Author: Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain

Orofacial Pain & TMJ Consultations Online – A New Era

An outcome of the coronavirus pandemic is orofacial pain specialists are conducting TMJ consultations online. The new era has begun…

As a dentist whose focus is directed toward treating orofacial pain and TMJ/TMD problems, I have seen first-hand the impact of life’s worries and challenges on people of all ages.

In normal times people seek my services because their jaw muscles are sore, tired, and aching. Any number of issues, from financial worries, relationship trouble, medical stress, family problems, poor sleep, or workplace tension, can upset the brain leading to muscle tightness and, ultimately, the onset of symptoms.

When your brain is upset, what would normally be perceived as tolerable pain can become so severe that it affects your life.

The Connection Between The Upset Brain & TMJ

A very common consequence of an upset brain is tooth and clenching and/ or bracing of the jaw muscles even without tooth contact. These activities can occur while you sleep, during the day, or both, overworking the jaw muscles and setting the stage for disruptive jaw or face pain, persistent toothaches, cracking/popping in the jaw joints, and the potential onset of TMJ problems (you can read more about TMJ here).

The current pandemic is affecting everyone. Even those who felt we had our lives under control before the crisis now face a threat we have few skills to confront. This stress can lead to an upset brain.

Therefore, it’s no mystery why patients currently under care, past patients, and those who never sought my care before are reaching out – desperate for relief.

TMJ Consultations Online Now

During the COVID pandemic, we were not to go about business as usual. But we have been able to address the pain relief needs of patients with online TMJ consultations. For a number of years, these telehealth options have been available, but it took a crisis like the pandemic to make orofacial and TMD pain practitioners all over the world realize how invaluable and effective online consultation visits can be!!!

It turns out that TMJ consultations online give me the opportunity to meet the person behind the symptoms, and do it in a safe and low-stress atmosphere. TMJ consultations also enable a spouse, partner, or other family members to be in attendance as a second set of eyes and ears.

And an added and unexpected benefit of TMJ consultations online is they enable patients, particularly those who are new to my practice, to meet me without my face obscured by a mask, glasses, and shield.

TMJ Consultations Online In The Future

TMJ consultations online will never fully replace the benefits gained by hands-on examinations in my office. However, I foresee I’ll be using them to reduce the time new patients need to spend in my office – by about 30 minutes. Until social distancing becomes less critical, reducing the time we all physically spend together is an important consideration.

I am grateful for platforms such as Zoom and Doxy as we move into our “new normal.” I clearly see that the use of technology, combined with imagination, and an ongoing commitment to providing safe and thoughtful care, will enable patients to get the care they need when they need it and for practitioners like myself, to provide it.

Today, TMJ consultations online for new patients are an innovative concept. In the future, they just may be the norm.

If an online consultation is of interest to you, please send an email to office@drtanenbaum.com with your contact information. A staff member will reach out to you.

Tags Orofacial Pain, TMJ

Facial Pain Jaw Problems Referred Pain TMJ

How To Self-Treat Jaw and Face Pain During Stressful Times

As an orofacial pain specialist in New York City and Long Island, patients come to me because they suffer from the painful symptoms of TMJ. Most often their symptoms are a result of their stressful lives.

During the pandemic, most people have been living with an unusually high level of stress. Poor sleep and limited exercise is one reason. Also involved are continually tensed shoulders, breathing in a strained manner, and grinding and clenching your teeth at night (or during the day). The result can be headaches, pain in the neck and back, or pain in your face, teeth, and jaw, or all of them.

How To Detect A TMJ Problem

When your TMJs (your jaw joints) are in trouble, it typically shows in five ways. You may have one, a few, or all of these symptoms:

Facial pain
Clicking or popping when you open and close your mouth
An unexplained toothache
Difficulty opening your mouth
Unexplained headaches, particularly when you wake up

It’s easy to understand how living with the pandemic for the past few years could trigger stress-related symptoms even in people who are normally calm and positive. I’ve seen hundreds of new patients never had a TMJ problem before the pandemic and just as many who suffered from TMJ in the past.

My advice is to become hyper-aware of how stress is impacting your jaw muscles. Stop every now and then during the day and take note if you are:

Holding your breath
Bracing your jaw muscles
Furrowing your brow
Clenching your teeth
Biting your nails
Raising your shoulders

Tips: How To Treat Jaw & Face Pain During Stressful Times

Control Your Daytime Breathing

Perform these three steps if you notice you’re holding your breath or breathing more rapidly than normal:

Slowly breathe in through your nose deep into your core and hold it for 3 seconds. It’s easier if you place the tip of your tongue on the roof of your mouth or behind your lower front teeth as you breathe.
Let the air out for three seconds through your lips and pause for 3 seconds.
Repeat 6 times.

Note: If your nose does not let air in (quite possible during allergy season) breathe in through your mouth in a slow, controlled way with your lips barely touching. There are no absolute rules; just do the best you can.

Loosen-Up Your Face and Jaws

Notice if you hold tension in your face or brace your jaw muscles when you’re at your computer, reading, or listening to the news. If you are, use this 3-step method to relax your face and jaw:

Let your jaw hang limp – kind of the way your hands hang limp when you drop them at your sides.
Keep your lips together, teeth apart.
Breathe.

Do this every time you notice tension in your face or jaw.

Stop Biting!

Biting your lips, cheeks, nails, or cuticles, can all lead to jaw muscle fatigue and pain. The 3 tips below may help you stop:

Keep your lips soft (don’t purse them).
Keep your lips touching lightly and your teeth apart (you don’t have to keep your mouth open.
Let your face and jaw hang in a neutral, relaxed posture (same as step 1 above).

Soften Your Shoulders

Many people experience headaches and neck and jaw pain as a result of tense shoulders. It’s called referred pain. To keep your shoulders soft:

Don’t hunch up your shoulders up close to your ears. Periodically stop what you’re doing and gently push them down.
Try not to cross your arms.

Both tips will ease your neck tension, help your breathing, and reduce the onset or the intensity of the muscle tension that leads pain.

Get Up & Move Around

It’s never a good idea to sit in one place for hours and hours even in less stressful times.

Every 45-minutes get up and walk around, even if it’s just to throw in a load of laundry or cook a meal.
If you’re experiencing severe neck tension or pain, the Feldenkrais Method® is a great way to manage it, too. It’s an easy and gentle technique that eases neck and jaw tension.

Use Moist Heat

Moist heat is a good way to treat jaw and face pain:

Use a wet towel, heat pack, or TMJ wrap – available in many pharmacies.
Apply the heat for 15-minutes
Then perform a gentle jaw muscle self-massage. Here’s how:
- Open your mouth halfway.
- With your index and middle finger massage the fleshy part of your jaw muscles in a circular motion for 10-seconds
- Then, move in the opposite direction for 10-seconds.
- Next, with your mouth still half-open, move your fingers to your temples right under the hairline and perform the same massage technique. If you feel muscle soreness as you massage, you’re doing it right.

Do this moist heat massage twice a day.

Purchase A TENS Unit

If your pain is severe and moist heat doesn’t help, go online and purchase a TENS unit (Nursal EMS TENS unit). Place the pads as directed on your jaw muscles (called masseters) and your large neck muscles (your trapezius) once or twice a day. Most TENS units come with simple instructions and there are many videos online with instructions.

Try Biofreeze®

Another method that works for many people is to rub Biofreeze® onto the jaw and neck muscles several times a day. Just make sure you keep it away from your eyes.

Calm Your Mind

Yoga or meditation are great ways to keep stress from impacting your body. Online you can find hundreds of classes, many of them free. I like the app Insight Timer. Headspace, Calm, and Buddhify are also terrific apps. Find the one that fits your style and needs and try not to make it a challenge but a regular part of your day and/ir when you really need it.

Is Your Body Tense While You Sleep? Try this:

If you wake up with headaches, facial, jaw, or teeth pain, you are problem clenching or grinding your teeth at night. Try these tips:

Drink warm chamomile or Sleepytime® tea before bed.
Try magnesium. Before you retire for the night, eat a banana or buy a magnesium supplement at the pharmacy (ask the pharmacist to recommend a good one).
If you’re really suffering, purchase a dental night guard at the pharmacy. The best one is made by DenTek™. However, some patients report that over-the-counter devices actually make them clench more! If that’s the case, talk to your dentist about having a custom-made nightguard made for you.

By following the above tips, you can treat your jaw and face pain at home. But note, it may take some time for your symptoms to subside. Don’t give up!

Now that life is getting back to normal it’s time we all assess our physical and emotional state and do what we need to do to feel better.

For more information about TMJ, please link here

Tags Facial Pain, Jaw Problems, Referred Pain, Teeth Grinding, TMJ

Persistent Toothache Referred Pain

What To Do If A Dentist Won’t Treat Your Toothache

Now and then, we in the dental field see patients who suffer from toothaches that don’t seem to be caused by a tooth. If you have pain that feels like it’s coming from a tooth, but your dentist won’t treat your toothache, it can be a very frustrating situation for you and for your dentist.

(Note, you may also be seeing a dental professional such as a periodontist or an endodontist. For this article, I refer to them all as dentists).

In a situation like the above, where it’s unclear why you have pain, there are two options.

Option One: “Wait And See”

When a toothache presents in an unusual way or won’t go away even after treatment has been performed, your dentist may ask you to give it some time. The hope is that your symptoms will lessen, become more recognizable, or the examination findings become more revealing.

It’s important for you, the patient, to understand why your dentist chooses this wait and see approach, especially when you’re in pain and just want some relief. It’s not because your dentist won’t treat your toothache, it’s because additional clues to the cause of often only appear after a bit of time has gone by.

In this case, your dentist might ask you some unusual questions, such as if you have been having other medical problems, sleep difficulties, a recent virus or even cancer-related therapies including chemotherapy. This is all in an effort to get a clearer understanding of why you have a toothache when there’s nothing that indicates there’s something wrong with your tooth.

During the wait and see period, your dentist won’t treat your toothache because they want you to suffer. In fact, they may offer short term pain medications to make you more comfortable and make stay in touch with you.

Option Two: “Treat Me Now Or I’m Leaving!”

Most dentists that won’t treat your toothache don’t want to put you through treatment if they are not convinced, without a doubt, that your pain is the result of decay or a root problem. If you are adamant about wanting your tooth to be treated and your dentist won’t do it, you can move along to a different dentist. However, it’s likely you’ll hear, “let’s wait and see” again.

There’s always a chance you could find a dentist you can convince to treat the tooth, despite the results of an exam and x-rays.

Try to understand that even if your dentist won’t treat it right away, they really do want to fix your toothache problem. They want you to feel better and be able to get on with your life. They have no vested interest in seeing you suffer.

If you insist on being treated and your dentist agrees (despite having no clear evidence that your tooth is in trouble) and the result is your toothache then goes away – great!

However, if your toothache does not go away even after treatment, your problem has just become a lot more complicated. Add to that the time and money you have invested – and you’re not going to be very happy.

Toothaches That Are Not Caused By Teeth

If your dentist won’t treat your toothache, it’s important you find out what they think could be the cause. It may sound weird, but tooth pain can be triggered by factors that have very little to do with the nerve in that aching tooth! Here are just a few possibilities:

Neck and/or jaw muscle problems, such as tightness, spasm, and fatigue – can be caused by life tensions, bad posture, aggressive tooth clenching, degenerative cervical spine conditions, and more. When muscles are in trouble this way for a prolonged length of time, the result is what can feel like a real toothache.
Sinus problems can make your upper teeth hurt – sometimes acutely.
Nerve problems often labeled as neuralgia or neuritis can create intense tooth pain.
Various medical conditions including systemic inflammatory diseases, migraines, autoimmune conditions, Lyme disease, and other infectious diseases.
Brain tumors can lead to toothache symptoms.
Past chemotherapy and/or radiation treatment in the head or neck area can lead to toothache symptoms.

What To Do If A Dentist Won’t Treat Your Toothache

If your dentist won’t treat your toothache dentist won’t treat it because the reason is unclear, there are three tests you should expect:

A careful exam and x-rays. Sometimes 3D scans can be helpful, too, to uncover what’s wrong.
Testing your teeth with hot and cold, percussion and mobility tests, and nerve testing with a pulp stimulator.
Local anesthetic injections to isolate the source of the pain.

If these tests do not identify a specific tooth that is the cause of your toothache, your dentist should ask you more questions. They should validate that your pain is real and explain why they believe the source could be somewhere else.

The Bottom Line

If your dentist and you both want to start work on a tooth, despite being unsure if the treatment will eliminate your toothache, be prepared to consider other sources of the pain if the toothache lingers. Remember, if your dentist won’t treat your toothache, they probably have a very good reason.

Learn more about persistent toothache and referred pain.

Tags Toothache

Jaw Problems Orofacial Pain TMJ

Orofacial Pain Is A Board-Certified Specialty

For decades, the field of orofacial pain was not a specialty recognized by the American Dental Association. This made it difficult for patients who suffered from TMJ and jaw problems to get proper treatment.

Equally difficult was the fact that dentists and dental specialists had a hard time finding practitioners to refer their patients to who had the experience and skills to assess and manage these problems and sometimes disabling pain conditions. For years, orofacial pain academies and the American Board of Orofacial Pain consistently urged the American Dental Association to designate orofacial pain as a board-certified specialty. Their efforts were always met with defeat.

As a result, practitioners were left to take on the challenges of treating patients with facial and jaw pain (TMJ), with the knowledge that people in leadership at the ADA had not yet grasped the importance and professional value of this initiative. Despite these setbacks, the push to create a new specialty was never abandoned.

On March 31, 2020, the American Dental Associations’ National Commission on Specialty Status finally approved orofacial pain as a specialty. (To see the full definition, scroll down)

What Does This Mean For Patients?

Because of this move, I expect more dental schools to expand their commitment to teaching the concepts of orofacial pain assessment and treatment. As a result, more dentists will graduate familiar with the pain problems they will encounter in their practices, including TMJ. In addition, over time, graduating dentists will pursue careers in the field and fill voids that currently exist in communities throughout our nation and the world. It’s too early to predict the full outcome of this important new designation, but I’m hopeful that people who are suffering will find it easier to get the treatment they so desperately need.

If you have questions about TMJ, please feel free to reach out to me.

Onward and upward!

Definition Of Orofacial Pain

The specialty of Orofacial Pain (OFP) “involves the assessment, diagnosis and treatment of patients with orofacial pain disorders, including temporomandibular muscle and joint (TMJ) disorders, oromotor and jaw behavior disorders, neuropathic and neurovascular pain disorders, and related head and neck pain, as well as expanding our knowledge of the underlying cause and mechanisms of these disorders. This specialty also includes screening, management, and coordination of care associated with sleep-related breathing disorders.”

Tags Jaw Problems, Orofacial Pain, TMJ

Bruxism Children & TMJ TMJ

Your Child Is Grinding His Teeth – What Should You Do?

Is this familiar?

You think your child is fast asleep, then suddenly, a screeching sound is coming out of his/her bedroom. What could be causing it? The most likely explanation is your child is grinding his teeth – an activity clinically known as sleep bruxism.

Sleep bruxism, which is often associated with jaw pain (TMJ), is the most common problem seen in my practice for the past 30 years. As a result, I know first-hand that a little information goes a long way to help parents understand what is happening and what can be done about it.

When A Child Grinds His Teeth, What’s Happening?

The first thing to understand is that a certain level of jaw movement during sleep is normal for most people. It’s called Rhythmic Masticatory Muscle Activity, or RMMA. Some people who grind their teeth experience higher levels of RMMA, which can result in tooth damage and jaw pain problems.

Much research has been done in the past few years on teeth grinding and sleep bruxism. One significant finding is that in many people who grind during sleep, their brain is becoming aroused and causing sleep to be fragmented. The result is the body’s fight-or-flight system becomes activated. In tandem, jaw motion (RMMA) increases and teeth grinding is often the result.

Teeth Grinding in Children Under 10-Years Old

If your child is under ten-years-old and grinding his teeth, it’s likely during the time when his baby teeth are being lost. If you hear the telltale screeching sound that indicates your child is grinding his teeth, look for evidence of tooth wear. If you see it, a visit to your child’s dentist is highly recommended. Also, ask your child if he is experiencing jaw symptoms such as joint popping, cracking, locking, or pain. If the answer is yes, it’s time to see the dentist.

Teeth Grinding In Adolescents & Teens

We have many clues about why adolescents and teens grind their teeth during sleep. Current theories include:

1. Large tonsils, a big tongue that clogs the airway, a small lower jaw, blocked nasal passages, or a long floppy soft palate can cause breathing problems during sleep, and, in turn, causes a drop in blood oxygen. The brain awakens and activates the body’s fight-or-flight system increasing the likelihood of sleep bruxism.

2. Adrenaline – During times of stress and anxiety, the level of adrenaline (catecholamines) in the bloodstream increases. For adolescents and teens who experience long-term anxiety, high adrenaline levels have been shown to induce sleep bruxism.

3. Chronic Pain – Migraines, gastrointestinal disorders, and back and neck pain set up ideal conditions for sleep disturbances and can lead to teeth grinding.

4. ADD/ADHD Medications – Medications such as Adderall, Concerta, and Strattera stimulate the fight or flight part of a child’s nervous system and result in sleep disturbances.

5. Caffeine – Many adolescents and teens drink coffee and high caffeine beverages during the day and into the evening. Caffeine has been proven to be a contributing factor to disturbed sleep patterns.

6. Nicotine – Nicotine is a stimulant. It’s widely known to contribute to sleep problems. The use of e-cigarettes, which are very high in nicotine, is particularly prevalent among adolescents and teens and can be a direct cause of sleep problems.

7. Not Enough Sleep – With the obligations of school and extracurricular activities, many young people are under a tremendous amount of pressure. They put in long hours and don’t get enough sleep. Others simply stay up late playing video games or communicating on social networks. Sleep quality is ultimately impacted, leading to restless nights of tossing and turning and the emergence of sleep bruxism.

What You Should Do:

By now, you can understand if your child is grinding his teeth, there are multiple risk factors. The good news is that teeth grinding is treatable and can be managed. There is a wide array of options at our disposal to help manage the problems caused by sleep bruxism for children who grind their teeth including oral appliances, jaw exercises, meditation, acupuncture, medication, and even BOTOX®.

But here’s the key – managing your child’s sleep bruxism will not cure it. It will, however, help him get through some tough periods. Meanwhile, the medical community continues to pursue a better understanding of the underlying causes of nighttime brain arousals.

If your child is grinding his teeth and you’re concerned, his dentist or orthodontist should be able to help. If the situation is dire, you can find someone in your area who focuses on Sleep Bruxism, such as a member of the American Academy of Orofacial Pain – AAOP. Choose a professional designated Diplomate.

Tags Bruxism, children & tmj, Teeth Grinding

Jaw Problems TMJ

Invisalign® & Aligner Therapy Can Trigger Jaw Problems

Today, in nearly every field of medicine, new and innovative therapies emerge that change lives for the better. But, over time, however, unanticipated complications can arise. Invisalign^®and aligner therapy to move teeth is one such innovation. It turns out aligner therapy can trigger jaw problems.

Invisalign^® & Aligner Therapy Move Teeth In Remarkable Ways

The use of clear aligners as an alternative to traditional braces has transformed how tooth movement is accomplished. Aligners are effective and practically invisible. That makes them an excellent choice if you don’t love the idea of walking around with a mouth full of brackets and wires for months or years.

There’s another reason that invisible braces are so popular – dentists, who in the past could not offer tooth movement services, can now provide them.

Why Aligner Therapy Can Trigger Jaw Problems – Sometimes

As a TMJ doctor, I see patients with jaw problems that have been triggered by aligner therapy. Common symptoms are jaw muscle and joint pain, jaw clicking, locking, and headaches. Patients who find that aligner therapy can trigger jaw problems tend to fall into two distinct categories:

1. People who never before had a TMJ problem.

2. People who previously had TMJ problems sometime in the distant past and experienced a re-emergence during aligner therapy.

In my experience (and my colleagues may dispute this), the common theme when aligner therapy triggers jaw problems has to do with patients biting down on the aligners. Many people tend to bite down hard on their aligners for hours at a time during the day. They don’t necessarily do it on purpose. Still, the result is that the upper and lower aligners are in contact for hours at a time.

Why Is It A Problem To Bite-Down On Your Aligners?

The natural rest position of your jaw is upper and lower teeth apart and nothing but air between them. When you bite down for a length of time beyond what is necessary to eat, for example, you disrupt the natural tone of your jaw muscles. Over time, jaw symptoms can emerge.

If your top and bottom aligners are in contact with each other for long periods, your jaw muscles are in a non-stop state of contraction. To illustrate, imagine how it would feel to make a fist with your hand for hours. Muscle soreness and pain would likely occur. Your jaw muscles work the same way.

In some patients, their jaw joints (TMJs) become so overloaded that they experience joint clicking and popping and even at times a locked jaw, often accompanied by pain.

Luckily, not every patient who bites down on aligners develops jaw problems. But, if you notice that you tend to bite down on your aligners and that your jaws are sore and joints making noise, you should consider taking a break for a while until the symptoms go away.

If you experienced TMJ problems in the past and your aligners have triggered your jaw problems to resurface, aligner therapy is probably not for you.

Note: Some practitioners recommend that their patients bite down on the aligners for the teeth to move more quickly. If that has been recommended to you, please ask your dentist if it is necessary. It’s smarter to slow down your aligner therapy and avoid jaw problems that may not go away once treatment ends.

The Bottom Line

If you previously suffered from TMJ problems, it’s critical to inform your dentist about it before you begin aligner therapy. If you are in the process of aligner therapy and have started to notice jaw clicking, locking, or pain, please stop wearing your aligners and speak to your dentist immediately.

Everyone wants a beautiful smile, and the miracle of Invisalign^® and aligner therapy is an excellent choice. However, it can also trigger jaw problems that may require long-term care.

Be an informed patient so you can make the right choice for you.

Tags Jaw Problems, TMJ

Bruxism Case Studies Orofacial Pain TMJ

The Connection Between PTSD & TMJ

Post author By Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain
Post date July 26, 2019
No Comments on The Connection Between PTSD & TMJ

Identifying the origin of a patient’s chronic orofacial and TMJ pain is what makes my work both challenging and rewarding. Sometimes the answers are readily apparent while at other times uncovering important clues is more difficult. In all cases, there is no substitute for obtaining a careful history as the insights gained often help point to the mechanism of pain that is driving a patient’s suffering.

With this thought in mind, I’ve treated numerous patients whose chronic orofacial and TMJ pain is the result of unresolved trauma to the nervous system. A careful history, however, reveals that this trauma is not because of a physical event such as a documented injury or ongoing activities such as nighttime bruxing, but instead, it is the result of personal anguish.

I’ve treated many patients whose problems are not caused by classic scenarios, but instead, are caused by unresolved trauma to their nervous systems. They feel they have no control over their lives, that there is no resolution to their grim situation, or are unable to escape a potentially dangerous environment.

These scenarios are commonly associated with individuals diagnosed as having Post Traumatic Stress Disorder, or PTSD.

These patients are not unlike our servicemen and women who return from overseas carrying the trauma of what they experienced. Although in my practice, military service is not the most common source of patient problems, these patients need just as much understanding and support as our soldiers.

PTSD Affects The Nervous System In A Specific Way

When dealing with a highly traumatic event or many persistent traumatic events over time, the body’s sympathetic nervous system goes survival mode. In medicine, it’s called the hyperactive state.

When the nervous system is in the hyperactive state for an extended length of time, tissue injury often occurs. It can be accompanied by pain, restricted motion in the joints, muscle cramping, and muscle fatigue. The body also releases stress hormones (primarily cortisol), which can cause biologic changes that prevent healthy healing and can lead to chronic pain. This particularly affects muscles that are already overworked or tense.

When a patient previously suffered from issues such as migraines, neck pain, or back pain – they invariably get worse. When the pain becomes persistent, that’s when feelings of anxiety, hopelessness, and depression can emerge.

A patient in this condition has trouble reacting to stressful situations in a healthy way, which creates even more life challenges.

PTSD & TMJ – A Case Study

“Jill” is a 39-year-old woman who arrived at my practice with the classic symptoms of TMJ: ongoing jaw pain, jaw tension, and limited jaw motion. Not unlike hundreds of other patients, her symptoms were the result of jaw muscle and joint tissue compromise.

However, upon examination, I did not detect the telltale signs of nighttime bruxism, nor any of the most common origins of chronic orofacial pain.

The next step was to sit down with Jill and see if I could get her to talk candidly about her life, which she did. It turns out that Jill is a single mom. She works full time, and her job is stressful and demanding. On top of that, Jill has another, even more, extreme stressor in her life. Her child was born with a severe medical condition, of which there is no cure, that requires constant care and monitoring.

Faced with the overwhelming pressure of raising a medically-compromised child, working at a stressful job, and constantly worrying about the future, Jill had been living in a continuous flight-or-fight mode for years.

As a result, Jill’s natural state was shoulders raised, quick, shallow breathing, and a tendency to brace her jaw muscles or clench her teeth for minutes, even hours, at a time.

Can A Combination Of PTSD & TMJ Be Treated?

So the question was, can someone like Jill, who problems are caused by the stress in her life that she can’t change, actually get better?

The road is not easy, but when a patient participates in TMJ treatment, there is hope. Meditation, Cognitive Behavior Therapy (CBT), psychotherapy, physical therapy, Tai Chi, breathing exercises, or other techniques, are useful. Being aware of and working to change daytime behaviors such as jaw bracing, tooth contact, breath-holding, and shoulder raising can also help.

Conclusion

It was not fast or easy, but by employing a number of these strategies, Jill continues to be “much better than the day I met her.” She takes fewer over-the-counter pain medications, sleeps more soundly, and most importantly, she believes that a better day is coming for her.

While it’s often impossible for someone suffering from PTSD to change her environment, she can make changes to how she exists within that environment. This can lead the way to unravel the complexities of PTSD and its associated symptoms.

Tags Bruxism, case studies, Orofacial Pain, Teeth Grinding, TMJ

BOTOX® Bruxism Case Studies Facial Pain Jaw Problems Orofacial Pain TMJ Women & Pain

Facial Pain – Is It Bruxism or Is It Bulimia?

TMJ /Facial Pain Symptoms & Eating Disorders – The Connection

As a TMJ doctor, every year I see a number of patients who are suffering from an extraordinarily high level of face and jaw pain. At first glance, the level of suffering they report is much greater than what I commonly see. One such group are people with a history of one particular eating disorder – bulimia nervosa. In these patients, the typical characteristics I see in people with TMJ are not present. Although their symptoms may lead them to believe that their pain is driven by stress-related jaw tension and bruxism (teeth grinding and clenching), the telltale signs are simply not there. That’s when I ask myself, is it bruxism or is it bulimia?

Is It Bruxism or Bulimia? A Case Study

Marci was 26 when she arrived at my office some three years ago. For several years she’d been dealing with debilitating jaw and face pain almost daily. The pain was centered at the angles of her jaw on both sides and it had become, as she described it, “unmanageable.”

Pain was ruining her life.

Many doctors and therapists had tried to help Marci find relief. She’d been prescribed pain medications and muscle relaxers. She’d been treated by physical therapists. She had acupuncture and trigger point injections. She even tried wearing an oral appliance to bed, thinking her problems were the result of bruxism.

Frustrated and discouraged, Marci was still suffering – with no resolution in sight.

4 Clues That Bruxism Was Not The Culprit

At first, Marci didn’t share her entire medical history with me. Possibly because she was embarrassed or simply didn’t think there was a connection. However, even without knowing her full history, several clues pointed to the fact that Marci’s pain was not caused by bruxism, but instead was a result of bulimia:

No signs of the kind of tooth wear characteristic of bruxism were detected.
Her masseter (jaw) muscles were not rock hard and well-built, typically a sign of bruxism.
The biting surfaces of her lower molars showed a complete loss of enamel.
Her face was extremely puffy.

So, Why Did I Ask If It Was Bruxism Or Bulimia?

In order to answer the question, is it bruxism or is it bulimia, each clue pointed to the answer. You see, bulimia can wreak havoc in the mouth because frequent vomiting exposes the teeth to acid, which can dissolve their protective enamel. This is seen on the back of the upper front teeth and in the center of the lower back teeth where regurgitated acid can pool. And, over time, frequent vomiting can cause the parotid gland (the largest salivary gland) to become inflamed and enlarged, resulting in acute nerve pain in the overlying jaw muscles and prompting facial puffiness.

Facial & Jaw Pain Caused by Bulimia – Treatment

Probing deeper into Marci’s medical history, I concluded that it was indeed bulimia, not bruxism that was the cause of Marci’s pain. Now it was time to offer a plan of treatment. I prescribed the medication nortriptyline (a once-popular antidepressant) that, when used in small doses has been shown to be effective in reducing pain in muscles by quieting nerve excitation. It is thought to work over time by increasing the activity of serotonin in the brain, according to the Mayo Clinic.

Marci also had a series of BOTOX® injections in her masseter muscles at my office, designed to not only reduce muscle tension but to also diminish the release of nerve-irritating chemicals. (See BOTOX® Injections For TMJ – 6 Things You Need To Know)

She was also given a custom-made topical salve containing a mixture of anesthetic, nerve membrane stabilizers, and anti-inflammatory medications to rub over the sore areas of her jaw three times a day.

A Much Happier Existence

Four weeks into treatment, Marci reported that her pain was more than 40% reduced. A second series of BOTOX® injections months later provided even better results. With her pain reduced, she was more motivated than ever to continue talk therapy, which she had started in an attempt to get a handle on her bulimia.

Today, Marci comes into my office every 4-6 months for a refill of her nortriptyline prescription and occasional BOTOX® injections. She’s nearly pain-free, almost bulimia free, and she leads a much happier existence.

Do You Know Someone Who Has Bulimia?

If you or someone you care about has bulimia and is suffering from facial and /or jaw pain, it is quite possible that a relationship exists. It’s very important to answer the question, is it bruxism or is it bulimia, so the right treatment can be put into place.

Although strategies like those used in Marci’s case won’t provide a cure, they can go a long way towards improving the quality of a suffering person’s life.

Live or work in New York City or on Long Island? You can schedule a consultation with me here or call 212-265-0110.

Tags Botox, Facial Pain, Jaw Problems, Orofacial Pain, TMJ, woman and pain

Bruxism Case Studies Persistent Toothache TMJ

Pain And The Brain – They’re Inseparable

As an orofacial pain specialist, I treat patients who suffer from facial pain and the pain symptoms associated with Temporomandibular Disorders (commonly referred to as TMJ), I think about pain, a lot.

A great deal of new scientific knowledge has been gained in my field in the past several years. Being familiar with this knowledge is an essential part of how I make difficult decisions about my patients’ pain problems. However, taking advantage of this knowledge is only part of it. My years of experience and knowledge of the right questions to ask are what enable me to figure out the “why” of a patient’s pain problem.

Case Study – Robin

Robin, a 43-year old woman, came to my office because she was experiencing tooth and jaw pain that seemed to have come from nowhere. She had always taken good care of her teeth at home and visited her dentist twice a year for routine cleanings and monitoring.

Robin was experiencing pain – and it was getting worse. She had already been to her dentist. Her dentist sent her to see a root canal specialist. Neither professional was able to detect anything to explain her pain, and, as a result, no treatment was rendered. Yet, her pain was getting worse.

When I first met her, Robin was using over-the-counter pain medication and avoided chewing on the painful side of her mouth. Her jaw felt stiff and tight. At times it felt like her jaw muscles were cramping. The simple acts of smiling and talking prompted her pain to flare. She was not yet miserable but was clearly heading in that direction.

Sometimes Robin’s pain would vanish for hours but then return with a vengeance. There was no discernible pattern.

Before I proceed, it’s essential for you to understand a few facts about pain. Contrary to what you may think…

Pain can occur without tissue damage.
The intensity of pain can have little to do with the seriousness of the problem.
Every pain experience starts in the brain, regardless of its origin or severity.
The intensity of pain is ultimately the opinion of your brain (and your brain is not always your friend).

Back To Robin

After an examination, it was clear to me (despite Robin’s high level of suffering) that no clear-cut physical findings existed to tie her pain to a specific tooth or jaw joint/muscle compromise. Sore jaw and neck muscles were the only recognizable finding.

Robin’s level of suffering appeared to be more profound than were my physical findings.

Pain & The Brain – The Right Questions To Ask

At his point, I asked Robin some very specific questions designed to identify the presence of any risk factors that could potentially be impacting her pain thresholds, and causing her jaw and neck muscle discomfort.

As I gathered her medical history, I was not surprised to find out that Robin experienced long-standing sleep deprivation and chronic, painful gastrointestinal problems. And that she was taking care of her aging mother and had a job, which required her attention 24/7.

When I put it all together, it was clear that Robin lived in a state of emotional distress. Essentially, she was ready for battle on an ongoing basis. Next, I looked at her for other clues and found them: raised shoulders, crossed arms, shallow quick breathing, and an acquired behavior of keeping her jaw muscles braced, usually with her teeth clenched, as well.

I concluded that Robin’s tendencies and behaviors had fatigued her jaw and neck muscles to the point where she experienced pain. And the tooth pain she experienced was actually “referred pain”, originating in her jaw and neck.

Essentially the parts of her nervous system that are responsible for maintaining normal pain thresholds and allowing the brain to interpret incoming nerve transmissions correctly were failing. This led to what is called a state of sensitization. In this state, normal life activities, such as opening your mouth, eating, smiling, and talking can lead to pain – even in the absence of apparent tissue injury.

Pain Is In Your Head

I carefully explained to Robin why her pain had developed at the same time validated that the pain was real. Many people in Robin’s situation have been told, “your pain is all in your head.”

But not the way they mean it.

I then outlined what I refer to as the “60/40 rule of care”. I was going to direct 40% of her treatment, which included physical therapy, muscle injections, and medication. She was going to be responsible for the other 60%. She was to do 20 minutes of physical exercise every other day, make an effort to get more sleep, and begin to pay attention to her diet to avoid heightened gastric distress.

Robin also agreed to address issues at her job, and most importantly, to pay attention to changing her stressful breathing patterns and postures driven and shaped by her challenging life.

Pain & The Brain – How Is Robin Now?

Although Robin cannot escape all of the risk factors of her life, she is now able to change the way her body and her breathing react to them.

Like many patients with her type of pain scenario, she has responded well to the strategies we put into place. She acknowledges that her participation in the process has been critical.

Today, when flare-ups occur, Robin now understands in those moments her brain is not her friend. And she is learning how to change her brain’s opinion – quickly.

Pain issues and sleep challenges do not have to be lifetime afflictions. You need someone who listens and possesses the knowledge and compassion to get your pain and sleep problems under control.

I am that someone – and you’re in the right place.
Dr. Donald Tanenbaum, DDS MPH

SCHEDULE A CONSULTATION

Tags Bruxism, Case Study, TMJ, Toothache

Children & TMJ Jaw Problems TMJ

9 Causes Of TMJ Problems In Teens & College Students

A Guide For Parents

I’m a dentist who focuses exclusively on treating people who suffer from jaw, tooth and head pain due to what’s commonly known as TMJ. Some of my patients tell me that they grind and clench their teeth all night (called sleep bruxism); some tell me they clench all day (called awake bruxism). Millions of people, in fact, suffer from bruxism and as a result, many experience jaw pain, headaches, toothaches, and ear pain. A surprising trend was uncovered during a recent review of my patient roster. We have seen a significant increase in young patients (between the ages of 16 and 25) who arrive at my office with complaints of a headache, intense jaw pain, and or daily facial pain. Why are there so many cases of TMJ problems in teens and college students and why do so many young people experience jaw and facial pain problems? What puts their jaw muscles and TM joints so at risk? Here are the nine most common risk factors:

9 Causes Of TMJ Problems In Teens & College Students

Screen-Related Activities: Countless hours with the head down while studying, playing video games, surfing the web, using social media, texting, etc. Neck tension is the result and is a risk factor that can prompt jaw problems.
ADD/ADHD Medications: These medications are stimulants, and although they’re usually taken early in the day, the effects often linger well into the evening. Stimulants, in general, tighten muscles and the jaw can be impacted.
Caffeine: Overconsumption and/or frequent consumption of coffee, Red Bull, or other high caffeine beverages keep the heart rate up and adrenaline pumping. Muscles are therefore at risk to maintain high levels of tension.
Nicotine: Another stimulant now consumed in high milligram doses in nicotine e-cigarettes which are popular mainly with college students, and young college grads. One vape cartridge apparently holds as much nicotine as three packs of cigarettes. Nicotine is a stimulant and can increase muscle pain.
Breathing Problems: Persistent allergies, sinus problems, and asthma often disrupt sleep and are associated with bruxism.
Airway Problems: Airflow can be blocked during sleep due to large tonsils, weight gain, or oral/jaw anatomy. Fragmented sleep has been associated with sleep bruxism.
Pain: Chronic pain is a significant source of sleep disruption. Neck and back pain and gastrointestinal pain can often fragment sleep, predisposing to more sleep bruxism activity.
Daytime Habits: Daytime habits such as nail and cuticle biting, pen chewing, excessive gum chewing, lip and cheek biting, and teeth grinding and clenching. All these behaviors can fatigue jaw muscles.
Anxiety & Psychological Disorders: Young patients often struggle to cope with life’s challenges and experience ongoing anxiety, which can lead to the onset of jaw tension and pain.

What’s A Parent To Do?

If your child complains about facial or jaw pain and you can say “Yes!” to at least two of the common risk factors listed above, it’s important to do something about it before it gets worse.

If you live in the New York metropolitan area, I invite you to make an appointment for a consultation at my office. We are thorough, compassionate and have many tools at our disposal to help your child.

If you are located outside the New York area, you can find a practitioner in near you on the website of The American Academy of Orofacial Pain. Choose a doctor who is listed as Diplomate.

I welcome your questions and comments.

Pain issues and sleep challenges do not have to be lifetime afflictions. You need someone who listens and possesses the knowledge and compassion to get your pain and sleep problems under control.

I am that someone – and you’re in the right place.
Dr. Donald Tanenbaum, DDS MPH

SCHEDULE A CONSULTATION

Tags children and tmj, Jaw Problems, TMJ

close up portrait of a man smoking an e-cigarette

Bruxism Jaw Problems

4 Surprising Reasons You Grind Your Teeth

In my practice, I often evaluate and treat patients who suffer from the effects of Sleep Bruxism. Bruxism is the clinical term for the act of clenching and/or grinding your teeth while you’re asleep.

Sleep Bruxism can cause all kinds of problems for people of any age. Most of the patients who end up in my office complain of some, or all, of the following issues, particularly in the mornings:

Jaw soreness or pain
Limited or stiff jaw motion
Headaches or earaches
Sensitive teeth
Jaw noises of all types
Locked jaw
Neck pain
Foggy brain
A bite that feels off-balance

Although millions of people grind and clench at night, not everyone ends up with these problems. For those who do, the need for care is critical because the potential long-term consequences of untreated Sleep Bruxism can be profound. They include, but are not limited to, a change in your facial profile, worn-down or fractured teeth, persistent jaw pain, headaches focused in your temples, jaw clicking and popping, and a locked jaw.

For many years, those of us in the field have felt that the primary fuel powering Sleep Bruxism is stress. As more research is performed and as practitioners like myself identify common risk factors, that thinking is changing. Life’s stresses cause adrenaline to be dumped into your bloodstream, which that can keep you from getting a good night’s sleep – and cause you to grind and clench your teeth.

However, there are other risk factors out there that can awaken your brain at night and fragment your sleep. Here are a few:

4 Surprising Reasons You Grind Your Teeth

1. ADHD Medication

More and more teens, college students and adults are turning to ADHD drugs to address daily focus issues. These medications, such as Strattera, Vyvanse, and Adderall, may be prompting new and/or higher levels of tooth grinding and clenching at night because they work to activate the body’s fight-or-flight mechanism.

For example, I’ve seen patients who were previously treated for Sleep Bruxism, had it under control but began experiencing symptoms again when they started taking ADHD medication. In the absence of other new risk factors, if you are on these medications, consider them when searching for the cause of your Bruxism.

2. Anti-Depressants

Certain SSRI antidepressants (such as Effexor and Paxil) can initiate Sleep Bruxism activity, too. Up to fifteen percent of people who are on SSRIs experience it, and many new studies have begun in this area.

If you’re on SSRIs and are clenching and grinding your teeth at night, consider trying a different drug.

3. Obstructive Sleep Apnea/Upper Airway Resistance

According to the American Sleep Apnea Organization, over 22 million Americans have an upper airway problem. The telltale signs are snoring and multiple awakenings during the night as the body attempts to get more oxygen. The lack of oxygen and subsequent constant brain arousals activate the sympathetic nervous symptom and may be another potential initiator of Sleep Bruxism. Though there is not a one to one correlation between Apnea and Bruxism, additional investigation and collaborations with sleep physicians may be warranted.

If you suspect you have an airway problem (if you don’t know, ask your significant other) it’s essential to have a sleep study performed – mainly because it allows your dentist to choose the correct an oral appliance for you.

4. Vaping

If you’ve kept your eyes open, you’ve noticed many people walking around using vape pens, some of which contain high amounts of nicotine, a powerful stimulant. Although the impact of nicotine on muscles, the nervous system, and sleep varies from person to person, it is indisputable that stimulants can and do influence jaw muscle pain and tension and can also disrupt sleep. For many people, nicotine adds to their already troublesome Sleep Bruxism and its resulting symptoms.

If you are using high nicotine vapes, please let your dentist or doctor know as you work through finding a solution for grinding and clenching.

In conclusion, if you’ve been waking up in the morning with a stiff, painful or locked jaw or if you experience morning headaches, sensitive teeth, earaches, a bite that feels off-balance, or your jaw clicks – there’s a good chance you have Sleep Bruxism.

See your dentist and discuss the risks factors that you can identify, especially those above. There are many effective avenues of treatment available to you.

You deserve a good night’s sleep!

For more on the long-term effects of Sleep Bruxism, link here.

Tags Bruxism, Jaw Problems

41991598 - glass medicine vials and hualuronic collagen or flu syringe.

BOTOX® TMJ

3 Questions & Answers About BOTOX® Injections For TMJ

BOTOX® first became popular as a way to reduce wrinkles and facial lines. But being treated with BOTOX® injections for TMJ problems has become very popular. It is effective in treating pain and/or overactive muscles – when administered by a trained and experienced professional.

As an orofacial pain specialist, I often turn to BOTOX® for TMJ symptoms in patients whose pain has not responded to traditional first-line therapies such as exercises, medications, relaxation techniques, oral appliances, etc.,

If you’re at a point where nothing has provided relief from your painful TMJ symptoms, BOTOX® injections for TMJ could be the next step. BOTOX® is injected into your masseter muscles – the big muscles that bring your teeth together and bulge when you clench your teeth.

Naturally, a lot of questions pop up when I recommend BOTOX® injections for TMJ to my patients. Here are three of them:

3 Frequently Asked Questions BOTOX® Injections For TMJ

“One side of my face has a more developed masseter muscle than the other side. Will BOTOX® for TMJ improve the symmetry of my face?”

Yes, BOTOX® injections for TMJ can be used to achieve facial muscle symmetry. But here’s the important thing to know. It must be injected with a protocol that will selectively reduce the muscle bulk. Both the location and volume of BOTOX® used must be carefully planned to achieve the result desired.

Don’t go forward until you find a practitioner who is highly trained and experienced in this type of treatment.

“How do I know if, or when, I will need more BOTOX® injection for TMJ?”

BOTOX® is injected into the jaw (masseter) muscles for one of two reasons: The first, and most common, is to reduce pain. The second reason that patients opt to have BOTOX® injected into their masseters is to slim down their jaw profile. Many people develop large, bulky jaw muscles as a result of clenching and grinding their teeth, which is called Bruxism.

If pain was the reason you chose BOTOX®, you’ll know you need more treatment if the pain returns and you have controlled all the risk factors that brought on the pain in the first place. If your pain is significantly diminished or completely gone, you may not need more injections.

For pain relief, the current protocol has defined waiting a period of three months between injections.

If achieving a slimmer-looking jaw was your reason for pursuing BOTOX®, what you see in the mirror is the indication that you need more BOTOX®. It is likely that more than one session of BOTOX® injections will get the job done, so keep that in mind.

In addition, if you have not learned to reduce the behaviors that made your jaw muscles larger, or addressed the impact of sleep bruxism if present, results will take longer to achieve and may never be fully satisfying.

Learn about the behaviors that cause enlarged jaw muscles and what you can do about them here.

“If I just stop chewing gum and eating hard food, will my bulky jaw slim down so I don’t need BOTOX® injections?

Your bulky jaw is the result of your masseter muscles being overworked over the course of many years. If you simply stop those activities your muscles aren’t going to slim down on their own. You are probably a good candidate for BOTOX® injections for TMJ.

But as long as you continue the behaviors that made your jaw bulky in the first place, such as teeth grinding and clenching, the results of the BOTOX® won’t last long.

The Bottom Line

BOTOX® can be highly effective as a treatment for the pain and jaw bulkiness that are symptoms of TMJ problems. However, if administered improperly it may not work or even produce some very unpleasant outcomes.

How To Find A TMJ Specialist

To find an orofacial pain specialist who’s trained and experienced in your area, go to this website www.aaop.org. Look for a specialist in your area with the designation Diplomate. If you live in the New York City metropolitan area, feel free to call my office at 212-265-0110 to discuss your case. I’d be honored to help you feel better.

Have more questions about BOTOX® for TMJ in the masseter muscles? Feel free to comment below:

Tags Botox, TMJ

29976177 - illustration of an irritated wife covering her ears while her husband snores

Sleep Apnea Snoring Women & Pain

Snoring Is Not Funny

Post author By Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain
Post date August 8, 2018
No Comments on Snoring Is Not Funny

For years snoring has prompted humorous cartoon depictions of bed partners sorting out their different views of the problem and hilarious videos revealing what the non-snoring bed partner will resort to in order to get a good night’s sleep.

The problem with snoring, however, is that both parties – the snorer and snoree (what I call the person who is forced to listen to the noise) are ultimately impacted. Sometimes severely.

Let’s start with the snorer. Although snoring was once regarded as merely an annoyance, research now shows that it is actually the result of airway turbulence, often accompanied by obstructive sleep apnea or upper airway resistance syndrome. Both conditions cause sleep arousals and lead to less than refreshing sleep and excessive daytime drowsiness.

Snoring Is Much More Than An Annoyance

People who have obstructive sleep apnea experience episodes (sometimes lots of them) when their breathing completely stops while they’re asleep. Breathing only resumes when a drop in blood oxygen wakes up the brain and causes them to take a breath. This repetitive cycle of stopping breathing and loss of oxygen to the brain often leads to injury and inflammation in the lining of the blood vessels and cardiac tissue, which makes snorers more susceptible to heart attacks and strokes.

And if that’s not enough, snorers with obstructive sleep apnea airway problems are more likely to have gastrointestinal reflux (heartburn) and experience brain matter degeneration, which is one of the causes of Alzheimer’s disease.

Sadly, the majority of snorers do not realize that their snoring is more than just an annoyance and, therefore, never even think to seek care. The link between snoring and cardiac problems, reflux, and brain degeneration is proof that it’s much more than a social annoyance. Plus, even if the snorer does not have an airway problem, research shows that the vibrational trauma created by snoring will eventually lead to tissue floppiness in the pharynx, which leads to more snoring noise, combined with injury to the nerves that help maintain airway health.

It’s obvious that snoring carries serious health risks for the snorer. But what about the poor snoree?

The Majority Of Snorees Are Women

The majority of snorers are men and, therefore, women are the majority of snorees. Countless women suffer a considerable toll due to the disrupted sleep caused every night by their snoring bed partner. And it’s loud. A snorer’s roar can reach the decibel levels of a construction jackhammer. Imagine trying to sleep with a jackhammer being operated in your bedroom.

For the snoree, constant sleep arousals can lead to chronic muscle and joint pain (TMJ problems included), headaches, daytime sleepiness, and cognitive impairment – to name just a few. In addition, we have evidence that fragmented sleep with multiple arousals can also be responsible for tooth grinding when sleeping.

CPAP Is Not The Only Option

Putting this all together makes a real case for snorers to realize that by not seeking care they’re going way beyond simply being insensitive to their bed partners. Happily, medical professionals now have many ways to treat snoring including oral appliances, which are an extremely helpful therapy for snoring and obstructive apnea. CPAP is not the only option!

So, if you’re a snorer it’s time to get help. Not only is it a smart decision for your health, it’s a smart decision for your relationship, too.

Successful TMJ Treatment – How Long Will It Last?

Two Case Studies

As a dentist who specializes in TMJ problems, my patients often ask me how long the positive outcomes of their successful TMJ treatment will last. It can be challenging to answer this question due to the fact that most patients simply stop coming into the office for care when their pain or jaw function problems have gone away. That leaves me to assume that their goals have been reached and they no longer need my care.

Or so I hope.

Many patients arrive at my office because they’re suffering because of compromised temporomandibular joints (TMJs) and associated arthritic changes, inflammation, or ligament and cartilage injuries. Others have tendinitis and or muscle pain. These are not easy cases to treat.

But, when the pain and discomfort have been reduced and jaw function improved to the degree that a patient no longer comes in for care, I am curious as to whether he or she is still feeling good a few years down the road.

Two recent encounters with former patients not only satisfied my curiosity but also reinforced my theory that when assisted by practical and time-tested TMJ treatment, Mother Nature can do a remarkable job of healing.

TMJ Treatment Case Study – Patricia

When Patricia first came into my office, she was 44-years old and had been suffering for many years from a painful, locking right TM joint. She finally decided to seek care when one morning she woke up and her jaw was locked to the point where she couldn’t insert even a pinky finger between her top and bottom teeth. She went to a specialist who ordered an MRI and concluded that the only option was surgery.

Patricia then sought me out for a second opinion. After I listened to her history, performed a physical exam, and reviewed her MRI results, I had to agree that a surgical approach was probably her best option.

However, Patricia was firmly opposed to surgery and persuaded me to try an alternative path of care. We settled on a course of TMJ treatment that included oral appliance therapy, physical therapy, BOTOX® muscle injections, a steroid joint injection, and instructions that guided her full participation in the process.

I’m happy to report that the non-surgical treatment worked. After a few months, Patricia stopped coming in for TMJ treatment altogether. I had to assume that she was still feeling better.

A couple of years after her last appointment I happened to be at a party and ran into her. She introduced me to her husband this way: “This is the guy who fixed my TMJ!”

And later that evening I noticed she was laughing and comfortably eating. I was assured then that success had indeed been realized. In Patricia’s case, the combination of treatment, her participation, and nature’s healing process got the job done.

TMJ Treatment Case Study – Susan

Susan was 45-years old when she became my patient. She’d been suffering from wicked migraines for years. Medication and a regimen of BOTOX® injections every three months had provided a bit of relief. But she had a feeling that her migraines were somehow related to her jaw muscles and that’s what brought her to me for TMJ treatment.

Many mornings when she woke up her teeth were clamped tightly together. And almost every day she was aware of what she could only describe as a “bracing” feeling in her jaw.

Like many people who suffer from jaw muscle tension, I suspected that Susan’s stress-filled 18-hour days were the culprit. She was in a perpetual state of “fight or flight” as if she always was ready for battle.

I agreed; Susan’s jaw muscle tension was a likely contributor to the severity of her migraines.

Susan’s treatment protocol included a custom-designed oral appliance to wear at night, a series of daily jaw and neck exercises, and daily self-directed muscle massage. I encouraged her to also pay careful attention to the pace and manner of her breathing during the day, especially while she was at work.

With TMJ treatment in place, Susan agreed to return in four months for a re-evaluation. But she never did.

Almost two years later as I was waiting in line to buy a movie ticket, I noticed Susan was also in line. She apologized for not coming into the office for a re-evaluation and told me that her migraines were now few and far between. She had followed the plan of treatment I designed and her jaw muscles were much less symptomatic and her migraines much less severe.

In Conclusion

If you commit to being an active participant in your care, the benefits of TMJ treatment can last for years. And, even if you’re someone who has suffered for decades from jaw problems, it’s never too late to seek an answer.

Learn more about TMJ treatment here.

Tags Case Study, Jaw Problems, TMJ

Sleep Apnea TMJ

The Connection Between Sleep Apnea and TMJ

Medical research continues to assess how poor sleep quality and sleep disorders in general influence pain thresholds and the experience of muscle and joint pain. One common area of study pertains to obstructive sleep apnea and the larger field of sleep-related breathing disorders – conditions that can lead to fragmented sleep.

Therefore, if you have TMJ pain, it’s really important to tell your doctor if you have a sleep-related breathing disorder (including sleep apnea), and here’s why.

The Connection Between Sleep Apnea & TMJ

According to the Mayo Clinic, sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts. You may have sleep apnea if you snore loudly, and you feel tired even after a full night’s sleep. [ The most common type of sleep apnea is called obstructive sleep apnea and occurs when your throat muscles relax and cause pauses in breathing. Each pause in breathing can last from a few seconds to several minutes and can occur up to hundreds of times per hour.

This fragmented sleep can have a detrimental impact on your overall health. Aside from the obvious impact of not getting enough sleep that can include irritability, trouble concentrating, and being sleepy during the day, sleep apnea can trigger headaches, migraines, heart problems, and increase your sensitivity to pain. There are a myriad of reasons that people develop sleep apnea. Obesity, a narrow airway, large tonsils, sedatives, and smoking or drinking alcohol before bed are just some of the risk factors.

The bottom line is this. When something restricts normal breathing, oxygen levels will drop. When your oxygen levels drop, your brain will become stressed. And a stressed brain opens up the possibility of many other problems, including sleep bruxism, which is when you grind and clench your teeth while you’re sleeping. Bruxism can cause your jaw joints (TMJs) to be overworked leading to all kinds of problems, including pain.

Sleep Apnea Can Lead To Bruxism

A number of years ago, TMJ doctors began to notice that a large percentage of their patients had the signs and symptoms of sleep apnea. Studies revealed that breathing restrictions, like those accompanying sleep apnea, can trigger the nightly occurrence of sleep bruxism.

The Role Of Pain – A Double-Edged Sword

If you’ve ever been in chronic pain you know that getting a good night’s sleep can be quite a challenge. Moreover, studies reveal that insufficient sleep can actually lower your threshold of pain, meaning you feel pain more intensely than if you were well-rested. The reason is this: when you don’t sleep well your body can’t produce a normal level of endorphins (the “feel-good” chemicals that promote a sense of well-being). On top of that, poor sleep can cause your nerve pathways to malfunction – which causes a more intense experience of pain.

So, it can go both ways.

When breathing difficulties disrupt your sleep, you become more at risk of developing bruxism. And if your overworked jaw muscles become painful, the pain can cause fragmented sleep. It’s a symbiotic relationship.

Hopefully, you can now see the connection between sleep apnea and TMJ. Please consider getting evaluated for sleep apnea if you’re suffering from TMJ pain. A careful evaluation process, which may include an overnight sleep study (which can now be done at home!) will determine the best type of treatment.

Conclusion

As the associations between jaw pain, sleep disruption and sleep bruxism continue to unfold, the need to be evaluated by a well-rounded team of medical professionals becomes even more important. The ability to have sleep testing done at home and the more recent emergence of telemedicine consults to assist patients in obtaining preliminary sleep consultations, improve doctors’ ability to arrive at accurate diagnoses. This in turn will lead to more effective treatment.

If you’re suffering from TMJ-related pain and have tried everything, it’s time to see a specialist in orofacial pain. If you live in the NYC metro area, I invite you to make an appointment for a consultation at my Manhattan or Long Island office. If you are outside of New York, go to this website www.aaop.org and search for a Diplomate in your area.

Note: BOTOX®, which has been frequently been mentioned in the news, can at times be a helpful treatment once the assessment process has been completed. You can read about the experience of one of my patients and how BOTOX® helped her here.

Tags Sleep Apnea, TMJ

Bruxism Persistent Toothache TMJ

8 Surprising Reasons Your Teeth Are Sensitive

One of the most common questions about dentistry that people ask on Google is this: “Why are my teeth so sensitive?”.

Unfortunately, there’s no simple answer to this question. There could be any number of reasons why your teeth are sensitive, some of which may surprise you. In the following article, I list 8 reasons your teeth are sensitive and a brief explanation of each. Does one apply to you?

8 Reasons Your Teeth Are Sensitive

1. Your Toothpaste Is Too Abrasive

In order for toothpaste manufacturers to gain approval from the FDA they must measure and report the abrasiveness of their products. However, they are not required to report the information to consumers. To help you find out how your favorite toothpaste stacks up, refer to the chart below. Your teeth are sensitive perhaps because of the toothpaste you’ve been using.

2. You’ve Been Using Whitening Toothpaste

Whitening toothpastes often contain chemicals that help to remove surface stains and therefore, make your teeth much whiter. However, these chemicals can damage the surface of your teeth. Several whitening toothpastes have received the American Dental Associations’ (ADA) Seal of Acceptance. However, it is recommended that you consult your dentist before using whitening toothpaste to avoid damage. So, if you’ve been brushing with whitening toothpaste and your teeth are sensitive, whitening toothpaste may be the culprit.

3. There’s Too Much Acid In Your Diet

Citric acid, such as what’s found in lemons, oranges, and grapefruits, can be very damaging to your tooth enamel. It’s not hard to understand how too much citric acid could cause erosion of your teeth enamel and therefore, sensitive teeth.

On the other hand, most people don’t realize that many popular beverages, many of which don’t seem to be acidic, are very acidic. My colleague, New York dentist Michael Sinkin, warns: “…many vitamin waters, energy drinks, and sports drinks are highly acidic and if consumed in large quantities can cause your teeth’s structure to break down.”

So, how can you find out if your favorite beverage contains enough acid to be the reason your teeth are sensitive? Check the pH! pH is the measure of acidity on a scale of 1-14. The lower the number the higher the acidity; tooth enamel begins to dissolve at pH 5.3.

The chart below shows the pH of some popular beverages. If you’ve been gulping Gatorade at the gym or if you slug down a Red Bull every afternoon to fight tiredness, those beverages may be the cause of your sensitive teeth.

Source:
http://michaelsinkindds.com/is-your-favorite-beverage-eroding-your-tooth-enamel/

4. You’re A Swisher!

The next time you drink a soda, juice, or a glass of wine, take note if you swish it around in your mouth before you swallow. Many people swish their beverages without realizing it, which can create a loss of tooth enamel and sensitize the teeth’s dentin and cementin. Wine connoisseurs in particular, who swish in order to better experience the nuances of vintages, are at especially at risk. It’s OK to swish a little, but try keeping it to a minimum.

5. Your Teeth Need A Cleaning

Even people with the means to go to their dentist two or three times a year often avoid it because of dental fear. You can floss and brush twice a day, every day, but it’s nearly impossible to remove all the tartar and plaque that will build up on your teeth naturally. When plaque builds up around and under your gums, it will cause inflammation, and therefore, sensitive teeth.

If you haven’t been to the dentist for a while you could be surprised to discover that most practices now are hyper-aware of how anxious some patients can be, even when they come in just for a simple cleaning. Dental fear is nothing to be ashamed of, so discuss it with your dentist and get those teeth cleaned!

6. You Breathe Through Your Mouth

Chronic sinusitis from allergies or a deviated septum can cause you to continually breathe through your mouth instead of through your nose. An article in RDH, The National Magazine For Dental Hygiene Professionals, states: “Mouth breathing affects the pH of the entire body… meaning the saliva.”

In other words, breathing through your mouth over a long period of time can actually make your saliva more acidic and could be the reason your teeth are sensitive. The best advice is to see an ENT (an Ear, Nose and Throat doctor) as soon as possible.

7. Your Jaw Muscles Are Being Overused

I’ve been treating patients who have tooth and jaw problems that stem from overworked jaw muscles for over 35 years. If you hold tension in your face and keep your teeth clenched together during the day, your jaw muscles are being overworked. Overworked jaw muscles can cause headaches, facial pain, persistent toothache, and sensitive teeth. Try to relax your jaw, especially when you’re working at your desk. For more help, read Problems of the Jaw.

8. You Grind Your Teeth While You’re Sleeping

Nighttime teeth grinding, also called Bruxism, is a common phenomenon that causes your jaw muscles to over-contract. In fact, some people grind their teeth so ferociously that they actually sprain their jaw ligaments, which is why their teeth are sensitive.

My practice is full of people who suffer from bruxism and just want to feel better. Our first step is to figure out what’s causing the grinding. Only once the underlying reasons are discovered can we put in place a treatment plan to eliminate the grinding and therefore, its damaging efforts.

Did you figure out why your teeth are sensitive? Whatever the cause, keep in mind that your sensitive teeth are a sign that something is going on. Don’t ignore it.

(Note: If the cause of your tooth sensitivity is related to overuse behaviors or nighttime teeth grinding and you live in the NYC metro area, please feel free to (212)-265-0110 for a consultation. If you’re outside my area, you can go to www.aaop.org and find a Diplomate in your area.)

Tags Bruxism, TMJ, Toothache

Jaw Problems

What Causes Lockjaw?

Post author By Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain
Post date January 23, 2018
No Comments on What Causes Lockjaw?

Suffice it to say, if you wake up one morning and your jaw is locked shut, you’re going to be extremely frightened. You have lockjaw clinically known as trismus. As a TMJ and orofacial pain specialist, I see many patients every year with lockjaw. So, what causes lockjaw, and is there anything you can do about it?

Before I answer that questions, I need to explain a bit about how our jaws work. The jaw joint is essentially a hinge and is controlled by four muscles: 1) the masseter 2) the temporalis 3) the internal pterygoid 4) the external pterygoid. These names may sound like extinct dinosaur species, but they are very delicate muscles that together perform the important job of opening and closing the jaw and moving it from side to side.

There are two causes of lockjaw – jaw muscle spasms or impaired, incapacitated or shortened jaw muscles. To determine if your jaw is opening normally try this – open your mouth and insert three full fingers horizontally with your fingertips facing into your mouth. If they fit easily, you’re in good shape. If they don’t, read on:

What Causes Lockjaw Is A Variety Of Behaviors & Conditions

Here’s what can cause lockjaw:

1) Daytime Behavior

When over-used, your jaw muscles, just like most other muscles in your body, can become fatigued and go into spasm. This results in pain, limited motion, or both. If you’re a gym rat, you’ve probably experienced that sensation from over-working your hamstring or calf muscle – limited motion, pain, or both. Your jaw muscles behave in exactly the same way.

Many types of daytime behavior can cause lockjaw. Your jaw muscles can become fatigued from excessive gum chewing, prolonged contact between your upper and lower teeth, frequent nail-biting, and if you keep your teeth clenched for long periods of time.

Prolonged tension in your upper neck can also cause lockjaw. Your jaw muscles can become shortened then it’s impossible for you to fully open your mouth. If you’re under a tremendous amount of stress, feel anger, discontent, worry, anxiety, or fear during a long period of time can be the cause of lockjaw symptoms.

However, millions of people chew gum, clench their teeth, and bite their nails and they don’t develop the symptoms of lockjaw. In my field, orofacial pain, we consider those behaviors risk factors – as opposed to being the cause of lockjaw symptoms.

2. Temporomandibular Joint (TMJ) Problems
Your jaw joints are also known as TM joints, are literally hinges that allow your top teeth and your bottom teeth to move independently of each other. Problems that arise in the TM joints can lead to jaw pain, jaw clicking, and lockjaw, to name just a few. The cause of lockjaw symptoms in these cases is a result of pain, muscle tightening, spasms, or mechanical interferences in the hinge itself.

3. Jaw Trauma
Trauma, such as from an auto accident or sports mishap, that has caused a fracture, inflammation, muscle bruising, hematoma formation, a sprain in the TM joint can cause lockjaw. A change in the joint’s anatomy can cause it as well.

4. Cancer Therapy
Cancer therapy, such as radiation to address head or neck cancer, can cause the jaw and neck muscles to become less flexible and lead to symptoms of lockjaw.

5. Head Or Neck Tumors

Certain tumors in jaw muscles and/or in the TM joint can cause lockjaw symptoms, as well. Tumors in the throat, larynx, pharynx, thyroid, parotid gland, or ear can also be culprits.

6. Tetanus
Most people already know that tetanus can cause lockjaw. Thankfully, modern medicine has made tetanus very rare in the United States today. It’s a bacterial infection that causes muscle spasms that most often start in the jaw then progress to the rest of the body.

7. Other Infections
Infections such as those associated with impacted wisdom teeth, infected tonsil, or infected salivary glands can also cause lockjaw.

8. Dental Work

Dentists often need to use a mandibular block injection with a local anesthetic to comfortably treat a patient’s lower molar tooth or to remove a lower wisdom tooth. Mandibular block injections are performed millions of times a day with no problems. But on rare occasions, a patient may wake up unable to open their mouth. This is sometimes accompanied by jaw pain that can last for a few days after the injection. The cause of lockjaw, in this case, is trauma to a nearby muscle, bleeding, too much anesthetic or a slowly-developing infection.

How Lockjaw Symptoms Are Diagnosed

To diagnose lockjaw, your doctor needs to identify the cause or risk factors associated with the symptoms. Every lockjaw situation is accompanied by some limited jaw motion. Some lockjaw symptoms include pain and soreness. Sometimes there is no pain at all – just restricted motion. A clicking jaw joint that suddenly doesn’t click anymore can be a clue, too. Your doctor may order x-rays, a CAT scan or an MRI of your TM joints, your head and/or neck depending upon the clues uncovered from your history and exam.

Every patient is different and in order for your medical professional to discover in your case what causes lockjaw it’s critical that you explain in detail what was going on right before your symptoms emerged.

How Lockjaw Is Treated

Once your doctor has figured out what causes lockjaw in your case, he or she will develop a treatment plan tailored for you. Your plan might include jaw exercises, warm moist heat applications, anti-inflammatory medication or antibiotics for a short period of time. Physical therapy may be recommended, as well.

For you, what causes lockjaw is only the start. A full recovery can take several months. It’s important to be patient.

Tags Jaw Problems, Lockjaw

64181160 - medical concept: tmd - temporomandibular disorder on black chalkboard. medical concept: black chalkboard with tmd - temporomandibular disorder. 3d rendering.

Orofacial Pain TMJ

The Latest In TMJ Treatment Strategies

This post has been updated and can be found here.

If you’re someone who suffers from TMJ, you’ve likely tried numerous strategies to feel better. Jaw problems show up as facial pain, jaw pain, and even persistent toothaches, any of which can ruin the quality of your life. The good news is that everyday studies are done and discoveries are made that help get to the bottom of what causes these problems, which helps us find new and innovative TMJ treatment strategies to tackle them.

As an orofacial pain specialist*, my life is dedicated to helping people just like you and it enables me to be at the cutting edge of what’s working and what’s not. At the end of 2017, I took a little bit of time to reflect on the strategies that are helping my patients, some of which are a bit “out of the box”. I thought I’d share them with you:

1. Healing Is A Process

The most important thing I want you to understand is this: Healing is a process – not an event. Only when the risk factors that got your jaw in trouble in the first place have been identified, can TMJ treatment strategies for healing be put into place. Most jaw problems come on slowly and that’s how they resolve…slowly. Treatment takes time. And, I can’t stress this enough: you must be an active participant if your healing is to be successful. That means doing the exercises, wearing the oral appliance, practicing the meditation techniques, etc. Patience is key.

2. Anti-Depressants Could Be A Culprit

Although not the most common scenario, some of my patients who are on SSRI anti-depressant drugs such as Paxil, Effexor, Prozac, and Lexapro experience increased muscle pain in the neck, face, and jaw. I came to this realization by the process of elimination. There were just too many patients in my practice who had none of the typical risk factors. All of them were on SSRIs. With the involvement of their prescribing physicians, switching to alternative medications or taking a lower dosage provided them with profound pain relief. If you’re on an SSRI, you may want to speak to your doctor about adjusting your meds.

3. Sleep Quality & Quantity

The quality and quantity of sleep you get is one of the clues I look for when evaluating a patient. If you have insomnia or a sleep-related breathing disorder (obstructive sleep apnea, for example), it must be addressed before we can commence a TMJ treatment strategy to ease your persistent pain problem.

4. Lowered Pain Thresholds

Many people suffer from acute jaw, facial, or tooth pain because their overall pain thresholds have dropped. The most common cause is simply the way they live their lives. By consistently burning the candle at both ends (long work hours, little sleep, lots of stress) you keep your body in perpetual fight or flight mode. You may not be able to change your job or keep your baby from crying all night, but I’ve discovered that Chinese temple exercises or Tai Chi for just 30-45 minutes a day can work wonders for people like you.

5. Night Tooth Clenching & Grinding

Bruxism, which affects more than 10% of the population, disrupts the quality of sleep and wreaks havoc on the jaw muscles. If you habitually clench and grind, there’s no way your muscles can heal. There are many ways to stop this damaging behavior including special oral appliances and meditation techniques, all of which over time are very helpful. But again, positive outcomes will depend upon your commitment and participation to the TMJ treatment strategies that are designed for you.

6. Supplements

Despite industry claims, it’s unclear if any supplements are truly effective for pain relief. However, some of my patients are convinced that Fish Oil and Magnesium help with pain relief. Some take turmeric daily, too, and swear by it. If you’re going to go the supplement route make sure your physician is aware and involved.

7. Food As Medicine

Research has finally identified some foods that can substantially reduce nerve sensitization and inflammation, both of which cause pain. Grape seed extract, organic chicken broth, and cocoa (72% dark chocolate) combined with other TMJ treatment strategies can help diminish pain-prompting risk factors. Unfortunately, the research is in its infancy and I can’t recommend specific quantities; but moderation is always a good mantra.

8. Breathing

People with chronic pain are known to breathe fast and shallow. This rapid breathing causes excessive amounts of carbon dioxide to be expelled and can lead to high levels of muscle tension and nerve excitation in the body. And, rapid breathing makes it harder for your body to use oxygen. For many patients, the treatment strategy involves slow-paced belly breathing, yoga classes (particularly those that focus on the breath), meditation (Headspace.com is a great app to help you learn), and overall mindful living.

Conclusion:

By caring for TMJ patients for over 35 years I’ve discovered two important things. The first is that taking the time to discover who my patients are (not just as patients, but as people) is the only way to put the right TMJ treatment strategies into place and successfully help them get better. And secondly, the patient’s full participation is required all along the way.

There’s no good reason that you should have to suffer from persistent jaw, tooth or face pain for the rest of your life. I hope you found this article helpful.

I wish you the best of luck on your journey to healing.

* Orofacial Pain is the discipline of Dentistry which includes the assessment, diagnosis and treatment of patients with complex chronic orofacial pain and dysfunction disorders, oromotor and jaw behavior disorders, and chronic head and neck pain, as well as the pursuit of knowledge of the underlying pathophysiology and mechanisms of these disorders.

Tags Orofacial Pain, TMJ

The Connection Between The Upset Brain & TMJ

TMJ Consultations Online Now

TMJ Consultations Online In The Future

How To Detect A TMJ Problem

Tips: How To Treat Jaw & Face Pain During Stressful Times

Option One: “Wait And See”

Option Two: “Treat Me Now Or I’m Leaving!”

Toothaches That Are Not Caused By Teeth

What To Do If A Dentist Won’t Treat Your Toothache

The Bottom Line

What Does This Mean For Patients?

Definition Of Orofacial Pain

When A Child Grinds His Teeth, What’s Happening?

What You Should Do:

Invisalign® & Aligner Therapy Move Teeth In Remarkable Ways

Why Aligner Therapy Can Trigger Jaw Problems – Sometimes

Why Is It A Problem To Bite-Down On Your Aligners?

The Bottom Line

PTSD Affects The Nervous System In A Specific Way

PTSD & TMJ – A Case Study

Can A Combination Of PTSD & TMJ Be Treated?

Conclusion

Is It Bruxism or Bulimia? A Case Study

4 Clues That Bruxism Was Not The Culprit

So, Why Did I Ask If It Was Bruxism Or Bulimia?

Facial & Jaw Pain Caused by Bulimia – Treatment

A Much Happier Existence

Do You Know Someone Who Has Bulimia?

Case Study – Robin

Back To Robin

Pain & The Brain – The Right Questions To Ask

Pain Is In Your Head

Pain & The Brain – How Is Robin Now?

Pain issues and sleep challenges do not have to be lifetime afflictions. You need someone who listens and possesses the knowledge and compassion to get your pain and sleep problems under control.

I am that someone – and you’re in the right place. Dr. Donald Tanenbaum, DDS MPH

A Guide For Parents

9 Causes Of TMJ Problems In Teens & College Students

What’s A Parent To Do?

Pain issues and sleep challenges do not have to be lifetime afflictions. You need someone who listens and possesses the knowledge and compassion to get your pain and sleep problems under control.

I am that someone – and you’re in the right place. Dr. Donald Tanenbaum, DDS MPH

4 Surprising Reasons You Grind Your Teeth

3 Frequently Asked Questions BOTOX® Injections For TMJ

How To Find A TMJ Specialist

Snoring Is Much More Than An Annoyance

The Majority Of Snorees Are Women

CPAP Is Not The Only Option

Two Case Studies

TMJ Treatment Case Study – Patricia

TMJ Treatment Case Study – Susan

In Conclusion

The Connection Between Sleep Apnea & TMJ

Sleep Apnea Can Lead To Bruxism

The Role Of Pain – A Double-Edged Sword

Conclusion

8 Reasons Your Teeth Are Sensitive

What Causes Lockjaw Is A Variety Of Behaviors & Conditions

How Lockjaw Symptoms Are Diagnosed

How Lockjaw Is Treated

Conclusion:

Invisalign^® & Aligner Therapy Move Teeth In Remarkable Ways

I am that someone – and you’re in the right place.
Dr. Donald Tanenbaum, DDS MPH

I am that someone – and you’re in the right place.
Dr. Donald Tanenbaum, DDS MPH