Dr Ted's new website is:
ojwforweightcontrol.com
As of January 1, 2017, Dr. Rothstein has limited his practice to providing Orthodontic Jaw Wiring for Weight-Control: OJW®: Weight-control. He provides this service in Brooklyn, NY and will soon announce a new office location in Portland,OR where the Oregon Board of Dentistry on June 23 created history by ruling that Dental Professionals are at liberty to Provide Weight-control services. See www.ojwforweightcontrol.com
Contact: 718 808 2656; drted35@gmail.com

TMJ Pain: What Now?

I recommend you view the one labeled “TMJ Pathophysiology” where you can see two short. Simulated real-life films: one of a normal functioning TMJ, and the second showing a TMJ with a typical “Disc” problem causing a click in the joint—Excellent!

TMJ16TMJ: Patient’s right side

What is TMJ?

The letters TMJ are an acronym that stand for the words Temporal-Mandibular Joint. This is the joint that operates the opening and closing of your mouth. [images]
The joint is composed of a part of the skull called the Temporal bone, the lower jaw bone called the Mandible which is connected to the Temporal bone. Lying between the Temporal bone and the Mandible is a disc of cushioning material controlled by the muscles that help to open the mouth.
You can feel the joint by putting your index fingers just in front of your ears and opening and closing the jaw (mandible). The right and left side together comprise the TMJ. However, doctors often call the pain you feel around the joint when you are under tension and stress “TMJ”.
They will tell you that “you have TMJ”. There are two basic kinds of TMJ problems: The first kind is related to pain that comes from some disorder of the parts inside the joint. This kind of disorder is much less common than the pain that originates in the muscles just surrounding the joint that help to open and keep the jaw closed.
A common example of this kind of pain/disorder occurs when you are under a great deal of stress and you begin to clench and grind (brux) your teeth , not only during the day but at night in your sleep. This extra ordinary (para-functional) chewing puts a great deal of stress on your TMJ. The muscles that hold the mouth closed go into a kind of painful spasm which can be very painful. The treatment is very simple: allow the jaw to rest, among many methods that are useful.
Orthodontists can often diagnose the problem easily because patients report that upon waking their jaws hurt. A simple removable device called a bite plate is usually very helpful to alleviate the pain. In some cases just limiting the jaw from making its maximum movements gives the TMJ and the muscles that create jaw movement a chance to rest can lessen TMJ pain over time.

TMJ Pain: What you can do right now

  1. You can take 2 Advil liqui-gel tablets every 6 hours for 2-3 days (Advil contains 200 mg. Ibuprofin  (NSAID-non steroidal) and Aspirin (beware of allergies) This will relieve pain and begin reducing any inflammation within the joints.
  2. Do not open your mouth more than 1/4″: That means for the time being you must talk “small” (lips very near each other when you are speaking).
  3. For the time being do not chew gum at all.
  4. Eat mushy foods; do not eat any thing that requires you to chew.
  5. Be very careful when you sneeze or when you yawn.
  6. Avoid any intimacies that require you to keep your mouth open (wide) for a prolonged period of time\
  7. More than likely one of the muscles that draws your mouth open is cramped (in spasm) as a result of you clenching your teeth tightly together during the day and or evening when you are sleeping in effect preventing your jaw muscles from relaxing as they should normally do.
  8. The object of treatment for this common problem  is to reduce stress (easy to say) and get you to stop clenching on your back teeth. The variety of treatment methods can make your head spin. The most commonly use device that I know of is a simple bite plate which can be worn 6-12 weeks.  The fee for a bite plate can vary between $685 and $1185.
  9. Sometimes the pain is caused because the crookedness of your teeth so you need to know if that is part of the cause.
  10. What you must certainly find out is whether the cause of the pain is from a cavity or abscess in and around your teeth back.
  11. Consequently it wise to visit a dentist. Even better,although I am biased, a consultation with an orthodontist might serve you better.
  12. This type of problem is not within the expertise of a chiropractor, acupuncturist.
  13. Sometimes the problem is not caused by a spastic muscle, rather it is caused by what dental professionals call an “internal derangement”of the TM Joints i.e. a problem I liken to “Tennis Elbow” or a knee joint problem wherein some part of the joint within is in disrepair.
  14. When your jaw has limited opening or cannot close “normally” more likely your problem is more serious.  Your Jaw tends to deviate toward the side with the joint that has the problem.
  15. A consultation for TMJ takes more time than other types of consultations. I charge $125 -175 depend on how long I need to do a thorough exam.
  16. You can save  a lot of time by preparing a written history of your problem and be sure to bring any device you are currently wearing to help you with your TM Joint discomfort.
  17. You may also apply a heating pad (warm not hot) in the evening and morning as long as time allows.
  18. There a few medications specifically/commonly prescribed for the jaw muscles to reduce spasm. One of these is Robaxin
  19. There are some meds that have an inherent side effect of causing the jaw muscle to go into spasm. Consequently, ask your physician if your meds have that effect or just look in your browser and ask : “What are the side effects of (name of medicine) or go to “Drug Side Effects
  20. Ecstasy, Cocaine and Methamphetamine are known to cause involuntary clenching.
  21. Get to a dental professional as soon if only to determine that 1. That the source of the pain/dysfuntion is  simple (muscle spasm of the “internal  pterygoid” or other chewing muscles) or 2. more complex i.e. part of the TM Joint, (some part “INSIDE” the right or left joint) is in a state “disrepair”.
  22. And to give you advice if it would help to have a “CAT” or “MRI” Scan (X-ray) $250 -$750 of the right and or left TM joints to get diagnostic information.
  23. Your ENT (ear, nose and throat) physician might also be a very good source of information because there are few conditions of the ear that can mimic TM pain.

Orthodontic Jaw Wiring: To limit excessive opening and movement of the jaw thereby allowing it to rest.

jaw-wiring

The OJW position of physiologic rest:

Is a parted resting position of the mandible at which the muscles of mastication are in  a minimally contracted position thereby allowing the lower jaw to be suspended from the maxillary teeth in a condition of  weightlessness”. Interocclusal wiring allows the mandible to move  2.0mm- 4.0mm laterally, vertically and antero-posteriorly  thereby minimally impeding speech and minimizing the possibility of temporo-mandibular joint (TMJ) stiffening. This position is often congruent with an observable interocclusal space of 2.0mm to 4.0mm and closely approximates the position we know as the “physiologic jaw resting”  position, the initial position  from which all jaw excursions begin.

(It is this condition of  jaw “weightlessness” that precludes the possibility that the upper/lower teeth are extruded during the time the OJW device is in place.).

Here is an overview of the problem as published in an American Dental Association publication:

What are the limitations for normal movement of your jaw?

jaw-movement

[The physiologic normal range/envelope of motion of the lower jaw: see norms
Vertically: 40mm
Laterally: 8mm: 4mm right 4 mm Left when teeth are slightly parted).
Protrusive: 6-8mm) The distance you can move the lower jaw
forward.

[The envelope of motion in OJW: Rothstein's OJW position of rest:
         Vertically: Most often 2.0mm, extendable to 4.0 on demand.
Laterally: 1.5-2.5mm, extendable to 2.5mm-4.5mm
in Protrusive: 2.5, extendable to 4.4mm]
  These three hyperlinks all go

  [The envelope of motion in OJW: Rothstein's OJW position of rest:
         Vertically: Most often 2.0mm, extendable to 4.0 on demand.
Laterally: 1.5-2.5mm, extendable to 2.5mm-4.5mm
in Protrusive: 2.5, extendable to 4.4mm]  These three hyperlinks all go
link to one location:

 

tmj_jointOverview:

More than fifteen percent of American adults suffer from chronic facial pain. Some common symptoms include pain in or around the ear, tenderness of the jaw, clicking or popping noises when opening the mouth, or even headaches and neck aches.

Two joints and several jaw muscles make it possible to open and close the mouth. They work together when you chew, speak, and swallow. These structures include muscles and ligaments, as well as the jaw bone, the mandible (lower jaw) with two joints, the TMJ’s.

The TM joint is one of the most complex joints in the body. Located on each side of the head, these joints work together and can make many different movements, including a combination of rotating and translocational (gliding) action, used when chewing and speaking.

tmjd-basicsSeveral muscles help open and close the mouth. They control the lower jaw (mandible) as it moves forward, backward, and side-to-side. Both TM joints are involved in these movements. Each TM joint has a disc between the ball and socket (see diagram). The disc cushions the load while enabling the jaw to open widely and perform rotating and translocational movements. Any problem that prevents this complex system of muscles, ligaments, discs and bones from working together properly may result in a painful TMJ disorder.

Diagnosis & Treatment

A dentist can help identify the source of the pain with a thorough exam and appropriate x-rays. Often, it’s a sinus, toothache or an early stage of periodontal disease. But for some pain, the cause is not so easily diagnosed. The pain could be related to the facial muscles, the jaw or temporomandibular joint, located in the front of the ear. Treatments for this pain may include stress reducing exercises, muscle relaxants, or wearing a mouth protector to prevent teeth grinding. They’ve been successful for many and your dentist can recommend which is best for you.

Several conditions may be related to TMD, but they can be quite varied, and they are often difficult to pinpoint. TM disorders can result when the jaw muscles or jaw joints are affected.

The joint, ligaments, and muscles used for chewing and grinding food may all be involved. In some cases, it is not possible to clearly determine the causes. In some complex cases, where more than one doctor is involved, it may be difficult to get a consensus on treatment.

Some TM problems result from arthritis, dislocation, and injury. All of these conditions can cause pain and dysfunction. Muscles that move the joints are also subject to injury and disease. Injuries to the jaw, head or neck, and diseases such as arthritis, might result in some TM problems. Other factors that relate to the way the teeth fit together—the bite—may cause some types of TMD. Stress is thought to be a factor. TMD affects women of childbearing age more than men, or older men and women.

Diagnosing TMJDs can be difficult and confusing. Presently, there is no widely accepted, standard test to correctly identify all TMJ conditions. In most cases a complete evaluation, including a detailed medical history, the patient’s description of symptoms, and physical examination of the head, neck, face and jaw provide information useful for making a diagnosis.Most current tests are intended to rule out other possible medical conditions. A diagnosis of TMJDs may be made only after every other possibility has been considered and eliminated. (For example, facial pain can be a symptom of many conditions: sinus/ear infections, various types of headaches, facial neuralgias (nerve-related facial pain), tooth decay, and even tumors.)Many TMJ patients see multiple healthcare providers in their search for answers.This list includes: primary care physicians, dentists, sleep specialists, ear, nose and throat specialists, neurologists, endocrinologists, rheumatologists, pain specialists and chiropractors.NOTE: Before undergoing costly diagnostic tests, get an independent opinion from another healthcare provider not associated with your current provider.

There are several ways the TMJ disorders may be treated. Your dentist will recommend what type of treatment is needed for your particular problem or recommend that you be referred to a specialist. Treatment may involve a series of steps. The step-by-step plan is in your best interest because only minor, relatively non-invasive treatment may be needed.

Diagnosis is an important step before treatment. Part of your clinical examination includes checking the joints and muscles for tenderness, clicking, popping or difficulty moving. Your complete medical history may be reviewed, so it is important to keep your dental office record up-to-date. Your dentist may take x-rays and may make a “cast” of your teeth to see how your bite fits together. Your dentist may also request specialized x-rays for the TM joints. Depending on your case, the dentist may refer you to a physician or another dentist.

Additional symptoms of TMJ:

  • pain in the neck and shoulders
  • migraine and/or chronic headache
  • jaw muscle stiffness
  • limited movement or locking of the jaw
  • painful clicking, popping or grating in the jaw joint when opening or closing the mouth
  • a change in the way the upper and lower teeth fit together or a bite that feels “off’
  • ringing in the ears
  • ear pain
  • decreased hearing
  • dizziness and vision problems

Here’s some specifics that might help you:

  1.  TMJ Syndrome Overview
  2.  TMJ Syndrome Causes
    Some causes of TMJ disorder/dysfunctionTMJ disorders are a group of complex problems of the jaw joint. TMJ disorders are also sometimes referred to as myofacial pain dysfunction and Costen’s syndrome. Because muscles and joints work together, a problem with either one can lead to stiffness, headaches, ear pain, bite problems (malocclusion), clicking sounds, or locked jaws. The following are behaviors or conditions that can lead to TMJ disorders.

    1. Teeth grinding and teeth clenching (bruxism) increase the wear on the cartilage lining of the TMJ. Those who grind or clench their teeth may be unaware of this behavior unless they are told by someone observing this pattern while sleeping or by a dental professional noticing telltale signs of wear and tear on the teeth. Many patients awaken in the morning with jaw or ear pain.
    2. habitual gum chewing or fingernail biting
    3. dental problems and misalignment of the teeth (malocclusion). Patients may complain that it is difficult to find a comfortable bite or that the way their teeth fit together has changed. Chewing on only one side of the jaw can lead to or be a result of TMJ problems. Trauma to the jaws. Previous fractures in the jaw or facial bones can lead to TMJ disorders.
    4. Stress frequently leads to unreleased nervous energy. It is very common for people under stress to release this nervous energy by either consciously or unconsciously grinding and clenching their teeth.
    5. Occupational tasks such as holding the telephone between the head and shoulder may contribute to TMJ disorders.
  3. TMJ Syndrome Symptoms
  4. When to Seek Medical Care
  5. Exams and Tests
  6. TMJ Syndrome Treatment
  7. Self-Care at Home
  8. Medical Treatment
  9. Next Steps
  10. Follow-up
  11. Prevention
  12. Outlook
  13. Multimedia

 

Insurance Coverage

Many medical and dental insurance plans do not pay for treatment of jaw joint and muscle disorders, or only pay for some procedures. Until the causes of the various TMJ diseases and disorders have been discovered, and quality science demonstrates that treatments are effective without causing harm, insurance companies will not recognize treatments that have questionable outcomes. Contact your insurance company to see which treatments are covered.


Costs

There are no standardized costs for TMJ treatments.

TEMPOROMANDIBULAR JOINT DISEASE AND TREATMENTan ADA publication click here
Temporomandibular joint – Wikipedia, the free encyclopedia
Finally, a self-help book for lay persons  “TMJ No More”   http://www.tmjatoz.com/


Doing your own Research

  1. Visit the AACFP.ORG website. This organization has a list of specialists who treat patients with problems involving TMJ, Headaches, Facial Pain, etc. You may be able to locate a specialist close to your home that can answer your questions.
  2. . Visit the AAFO.ORG website. This organization also has a list of some specialists who deal with head pain problems. Try to find at least three specialists in your area that belong to both of these organizations.
  3. Interview the doctors that you find. The most important aspect of successful treatment is a proper diagnosis. An in-depth examination must include detailed patient examination forms, as well as some of the following diagnostic methods:a. Transcranial X-Rays, Cephalometric X-Rays, MRIs, CatScans, or Tomograms. A skilled specialist must use one, or all of the above, for adequate diagnosis of your problems.
    b. Complete Orthodontic Examination, Proper treatment of facial pain problems involves repositioning the jaws into better alignment with each other. Proper diagnosis, using orthodontic measurements, must be made before any such treatment is proposed.
    c. The specialist you find must be skilled at functional orthodontics, as well as prosthodontics. He/she must be able to align your teeth and jaws using either braces, appliances, or crowns/bridges/implants. This requires an immense amount of skill and knowledge.
    d. Your future specialist must also work closely with a team of doctors, including ENTs, neurologists, physical medicine, therapists, chiropractors, etc. for optimal care.
    e. We also recommend finding an ENT specialist, who should evaluate your airway, sinuses, ears, etc. This specialist should also work closely with sleep lab in your area, in order to properly evaluate your sleep patterns.


TMJ Do’s and Don’ts: a NY Times article by Jane Brody
THE NEW YORK TIMES HEALTH TUESDAY, FEBRUARY 3, 2009

TMJ-do-donts

     TEMPOROMANDIBULAR JOINT DISEASE AND TREATMENT,
an ADA publication click here

"Experience and reputation really count when it comes to providing quality patient care."