it is a resort community located at the edge of the Cascade Mountains on the shore of Lake Chelan. Roughly a three hour drive from Seattle, Chelan is not exactly a convenient seminar location, but a beautiful one due to its breathtaking scenery, vineyards and plethora of outdoor activities.
The featured speaker at the seminar was Dr. Robert Jankelson a recognized leader in the field of neuromuscular dentistry. Since his retirement from clinical dentistry in 1991 and subsequent move to Chelan, Dr. Jankelson has successfully fulfilled his dream of establishing a premier winery, Tsillan Cellars.
For those of you who love wine, Tsillan Cellars is a must see. As you enter Chelan on the main road along the lake, you can see the Tsillan Cellars Italian villa with bell tower. I encourage you to take a break, enjoy the wine, spectacular views and authentic Italian cuisine at Sorrento’s Risotorante.