The Problem with TMJ Surgery

I’ve been successfully treating TMJ disorders with conservative splint therapy, orthodontics, and reconstructive crown and bridge work for more than 25 years. During that time, I’ve encountered less than a handful of patients who could only be helped with joint surgery. I have, however, consulted with and treated dozens of patients who have been plagued with continuing pain and the inability to chew correctly following TMJ surgery on one or both joints.

Unlike splint therapy, orthodontics, and reconstructive crown work which all focus on gently encouraging the joints to find a better position on their own through repositioning the way the teeth fit together, joint surgery often physically forces the TMJs into a completely new anatomical position. There is no ability for the joint to ease back and forth between positions or make the minute adjustments so often required to adapt to the constantly changing landscape of the mouth. The joint is simply moved or shaved, and there is no way for it to move back if the new position is not ideal.

Forcibly moving the joint with surgery may help create more room for the disc to move freely and correctly, resolving pain and functional issues associated with locking and popping, but surgery almost never takes into consideration the most important function of the jaw: making the teeth fit together for chewing. Too often, I have heard clients recount stories of being told to simply stop chewing and stay on a soft diet for the rest of their lives when their teeth no longer fit together after TMJ surgery. A long-term soft or liquid diet is not ideal for anyone, nutritionally or otherwise. And for a person in their 30s, 40s, or 50s? Never chewing again is simply not a good enough answer.

Unfortunately, the inability to chew is not the only potential negative outcome of TMJ surgery. Some patients experience recurrence of pain symptoms, locking, and popping within a few years after the surgery. The most unfortunate cases I see are in patients who undergo surgery and then end up in the same pattern of symptom management that they were in before the treatment. These individuals find themselves back in an orthotic to control pain and locking, experience severe pain flare-ups several times per year, and require regular physical therapy, chiropractic adjustments, or massage therapy in just to maintain the most basic levels of function.

There are certainly circumstances where TMJ surgery may be the only answer, but those cases are extremely rare and usually involve some sort of trauma. The most successful case of TMJ surgery I have ever seen was a surgical unlocking of the discs done on a patient whose discs were displaced through a blow to the chin sustained during a bicycle accident. Again, these cases are the exception rather than the rule. I caution all my patients not to put themselves into the surgery category until all other treatment options have been ruled out or exhausted.

TMJ disorders exist on a broad spectrum of severity, with most cases being transient or easily managed with non-permanent changes to the the teeth or joints. In order to help you better understand this spectrum and the variety of non-surgical treatments available that may be of help, I’ve created a new resource entitled The Benefits of a Non-Surgical Approach to TMJ Dysfunction. I hope you will share this information with anyone you know who suffers with TMJ-related pain and dysfunction. As always, current or prospective patients are always encouraged to call or bring questions about their specific circumstances to their next regularly scheduled appointment.

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Not All Nightguards Are The Same

There are many different philosophies when it comes to constructing a nightguard. In its simplest form, the primary function of a nightguard is to protect the teeth from the destructive actions of clenching and grinding during sleep. Upper nightguards with a flat surface are a popular and simple solution to to this problem. However, after more than 30 years of studying and treating bites, joints, and airway issues, I have found that while many upper nightguards may protect the teeth from tooth-on-tooth damage, they often disregard important elements of a balanced bite and an open airway.

Traditional upper nightguards are generally made by taking a single impression of the top teeth and palate, and then sending that single impression to a laboratory to have a simple nightguard made. Little attention is given to the physiology of the joints and muscles, resulting in many upper nightguards that actually shove the lower jaw backwards, causing pain and compression in the joint space. Many of these nightguards are also constructed with a flat biting surface for the bottom teeth to slide against. The idea is that the teeth are grinding around anyway, so why not give them full freedom to do so?

The problem with that concept is based on a fundamental misunderstanding of why people clench and grind in the first place. Stress can certainly play a role, but nighttime clenching and grinding can also be a physiological effort to open the airway or to find a more comfortable resting place for the teeth that better supports the joints and muscles. A flat plane that the teeth literally skate around on can actually causing grinding to increase as the muscles and joints struggle to find any resting place at all.

Upper nightguards can also exacerbate breathing problems, especially for those people who already snore, suffer from allergies, or have any form of sleep apnea. Most upper nightguards are fairly thick across the palate. This construction crowds the tongue further back into the throat, constricting the airway. When this happens, patients will often stop wearing the nightguard even if they don’t know why because it feels claustrophobic or simply “too big”.

In my practice, I always recommend and construct lower nightguards for my patients. Even if a patient has no known joint or breathing issues, my goal as a neuromuscular dentist is to always protect the balance that already exists. A lower nightguard allows more room for the tongue and, when constructed properly, holds the lower jaw in a neutral, relaxed position to support the joints and muscles.

When we make a lower nightguard, impressions of both the upper and lower jaw are taken, and a bite registration is used to determine the ideal relationship between the upper and lower teeth when the joints and muscles are at rest. A bite, or resting place, is carefully constructed into the surface of the nightguard. This bite is not a locked position, but rather a subtle suggestion to the teeth to settle into a more relaxed position when not engaged in a grinding activity. Full freedom of movement is still possible and careful attention is paid to potential interferences when the jaw moves forward and side-to-side during the final fittings.

A nightguard is a simple device in theory, but like any other treatment or device that introduces a change in the body, great care must always be taken to reduce or eliminate any unnecessary and unwanted changes to other systems. If you are considering a nightguard, or you have questions about the construction and efficacy of your current nightguard, I encourage you to seek out an opinion from a neuromuscular dentist. Current patients or individuals who would like to become patients within my practice are always encouraged to call or schedule and appointment to further discuss my approach to nightguard construction and to determine if a nightguard is the correct appliance to address all your functional needs.

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Listening to Pain: The Key to Healing

In my practice, I treat many patients who suffer from chronic pain. Malocclusion, or a misaligned bite, can stress the facial muscles, compress and malform the TMJ, and cause a great deal of pain in the jaw joints, face, head, ears, and neck. But in all the years I’ve been treating TMJ and chronic pain, I’ve never seen a patient who’s sole source of pain was exclusively from a bad bite or compressed joints. Chronic pain is nearly always multifactorial. There may be a primary underlying cause, but lifestyle habits and stress levels can not only crank up the volume on an existing condition like TMD, but also create a great deal of pain all on their own.

Many patients we work with have travelled a long journey trying to understand the clinical reasons for their pain. They have visited doctor after doctor, receiving different diagnoses, treatments, and medications. Some even undergo surgery in an effort to find some kind of relief, yet still they have pain. Unfortunately, many of these patients we work with are often completely unaware of how their own lifestyle habits and stress levels could be hindering their ability to heal. This is not the patient’s fault. As healthcare practitioners, it is our job to help patients understand not only what we can do to help them, but perhaps more importantly what they can do every day to help themselves.

No doctor can possibly understand what it feels like to be in your body better than you. Pain is your body’s way of telling you something is wrong. With a little time and careful listening, many patients can uncover physical habits and lifestyle choices that create or exacerbate their pain all on their own. Doctors can run tests and take x-rays, but a doctor does not live with you 24-7. Only you know that every time you skip breakfast, you end up with a headache. Or that every time you do a particular weight-bearing exercise, your teeth and jaw ache afterwards. Or that every interaction you have with a co-worker, friend or family member seems to trigger a migraine. Just by paying attention to when your body experiences pain and what is happening in and around that moment, you can gather more information about the possible triggers for your pain than any doctor ever could.

Now, can another person actually cause you physical pain just through conversation? Probably not, but the stress of that conversation may cause you to clench your teeth, tighten your shoulders, and breathe more shallowly. All of those things will definitely give you a doozy of a headache. Medication may help in the short term, but the ultimate cure for that kind of pain is to learn how to interact differently with the people in your life who cause you stress, or to eliminate those relationships altogether if possible. Medication can not do that for you, but practical tools do exist to help you manage relationship stress and decrease its effect on your physical body.

Pain is not a comfortable experience for anyone. It is not meant to be. Your body is trying to get your attention. Listen, look inward, and try to understand its message. You may be surprised at how much information you will receive.

In order to help you do just that, this month I have created a tool that will allow you to see more clearly the many messages your body is trying to send you through your pain. The Daily Headache Diary is a tool for you to use in conjunction with the entire Headache Series. By tracking your diet, medications, and answering a series of questions each day about your habits, you will begin to see if there are any patterns in your daily or weekly routine that regularly coincide with headache pain. That information is incredibly valuable. Even if you do not know what to do with it right away, keep listening, share your new understandings with your treating physicians, and try some of the simple adjustments suggested in the Headache Series to see how much headache pain you can reduce or eliminate all on your own. We are each our own best healers when it comes to chronic pain. Trust your body. It does not lie.

By the way, this is also a helpful tool for other types of pain.

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Silver Fillings Are More Expensive Than You Think

It’s hard to find many people over the age of 30 in the United States who have not had at least one silver filling in their lifetime. In fact, it’s really only been in the last 35 years that comparable alternative materials have been developed for fillings in the back teeth. Our back teeth can take a beating over a lifetime. Average chewing forces alone in the molars can exert about 70 pounds per square inch, but for people who clench and grind regularly this force can increase by 6 to 10 times as much, or more. Obviously, any material used to restore the back teeth needs to be strong and durable.

For many years, the argument for silver fillings has been based on their strength, durability, ease of placement, and cost. Silver fillings are the least expensive filling material available on the market and require the least amount of preparation work on the tooth in order to place them. Yes, silver fillings contain metals and mercury, but proponents believe that the risks of mercury exposure or metal sensitivity are low. Certainly, dental insurance companies would prefer to only pay for silver fillings rather than more expensive metal- and mercury-free alternatives. And for the low-income population without insurance or additional resources, proponents believe a silver filling is better than no filling at all.

There is some truth to that statement. However, the ease and inexpense of the initial placement of a silver filling is not the only cost associated with that filling over a lifetime. The truth is that no filling material will last forever, but silver fillings by their very nature can set up more long-term damage in the teeth than other alternative materials now available. Even if we set aside all the valid concerns about metals and mercury, silver fillings just aren’t the best materials on the market anymore.

Silver fillings are not bonded to the teeth, which means that the margins are not actually sealed. That unsealed microscopic channel between the edge of the silver filling and the tooth makes it nearly impossible to protect the margins, even with exquisite home care. Inadequate or irregular home care will definitely leave these unsealed margins extremely vulnerable to recurrent decay, causing the filling to need replacement with larger and larger silver filings over time. But that’s not the only weakness that a silver filling can present.

Silver fillings also expand and contract in relation to temperature changes in the mouth at a very different rate than the healthy tooth surrounding them. Over time, as we eat hot and cold foods, these differing expansion rates can set up fracture lines in the tooth enamel that leave the tooth even more vulnerable to recurrent decay and breakage. No filling material on the market can exactly match the expansion and contraction rate of enamel yet, but silver fillings are the most likely to set up these kinds of expansion fractures in the shortest period of time.

So if the mercury content, unsealed margins, and the expansion/contraction rate of silver fillings are all of concern, why are silver fillings still in use? The answers are simple: it’s cheaper and easier than newer, better materials. Cheaper and easier may make sense in the short term, but the more we learn about silver fillings and the long-term consequences for the health of our teeth, our bodies, and our environment, those silver fillings may be far more expensive over time than we realize.

In my practice, I have not placed a silver filling in any patient in more than 20 years. I would not place a silver filling in my own mouth, in my children, or in my grandchildren. I do agree that when the only option is a silver filling or no filling, then the silver filling is the better choice. But I do not agree that silver fillings are cheaper in any way other than the initial cost of placement. We can do better across the board and especially by our low-income population, and it is my sincere hope that by keeping the conversation open and continuing to make as much information available as possible, that someday we will.

To learn more about silver fillings and all the other options available in dental filling materials, please visit my newest resource article, A Comparison of Dental Filling Materials.

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The Benefits of Botox in Dentistry

I have to admit that utilizing Botox, or botulinum A, as a therapeutic treatment for dental and TMD-related conditions was not something I ever anticipated integrating into my practice. Like many of us, my first impressions of Botox came through the huge media attention surrounding the introduction of Botox Cosmetic in 2002. I was hearing a lot about Botox parties for frown lines and wrinkles, but at that time, I had no idea that Botox had been used as a therapeutic medical treatment long before the introduction of Botox Cosmetic.

Botox, as manufactured by Allergan, is now one of three formulations of botulinum A available for medically therapeutic treatment. Botulinum A is a controlled form of the botulinum toxin, a nerve toxin produced by infection with the bacterium clostridium botulinum, commonly known as botulism. One of the most devastating effects of uncontrolled botulism is extreme muscle paralysis. Untreated, this paralysis can become deadly. However, as early as the 1950s, scientists began studying the botulinum toxin as a separate entity from the bacterial infection and discovered that, in small doses, the toxin itself could be used to reduce muscle spasm.

Through the 1960s and 1970s, scientific studies continued to explore the use of botulinum toxin specifically as a treatment for strabismus, or crossed eyes. Finally, in 1989 after nearly 40 years of scientific research, Botox (as introduced by Allergan) was approved by the FDA for the therapeutic treatment of crossed eyes and eyelid spasms.

Today, even though Botox Cosmetic still remains the most visible use of the botulinum toxin, many additional medically therapeutic applications of botulinum A continue to be researched and discovered, including dental applications.

Targeting specific muscles around the lips, botulinum A can significantly improve conditions like gummy smiles, upside-down smiles, lip lines and creases, as well as chronically puckered chins. These treatments are not permanent, but there is growing evidence to support that treatment with botulinum A over time can retrain these muscles into a state of improved relaxation and natural function.

Treating other muscles of the face, head, and neck with botulinum A have also demonstrated measurable relief for headache pain related to chronic and unrelenting tension in these muscle areas. Of course, headaches are almost always caused by multiple triggers and those factors should be concurrently addressed during botulinum A therapy. But for those patients whose muscles simply cannot seem to let go of chronic spasm, treatment with botulinum A can sometimes offer a level of relief that might otherwise not be achievable through other types of therapy.

Certainly, treatment with botulinum A is not appropriate for everyone, and it is not a permanent cure for any of the conditions I’ve mentioned. However, it can be an invaluable tool in improving pain levels and visual appearance while other more permanent treatment solutions are being pursued. If you would like to learn more about each of the specific botulinum treatments that are now available in our office, I invite you to take a look at our newest resource article, Botox in Dentistry. Current or new patients are also always welcome to ask about botulinum treatment at any regular dental appointment, or to call the office to schedule a consultation.

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