Trigger Point Injections For Jaw Muscle Pain

Amidst the commonly used therapies to address jaw muscle pain is a technique called muscle trigger point injections (sometimes referred to as “needling”).

Trigger point injection therapy was developed over 50 years ago and has been effectively used to treat muscle pain in the back, neck and jaw ever since. This technique mechanically breaks up the knots (trigger points) that form as a result of muscle fatigue, strain, injury and overuse (in my practice, that means teeth clenching and grinding). Once formed, trigger points can remain latent and not produce symptoms, but when they become active they are capable of producing intense muscle pain.

The Needling Process

Because trigger points form at predictable locations, we can use the needling process to mechanically stimulate the affected muscle, as if the muscle was being “tenderized” and actually “break up” the knots in the muscle. Often local anesthetic (lidocaine) is used so that the site of injection is less tender the next day.

Trigger point injections can be very valuable in the treatment of jaw muscle pain, which characterizes TMJ syndrome, one of the specialties of my practice. But, in order to be effective, a series of trigger point injections is necessary if benefit is to be obtained. Treatment sessions can be spaced weekly and delivered three to four times.

My patients are sent home with a series of stretching exercises, which are critical following the injections and must be performed daily. In addition, careful attention must be given to identifying factors that will likely perpetuate the problem (such as teeth grinding and jaw clenching). For many patients, monthly trigger point injection sessions are preferred over long term the medications that would be necessary if their muscle pain escalated to troublesome levels. What’s more, trigger point injections can be safely used during pregnancy (without local anesthetic).

The majority of my patients who suffer from the debilitating effects of severe jaw muscle pain benefit greatly from this simple therapy. And, trigger point injections, combined with other treatments, are extremely helpful in the long-term management of jaw muscle pain.

Dr. Donald Tanenbaum is a specialist with offices in New York City and Long Island, NY. He is uniquely qualified to diagnose and treat facial pain associated with jaw problems, TMJ, referred pain, nerve pain, and migraines. Find out more at www.nytmj.com.

Tags jaw muscle pain, needling, trigger point injections

Headaches TMJ

Migraine Headaches & TMJ: The Connection

For years, patients have come to my office with acute and longstanding TMJ problems and report that they have suffered with migraine headaches as well. These problems have in fact been labeled with the term “comorbid,” representing two or more medical conditions existing simultaneously regardless of their causal relationship.

As a result of these patients’ jaw symptoms, treatments such as oral appliances, jaw exercises, muscle trigger point injections and massage/physical therapy have been routinely used. As a result of varied and unpredictable treatment results particularly among my female patients, several things have become clear:

The patients’ TMJ symptoms often did not respond sufficiently to treatment if the migraine headaches were not under control.
Migraine headaches that are under control by the use of medication can become more problematic when an acute TMJ problem is present.
Patients whose migraine headaches are under control actually reported a further decrease in the frequency, duration and intensity of their migraines once TMJ treatment is started.

Though these are anecdotal observations, a recent article in the Journal of Orofacial Pain provides some insight into these observations. Some important factors to keep in mind are:

Patients who have both TMD and migraines have an increased likelihood that the nerves in their face and jaw will fire excessively even when prompted by normal stimuli, such as talking, opening or closing the jaw, eating food of normal consistency, or when the face is placed on a pillow. As a result, the likely emergence of pain and muscle tension increases.
In women with migraines, inflammation in the TM Joints and jaw muscles can produce higher levels of suffering due to the way pain signals from these structures are interpreted in the brain.
TMD pain could reduce the benefit of medications being used to treat migraine headaches.

As a result of these findings, it is now even more important to merge the evaluation and treatment strategies employed by practitioners that focus their practices on these two patient groups. A collaborative approach that can integrate TMJ treatments inclusive of oral appliances, trigger point injections, jaw/neck exercise, massage, and physical self regulation techniques with migraine therapies such as medication, diet, cognitive behavioral, and sleep strategies employed by our medical colleagues is clearly the way to go.

Tags Dr. Tanenbaum, Migraine Headaches, migraine headaches and TMJ, migraines and TMJ

working out in the gym on a bike

Jaw Problems TMJ

Indoor Cycling Classes Can Cause Jaw Pain and TMJ

Over the past few years in my practice we have seen an increasingly number of female patients who are committed fans of high intensity indoor cycling workouts (sometimes called “spinning”) such as Soul Cycle. They have been arriving complaining of jaw pain, limited jaw motion, and jaw clicking, all the typical signs of TMJ or Temporomandibular Disorder. What we’ve determined is that these popular high intensity indoor cycling programs may be detrimental over time for some women, particularly as they relate to the upper neck muscles.

Indoor Cycling and TMJ – What’s the Connection?

Many TMJ disorders start in the muscles of the head and neck region. Tight, fatigued, and overused neck muscles can cause changes in head position and consequently changes in the tone of jaw muscles and the position of the lower jaw (even when at rest). Over time these subtle changes can cause jaw pain and tightness. In addition, there are trigger points in the neck muscles that when active can refer pain to the jaw and lead to muscle contracture of the jaw muscles, leading to diminished jaw motion and sometimes changes in how the teeth come together.

By working one’s upper body while pedaling a stationary bicycle, the head and jaw posture is often strained in a way that can lead to extreme muscle fatigue. The head weighs about 18 lbs. and in the midst of an intense cycling class this 18 lb. ball is hanging forward and bouncing around. As a result of this challenge to the biomechanics and physiology of the neck, muscle pain and at times even nerve pain, can emerge in the face and jaw, a condition commonly referred to as TMJ.

Case Study: TMJ and Soul Cycle

Knowledge of how the neck works is important in understanding why TMJ problems can be caused by intense indoor cycling classes. My patient Nancy is a perfect example. She is 27 years old and recently came to see me complaining of severe jaw pain, limited jaw motion, and jaw clicking. A thorough interview revealed that the only change in Nancy’s daily routine was the inclusion of three to four Soul Cycle classes per week. Discussion also revealed that she had been experiencing jaw tension during class that often lingered for hours afterward. What started out as a short-term symptom had evolved into even more troublesome problems. I recommended that she give herself a break from Soul Cycle, engage in a short regimen of physical therapy, and take anti-inflammatory medication for a limited period of time. We’re happy to report that today Nancy’s jaw problems have been resolved.

I recognize that intense indoor cycling fitness programs such as Soul Cycle can have tremendous personal and physical benefits. What should be kept in mind is this: many classes every week over a long period of time may actually put your jaw at risk. And what good is a fit body if you can barely open your mouth?

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 Donald Tanenbaum, indoor cycling and jaw pain, indoor cycling and tmj, soul cycle and jaw pain, soul cycle and tmj, spinning and tmj, TMJ

Facial Pain Tinnitus TMJ

Tinnitus, Facial Pain and TMD – Are They Related?

It is not uncommon to see patients that present with facial or jaw pains that are not associated with disease, injury or illness of any type. These patients, typically women between the age of 18-55, relate that their pains came on without specific events, emerging spontaneously upon awakening one morning after a fatiguing day or associated with a routine meal, for example. As all medical and dental investigations are unrevealing, answers are searched for and often prompt comments like “there is nothing wrong.”

Over the course of the last several years I have also seen numerous patients present with the same historical account, but instead of suffering with pain they complain of debilitating ear ringing, humming, buzzing and whooshing sounds. For these patients the onset of their ear complaints (often lumped under the term tinnitus) also started for no good reason and prompted multiple tests which were all normal.

So what is going on with these two patient groups that are plagued with symptoms that have no specific origin. How to ease their suffering? From my perspective, the pain and ear noises (tinnitus) represent a specific type of sensory disorder that typically occurs after prolonged periods of challenging life circumstances and emotional distress. In short, these patients consistently relate that they have lost control over their daily existence. As a result, the human brain is upset, and an upset human brain loses its ability to regulate nerve function, muscle tone, heart and breathing rates, and hormonal regulation. The end result is something called sensitization…when normal stimuli are perceived by the brain as noxious (like putting a shirt on after a sunburn).

For the patient with tinnitus, I believe that everyday normal sounds are interpreted as noxious and patients describe their symptoms with variable choices of language, such as humming, ringing, buzzing, hissing, whooshing, and “fullness.” For the patient with facial pain any type of superficial stimulation (a hug, chewing, yawning, or speaking too much) prompts the sensation and experience of pain.

The good news is that with time (months or years) the majority of these patients improve (at times the relief occurs for “no good reason” the same way the symptoms emerged. The key is for these patients to avoid unnecessary and unproven treatments, particularly if surgical explorations are involved. The most useful treatments involve strategies to quiet the mind and body. Programs like the Stop and Breathe Program advocated by Susan Ginsberg have provided relief for patients along with Transcendental Meditation, Biofeedback, Autogenic Training, and Progressive Muscle Relaxation to name just a few. The use of medications like Clonazepam and/or supplements can also be found to be helpful. And, periodic assessments with pain doctors and audiologists are always advised.

Tags Facial Pain, tanenbaum, tinnitis, TMD

Facial Pain

Facial Pain & Diabetes – The Connection

Recently I had the opportunity to evaluate a 55-year old woman who complained of right side facial pain that by its description seemingly had a nerve-related origin. Her pain was daily and was most intense during the first few bites of a meal. In addition, as she brought food to her lips, (which initiates salivation), her pain greatly intensified. The pain was described as bright, sharp, and debilitating during eating and lingered even after the meal was over.

Prior to her consultation in my office she had seen a number of ENT doctors whose evaluation did not lead to a diagnosis or an effective course of treatment. All dental exams and X-rays were also negative. What then could be causing this pain problem characterized by nerves that were firing abnormally essentially sparking when stimulated? Trauma and disease had been ruled out as the source of the pain based on the patient’s pain history and complete MRI scanning.

How did I approach this mystery? There was a risk factor that needed consideration: the patient was diabetic! While many patients with diabetes experience no nerve symptoms, others have pain, tingling, and even numbness. This condition is called diabetic neuropathy. Diabetic neuropathy in fact can impact every organ in the body. Some studies have shown that 60% to 70% of patients with diabetes have some form of neuropathy and the highest rates are in those who have had diabetes for more than 25 years.

The causes of diabetic neuropathy are multiple and researchers are now studying how prolonged exposure to high blood glucose causes nerve damage. Nerve damage, however, is likely due to a combination of factors:

Metabolic factors: high blood glucose levels, and possibly low levels of insulin
Neurovascular factors: lead to damage of the blood vessels that carry oxygen and nutrients to nerves
Autoimmune factors: can cause inflammation in nerves
Lifestyle factors: smoking or alcohol use (in this case, the patient also smoked!)

So my patient’s intense facial pain was most likely glossopharyngeal neuralgia, a type of neuropathy that individuals with diabetes may develop, particularly when aggravated by chronic smoking! Glossopharyngeal neuralgia causes sudden, intense pain in the throat, mouth, tongue, jaw, ear, and neck and may be brought on by swallowing, sneezing, chewing, clearing the throat, eating spicy foods, drinking cold liquids, speaking, laughing, or coughing.

As with other neuralgic pain, the course of treatment has been to use medications to reduce the spontaneous firing of nerves in the presence of normal stimuli, in this case eating. Though glossopharyngeal neuralgias are often quite receptive to medications, my patient’s history of diabetes and long-term smoking will likely be complicating factors that will influence her ability to respond to treatment.

For more information about neuropathy and diabetes, link here.

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 diabetes risk factors for tmj, diabetic neuropathy, Dr Donald Tanenbaum, Facial Pain, facial pain and diabetes

Ear Pain Tinnitus TMJ

TMJ and its Relationship to Ear Problems and Sinus Symptoms

Many of my TMJ patients also complain of ear problems and sinus symptoms. Is there a relationship between these painful and uncomfortable conditions and TMJ dysfunction? Let’s start with ears.

Ear Problems & TMJ

The experience of ear symptoms in patients with TMJ is very predictable due to a number of factors. Most importantly during growth and development the structures of the ear, the TM Joint and the jaw muscles originate from similar cells and as a result share nerve pathways that can influence muscle tone and performance. For instance, the muscle that determines the size of the Eustachian tube (influences ear pressure) is directly influenced by the same nerve that serves the jaw muscles and TM Joint. As a result, a TMJ problem can lead to changes in the way the Eustachian tube effects the ear, at times leading to symptoms of ear pressure, fullness, clogging, pain and even ringing.

In addition, the tension across the tympanic membrane and the position of the malleus bone can also be altered in patients with TMJ. As a result, ear symptoms can emerge and linger. In some cases, patients also experience tinnitus. Ringing ears or tinnitus is only occasionally related to TMJ problems. A relationship may exist when the tinnitus changes during jaw movements and or eating. If the tinnitus (pitch and intensity) does not change as a result of jaw function and remains constant on a daily basis it is unlikely that TMJ therapy can help.

For a complete discussion of the TMJ tinnitus connection, visit: https://www.nytmj.com/tinnitus-jaw-connection.

Sinus Symptoms & TMJ

With regard to sinus symptoms it is common for patients with TMJ to complain of pain and pressure in their sinuses, despite the fact that there is no sinus disease, infection, or inflammation. The reason is due to mechanisms of referral, where the site of the symptom is not the origin of the symptom. Jaw muscles in particular can refer pain to the sinus region often making a diagnosis difficult. Muscles that are tight, inflamed, and fatigued due to overuse behaviors and sleep bruxism commonly lead to sinus symptoms. As a result TMJ therapy that reduces muscle problems often leads to the relief of the reported sinus symptoms. Some common treatments include jaw exercises; jaw muscle conditioning, massage, bite plates, and injection/needling therapy that relax tense overworked muscles.

The bottom line is that if a patient seeks care with ear and or sinus symptoms that have no apparent relationship to disease, injury or illness, then there is a good chance that an underlying TMJ problem may be responsible.

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 Donald Tanenbaum, ear pain and tmj, ear pressure and tmj, ringing ears and tmj, tinnitus and tmj, tmj and sinus symptoms

TMJ

Can A Mattress Cause TMJ?

Post author By Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain
Post date August 6, 2013
No Comments on Can A Mattress Cause TMJ?

Is there a connection between your choice of a mattress and TMJ problems?

While there aren’t a lot of studies that probe the relationship between one’s choice of a mattress and TMJ pain, it’s fair to speculate that choices that prompt more restful and predictably sound sleep are obviously advantageous.

With regard to choosing a mattress, there are a number of options provided on the showroom floor of any decent-sized mattress company, and they all vary according to personal tastes. From natural and organic feather beds, to hypoallergenic materials, from old fashion coils and springs to memory foam and electronic Posturepedics, there is a mattress for every body type, weight, and co-sleeping situation.

How can your mattress choice affect TMJ, though? Bottom line is, if you already have trouble sleeping, either from insomnia, obstructive sleep apnea, chronic body pain, or tooth grinding, you never want to compound the problem with a mattress that makes you toss and turn all night.

While there may not be a lot research into mattresses and TMJ, there is research to support a relationship between sleep quality and sleep quantity with the potential onset of TMJ pain problems. Whichever mattress you choose, make sure it’s not a source of irritation that can prevent sleep or roust you from your sleep in the middle of the night. Poor sleep can lead to excess jaw clenching, grinding, and jaw muscle tightening.

We commonly hear people complain that they wake up with their hands clenched, teeth together, and shoulders raised. Could this be the symptom of a poor mattress disturbing sleep? Something to think about.

Let us know in the comments if you’ve experienced a better night’s sleep after thoroughly researching and settling on the right mattress for you.

Tags can a mattress cause TMJ, causes of TMJ, Dr. Tanenbaum

Bruxism Nightguards & Oral Appliances TMJ

Biteplates Need To Be Monitored

Post author By Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain
Post date June 18, 2013
No Comments on Biteplates Need To Be Monitored

Thousands of people every year are prescribed biteplates by their dentists. There are two common scenarios that prompt a dentist to make this recommendation.

Scenario 1: Tooth Grinding

You went to your dentist for a routine appointment and you were told that there is evidence that you are grinding your teeth at night (sleep bruxism). Your dentist may in fact show you areas of tooth wear on your teeth. You have no jaw or tooth pain, which is good, but a biteplate is made to protect your teeth at night while you sleep. This biteplates may be made of hard acrylic, dual laminate materials with a soft inside and hard outer shell, or may be totally soft and pliable.

Since you have no symptoms of jaw or tooth pain, there is no need to do anything else. Your dentist should ask you to bring it with you when you go in for a routine tooth cleaning appointment. Overtime it may have to be remade due to wear and tear, or adjusted if new dental restorations have been placed.

Scenario 2: Jaw Pain, Stiffness, and more…

You are experiencing pain/tightness/stiffness in the jaw muscles, pain in the Temporomandibular Joints (TMJ’s), or clicking that is new or getting worse. Your symptoms may be worse in the morning as many people often wake up with symptoms of jaw pain, diminished jaw motion, and even a jaw that feels locked and out of place. Your dentist will in this situation commonly make a biteplate that can be modified over time as your symptoms change. It may have a flat biting surface or inclines to address your specific problem.

These adjustable biteplates need to be monitored as your condition improves, or if it is not helping to reduce symptoms. Just like an orthopedic splint for the knee, problems, modifications, or changes are required overtime as the situation dictates.

If your jaw problem was due to a specific trauma or injury (sports related/eating/accidental) which lead to a joint sprain, muscle strain, or joint inflammation, as healing occurs you will likely wear the appliance less until you don’t need it at all.

However, if your jaw pain, locked jaw, decreased motion, sore teeth, or headaches resulted from persistent and aggressive sleep bruxism , then long term use of the biteplate may be required. Periodic visits to the dentist will be required to determine when, and if the biteplate use can be reduced or eliminated. Regardless of the reasons that you needed a biteplate to begin with, please make sure your dentist monitors its use at least once a year.

Learn more about biteplates and oral appliances.

Tags Biteplates, Bruxism, Donald Tanenbaum, jaw pain, Mouthguard, Oral Appliances, TMJ, Tooth Grinding

Facial Pain

Facial Pain and TMD: A Persistent Domestic Stress Disorder?

Three patient visits in the past week alone made me think that it may be time to consider formulating a new diagnostic term to categorize the countless people that I see who are suffering with facial and jaw pain but who have no history of disease, identifiable injury, or illness. I am therefore proposing a new term: Persistent Domestic Stress Disorder (PDSD), modeled after PTSD (Post Traumatic Stress Disorder) which was coined in the 1980’s as a result of ongoing studies of Vietnam veterans who returned from combat as different people.

Though defined in many ways, the most classic definition of PTSD is a “debilitating condition that affects people who have been exposed to a major traumatic event” (“Post- Traumatic Stress Disorder, PTSD”). Traumatic events that may trigger PTSD include violent personal assaults, natural or unnatural disasters, accidents, or military combat. To fit the criteria of PTSD the individual must exhibit certain symptoms subsequent to the event(s).

Symptoms of PTSD:

Intense fear, helplessness, loss of control over daily life events
Persistent re-experiencing of the traumatic event
Continual avoidance of reminders associated with the event
Increased arousal, an overwhelming inability to cope with flashbacks, insomnia, and nightmares
A duration of these conditions for at least one month*

Surely many of these elements are absent in our pain patients but there are unfortunately many similarities, therefore my new diagnostic term: Persistent Domestic Stress Disorder. Though domestic challenges and specific events may not be as vividly upsetting as those encountered in war, they are no less traumatic to the mind and soul.

Consider the following scenarios I commonly hear: 80-hour weeks to preserve a job or to become eligible for advancement, 24/7 care for an elderly parent with progressive dementia, persistent worry in our young adult patients focused around achieving in school or finding the right partner, verbal or physical abuse at home or in the workplace, fragile and unsatisfying marital relationships, uninspired children that need ongoing emotional and financial support, and coping with personal medical infirmities that cast doubt on one’s future. These are just some of the profiles that are seen routinely in my practice.

As a consequence of these challenges I see increased arousal in my patients’ nervous systems (always in “fight or flight” mode with excess levels of adrenaline and cortisol being found in their bloodstream). I hear complaints of insomnia (inability to get to sleep or stay asleep), I see shallow breathing patterns (with the end result of imbalances in the levels of oxygen and carbon dioxide in their systems) and I see acquired behaviors (such as tooth clenching, furrowing of the brow, raised shoulder, etc.) that fatigue the muscles of the head, neck, face and jaw.

As these challenges persist well beyond one month, the brain remains under siege and ultimately subtle changes in neural thresholds and muscle tone result leading to pain symptoms along with complaints of ringing/fullness in the ears, burning in the mouth, loss of balance, or tingling in the face. Patients arrive at my office often exhibiting helplessness and are easily moved to tears when they are reminded of the issues in their lives that they have been trying to avoid thinking about.

Though bringing these concepts to light may make patients wonder if they can actually feel better when faced by these huge obstacles, there truly are strategies that can be employed that bring definitive relief.

If you are suffering from facial or jaw pain, your symptoms are real. They are common and familiar to those of us trained in the recognition and treatment of Orofacial pain and Temporomandibular disorders. There is no “quick fix,” rather comfort will only be realized if nerve thresholds return to normal, muscle tension eases, sleep is regained and optimism and control are restored within an individual’s personal world.

You can be helped to feel better. Fortunately there are strategies that work and health care providers like myself who can help.

Read more about how I work with patients suffering with facial and jaw pain, and the symptoms of TMJ on my website.

*Spinrad 1

Tags Dr. Tanenbaum, Facial Pain, facial pain and PTSD, Persistent Domestic Stress Disorder, TMD, TMJ

Nightguards & Oral Appliances Sleep Apnea Snoring

Who is Monitoring Your Snoring or Sleep Apnea Appliance?

Based on the number of emails I weekly receive advertising courses for dentists to learn how to make and provide oral appliances for snoring and sleep apnea I can only assume that an increasing number of adults are receiving these devices. Though these devices can provide great benefit socially (allowing bed partners to sleep in the same room) and medically by reducing the risk of heart related problems, once inserted these devices must be monitored.

Why You Should Always Monitor Oral Appliances

1. Is the oral appliance doing what it is intended to do? For the simple snoring patient the answer is easy. For the apnea patient, the answer is a guess unless a follow up sleep study (home test or laboratory) is done. Just the cessation or reduction of snoring may not mean that the apnea condition has been adequately addressed. The dentist who puts in the device must direct the follow up process.

1. These appliances can cause tooth shift, opening spaces between teeth leading to food traps, and lead to movement of front teeth that were straightened with braces. These problems can be eliminated or minimized with follow-up visits.

1. In approximately 15 percent of patients that wear these appliances over one year, there is a good chance that a bite change will occur not allowing the back teeth to hit as they once did. Heavy contacts are put on the front teeth with likely consequences such as chipping and reduced mobility. Follow-up visits can not only prevent this from happening but if noticed, modifications can be made with regard to how often the appliance is worn and where the position is set.

In some people these appliances can lead to jaw problems such as muscle or joint pain, joint noises, and even limitations in jaw motion and functional abilities. Since the jaw is an orthopedic system, healing will then be dependent on making appropriate changes, which can only be determined by follow-up visits.

The Take Home Message About Monitoring Oral Appliances

If your dentist is not insisting on follow-up visits, speak up and get back on his or her schedule. Also, these appliances do not last forever! Replacement is usually necessary after 3 -5 years based on normal wear and tear.

Tags Dr. Tanenbaum, follow-up visits oral appliances, oral appliance for sleep apnea, oral appliance for snoring, Oral Appliances

TMJ

TMJ Symptoms: Is Technology Necessary To Feel Better?

Recently as I flipped through a running magazine I came across an article that discussed the process of getting better following a leg injury. After reading this article I reflected for a moment on the current state of thinking within the dental profession as it relates to TMJ treatment options and the process of getting better following the emergence of symptoms in the TM Joints and jaw muscles.

The running article in a straightforward fashion outlined the principles of healing that would be required for typical leg injuries, inclusive of sprains/strains in order to get better. The focus, as expected, was on resting the injured tissues, supporting the injured tissues with wraps and braces based on the established diagnosis, heating/icing the area of concern, using medications to decrease pain, inflammation, and spasm, and employing home care strategies or formal physical rehabilitation efforts. The article repeatedly conveyed the theme that healing is a process and that similar orthopedic injuries may require different timeframes and treatment selections from person to person.

Unfortunately when it comes to TMJ problems, there continues to be a constant emergence of alternative strategies that seem to suggest that healing can only occur if assisted by some sort of high-tech wizardry and rearrangement of the teeth and jaw relationships. In fact, over the last 6 to 12 months endless email messages have been sent to dentists in the U.S. and abroad that offer new technologies that not only ‘cure’ TMJ problems but add an ongoing profit center to dental practices.

According to the ‘experts’ who are behind the sales pitch, accurate diagnoses can only be made with electronic instrumentation, which tracks jaw motions, and sensors which record the sequence, intensity, and duration of tooth contacts when the teeth are brought together.To the uninformed and sometimes vulnerable patient, these bells and whistles are rather convincing but unfortunately add cost and unnecessary treatment, usually inclusive of multiple sessions of ‘bite balancing’ or ‘bite reconstruction’ based on data collected on technology that has no scientific support.

To further cloud the issues, if a patient gets better during the weeks or months of technology guided treatment, success is attributed to the technology, not to the passing of time, or other strategies that may have been initiated.

The take home message

Jaw problems like other orthopedic problems typically get better without electronic technology. Though seeking professional care may be essential to your recovery, if more time is spent by the doctor you chose hooking your head and jaw up to sensors and tracking devices, getting a second opinion is recommended and probably in your best interest.

To learn about other possible jaw & facial pain treatments, please click below:

Tags Dr. Donald Tannebaum, electronic devices and TMJ, TMJ treatment options

TMJ

Are Anti-Inflammatory Medications Safe for TMJ?

Though it is common for many TMJ sufferers to take anti-inflammatory medications called NSAIDs, which are available without a prescription in local pharmacies and in super-sized containers in big box stores, they are not as safe as presumed.

The most common of these over the counter medications are Advil and Aleve and many of my patients down them as if they are sugar-coated candies. Even when the medications are not working, patients continue to use them, wrongly assuming that since they are available without a prescription that they are safe in any quantity.

For the most part, short-term use of these medications for a period less than ten days should not pose any health concerns. Unfortunately, many TMJ problems may require weeks of use in order for muscle and joint inflammation to be controlled. As a result, these medications can pose cardiovascular, kidney, and gastrointestinal risk.

In particular, patients with a previous history of a heart attack are more at-risk for another episode when taking this class of medication. Medications for high blood pressure and so-called ‘water pills’ (anti-diuretics) may also not work as well when NSAIDs are taken at the same time. Kidney performance can suffer as well when taking these medications in an uncontrolled manner over an extended period of time.

Though these medications are commonly associated with stomach upset prompting patients to discontinue their use after a short period of time, many patients tolerate these drugs for long periods before the side effects of upset stomach and bloody stools are experienced. By this time, damage may have already occurred to the stomach and other parts of the digestive system. So here are some suggestions:

Using NSAIDs Safely

Don’t take these medications for more than two weeks without professional guidance.
Make sure you take these medications with at least twelve ounces of water or after a meal.
Take these medications at the recommended time interval between doses and not before, even if pain begins to increase.
Don’t rely on these medications to ease symptoms. Use other strategies at the same time to help decrease inflammation. These other efforts can include following a soft diet, using ice/heat, self or professional massage, stretching your jaw muscles; the list goes on.
If while taking these medications you begin to bruise easily, discontinue use immediately and consult with your physician.
If you have a history of hypertension, routinely take your blood pressure when on these medications.
If your stomach begins to hurt or your stools darken, discontinue these medications and consult with your doctor immediately.

In summary, NSAIDs are tremendously helpful medications, but benefit and risk should always be weighed. If you are not sure, whether to use or continue using these medications, professional consultation is always advised.

There are more treatment options available to help alleviate TMJ pain:

Tags Dr Donald Tanenbaum, NSAIDs and TMJ pain

TMJ

The Truth About TMJ Arthritis

Post author By Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain
Post date April 2, 2013
1 Comment on The Truth About TMJ Arthritis

When people describe their arthritis pain they often mention knees, hips, hands and shoulders. Though rarely mentioned, arthritis can also be experienced in the jaws, specifically focused in the temporomandibular joints, or TMJs. Just as with these other joints, arthritis in the TMJs can be experienced as pain, stiffness, and limited motion and function.

Most of the arthritis experienced in the TMJs is the result of past trauma, or longstanding jaw problems that have caused wear and tear to the bones, cartilage, ligaments, and lubricating system (degenerative changes). As a result, friction develops giving rise to joint noise, and at times pain and function that is limited.

It is interesting to note that most arthritic changes that occur in the TMJs over time are not accompanied by acute pain. In fact, in aging populations around the world, most arthritic changes in the TMJs are not even accompanied by the need to seek care. The arthritic changes may prompt annoying and at times frightening noises, but for the most part do not limit eating, opening or closing the mouth, or talking.

At times however, arthritic changes in the TMJs cause bite changes that lead to changes in facial appearance and inefficient chewing. If pain accompanies the arthritis and lingers there may well be a need to seek professional guidance. The use of medications, steroid injections, exercise, massage, physical therapy, and dental splints may be essential in controlling the arthritic process. Treatment at times can span months in order for the arthritic process to be arrested.

The most problematic arthritis we see is in young females between the ages of 16-25. The arthritis often results from a number of risk factors including gender, genetics, overuse behaviors, sleep bruxism, and structure including the way the teeth come together. A multi-disciplinary approach is often needed to manage these problems. Certainly, painful arthritic problems need to be treated by a professional.

Other arthritis problems may include psoriatic arthritis, gouty arthritis, and rheumatoid arthritis. These may need to be investigated by a rheumatologist and at times require long-term care inclusive of medications.

If you are currently suffering from TMJ, please consider trying these 15 home remedies for TMJ pain. If they are ineffectual or the pain worsens, seek a medical professional immediately.

Tags Dr. Tanenbaum, facial pain and arthritis, TMJ arthritis, TMJ pain relief

TMJ

Home Therapy for TMJ

Post author By Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain
Post date March 28, 2013
1 Comment on Home Therapy for TMJ

I’m a TMJ specialist. Patients often tell me that they’ve been told that there is no treatment for TMJ problems and that they will struggle with this problem for the rest of their lives. To the contrary! TMJ problems like all other orthopedic problems are common and treatable.

We have many types of specific treatments for TMJ in the office, but there are also a number of home therapies that have shown to be rather beneficial for the vast majority of TMJ sufferers. Whether your TMJ problem is focused in the jaw muscles, the jaw hinges (the temporomandibular joints), or the associated tendons and ligaments, the basic principles used to treat all orthopedic problems apply.

Rest, support, medication, and rehabilitation are often the key ingredients to success. Though only some jaw related problems require professional care, ALL TMJ problems require home care strategies to achieve the goals of pain elimination and restoration of function. What follows is a thorough list of home care strategies for overcoming TMJ pain.

15 Home Therapies for TMJ Sufferers

1) Apply heat over tender muscles and apply cold over tender joints. At times, my patients choose to cool with ice packs first over both the muscles and joints for 5 minutes and then follow with heat for 15 minutes. This can be repeated several times a day.

2) Avoid overuse of jaw activities and behavior that fatigues the jaw muscles. This is critical to achieve healing. Overuse activities include gum chewing, nail & cuticle biting, biting on pens, pencils, straws, ice, plastic items, eyeglass frames; the list goes on.

3) Avoid clenching your teeth during the daytime. For techniques to help you overcome this behavior, click here.

4) Avoid cradling your phone between your shoulder and neck and try to reduce the amount of time you are texting. Your head in a forward posture for lengths of time wreaks havoc on your neck and jaw muscles.

5) Apply pain-soothing gels over the jaw, neck muscles, and jaw joints. These may include BenGay, Aspercreme, Biofreeze, but many other preparations are available in the local pharmacy. (Note: some of these products contain menthol, arnica, aspirin, and other anti-inflammatory ingredients so make sure you are not allergic or sensitive to these products.)

6) Try TENS stimulation. TENS is a form of muscle stimulation that can help reduce spasm, muscle tension, and relieve pain. TENS devices can now be found on the Internet, but be advised as they do require instruction in order to be used safely.

7) Muscle massage techniques can be used over the temporalis muscle and masseter muscle (which is the big muscle that bulges when you clench your teeth). These muscles can be rubbed and massaged as you would for a sore calf or thigh muscle, applying enough force to be uncomfortable but not too much force that your eyes tear. This can be done for 2-3 minutes 3-4 times a day and the best place to do it is in the shower. There are a number of YouTube videos you can watch to help guide your technique.

8) Avoid hard, large, tough, and/or chewy food. I don’t recommend a mushy diet but rather a thoughtful diet. If you experience pain during or after a meal, you probably ate the wrong food.

9) Minimize caffeine intake (even chocolate) and nicotine use.

10) Abstain from drinking alcohol close to bedtime hours as it leads to restless sleep.

11) Hydrate with a good amount of water throughout the entire day.

12) Try your best to get 7-8 hours of restful sleep every night.

13) Avoid electronic stimulation prior to going to bed. Your cellphone, laptop, and other various devices can all negatively affect your sleep cycle.

14) Exercise routinely, at least a few times throughout the course of the week, to build endorphins and reduce daily stress. Endorphins are our bodies’ natural painkillers.

15) Practice diaphragmatic breathing or even meditate during the day to slow the number of breaths you take per minute.

Certainly you may need more directions of care, as every patient is unique, but these ideas, if pursued consistently, will surely provide some relief or buy some time until you are able to see the proper medical professional. If any of these recommended techniques increase your pain or aggravate your jaw in any way, they should be discontinued immediately.

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 Dr. Tanenbaum, Facial Pain, home care to relieve TMJ pain, home therapies for TMJ sufferers, home therapy for TMJ, Jaw Problems, TMJ

Women & Pain

Women, Sleep, & Pain

Post author By Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain
Post date February 27, 2013
No Comments on Women, Sleep, & Pain

In my practice, it has been a given that over the course of any, day, week, month, or year, the number of female patients seeking care significantly outnumbers male patients coming through the door. In fact, recent statistics have revealed that 77-82% of the patients we see with muscle pain, migraines, nerve pain, or TMJ problems are women.

As a result of this on-going theme in practices all over the world, researchers have focused on isolating the reasons why this gender dominance occurs when it comes to facial pain problems. Though absolute answers have not been agreed upon, there seems to be a general consensus that women seek care more than men for facial pain problems for three specific reasons.

Why Women Seek Care For Facial Pain More Than Men Do

The origin of many Facial Pain problems appears to be related to biologic factors. The most important likely relates to the hormone estrogen and it’s influence on inflammation, tissue injury, and the way the brain perceives pain.
Women have fewer ways to express anger than their male counterparts, and as a result their autonomic nervous system (involved in the “fight or flight” response) fires excessively.
Women look for answers to symptoms and medical concerns to a much greater extent than men and as a result women visit physicians more than men.

Other Gender Concerns?

Now there also appears to be gender concerns when it comes to the condition obstructive sleep apnea, which puts patients at risk for multiple medical problems including daytime sleepiness, cardiovascular disease and brain injury as a result of oxygen deprivation while sleeping. A small percentage of our facial pain patients have been diagnosed with this problem and many of them wake up with morning headaches and commonly report grinding and clenching of their teeth when they sleep. What is most interesting, however, is that according to a recent study at the University of California, Los Angeles, women who have sleep apnea may experience more damage to their brain cells as a result of the condition than men with obstructive sleep apnea.

In this study of 80 participants, researchers analyzed brain nerve fibers to find differences in brain cell damage between those with sleep apnea and those without, as well as between men and women with the obstructive sleep apnea. In addition to finding a higher severity of brain cell damage in the women with sleep apnea, they also found that the women with this sleep condition had more symptoms of depression and anxiety than the men. The researchers caution that additional studies are needed to fully understand these results.

Why is this important?

Knowing that between 2 to 4 percent of middle-aged women experience obstructive sleep apnea, and that upwards of 90 percent of them will never be diagnosed, there are millions of women who may be at considerable risk from the consequences of impaired breathing while they sleep.

As a result of these concerns, all my patients, regardless of gender, are screened for sleep-related breathing disorders including snoring and obstructive sleep apnea as a matter of course. As the stereotyped sleep apnea patient has always been an overweight male with a large middle section many of my female patients are rather surprised when testing reveals that they have an airway problem when sleeping. With this knowledge in hand my ability to help my patients is greatly enhanced.

Tags Dr. Tanenbaum, women and facial pain, women and sleep apena, women and snoring, women sleep and pain

Case Studies Women & Pain

PCOS, Toothache, and Facial Pain – The Connection

Case Study: Regina, Female, Age 45

In this case study, I discuss the connection between PCOS (Polycystic Ovary Syndrome), Toothache, and Facial Pain.

For over two years Regina had suffered with toothache pains, which persisted despite several root canal procedures and ultimately the extraction of several teeth. Even with these efforts and consultations with a number of dentists and dental specialists, she continued to suffer.

Evaluations by an internist and a neurologist led to further upset as she was told that “there is nothing wrong” and that she should return to her dentist.

Regina did not know where to turn.

Like many other patients that I see, Regina did in fact have tooth pain but the origin was not in her teeth. Her pain was due to a type of neuropathy (damage to the nervous system) that was likely related to a medical condition called PCOS and it’s association with Type 2 Diabetes.

PCOS, the common abbreviation for Polycystic Ovary Syndrome, is a condition in which a woman has an imbalance of female sex hormones. This may lead to menstrual cycle changes, trouble getting pregnant, and other health issues. Most important, however, the disorder shares a key factor with Type 2 Diabetes; namely the imbalance of blood glucose and insulin called Insulin Resistance.

Simply stated, Insulin Resistance is a malfunction of the body’s blood sugar control system (insulin system) is frequent in women with PCOS, who often have elevated blood insulin levels. Researchers believe that these abnormalities may be related to the development of PCOS.

In individuals where diabetes is not well controlled there are often constant high levels of blood sugar. Over time this can cause damage to both blood vessels and nerves throughout the body, including these structures in the face. The nerves can become physically damaged or inflamed causing pain, numbness and weakness.

According to the National Diabetes Information Clearinghouse, when this affects the nerves of the face, it is called a Focal Neuropathy. In fact, Diabetes is the biggest risk factor for neuropathy today!

How Was Regina Helped?

With the knowledge that Regina’s tooth pains were unrelated to her teeth but rather to her underlying PCOS and Diabetes, the focus of her treatment completely changed. All dental efforts (which had previously done nothing but make her pain worse or spread to adjacent teeth) were suspended and she was put into the hands of a group of medical specialists, of which I was one, who focused on her blood glucose levels and her weight gain, which had made her anxious and constantly upset.

I prescribed medications to diminish Regina’s nerve excitability and taught her strategies to ease jaw muscle tension, spasm and pain, which had developed secondary to her tooth pain suffering, which had persisted without answers. An oral appliance was also prescribed while sleeping as her variable blood glucose levels has impacted the quality of her sleep and led to increased levels of night clenching. My interventions helped ease her suffering considerably while her other physicians addressed the blood sugar issues.

Regina Today

For the most part Regina is pain-free except the when her blood glucose levels fluctuate excessively during times of high stress or sleep deprivation. When she does come to my office once in a while complaining of tooth pain and sensitivity in teeth that are structurally sound, I provide reassurance that her pain is real, but just not in the teeth.

This validation and getting Regina back on track with regard to sleep, stress, glucose levels, and weight remain critical to her long-term comfort.

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 Donald Tanenbaum, PCOS, PCOS and facial pain, PCOS and toothache, Polycystic Ovary Syndrome, Type 2 Diabetes and facial pain

Jaw Problems Tinnitus

TMJ TMD and Tinnitus

Post author By Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain
Post date January 7, 2013
No Comments on TMJ TMD and Tinnitus

Case Study: Barry

In past blogs I made reference to the relationship between jaw problems, TMD and the occurrence of Tinnitus (ringing in the ears). Though I don’t believe that the majority of Tinnitus problems relate to the jaw, there are unquestionably a number of specific Tinnitus complaints that occur as a result of muscle problems in the jaw and upper neck.

The relationship exists as a result of the shared nerve pathways between structures in and associated with the ear and those of the jaw and neck. Tense, inflamed, and hyperactive jaw and neck muscles can adversely impact the Eustachian tube, the tympanic membrane, and the malleus bone, all critical ear structures. In the presence of ongoing TMD problems, aggressive clenching, night bruxism, neck tension, and ear symptoms inclusive of tinnitus can therefore surface. The typical Tinnitus patterns that my patients describe are often present on awakening, vary in intensity from day to day and at times are influenced by opening and closing the mouth, chewing, and jaw/head positions.

Recently Barry, 55 years old, came to the office concerned about his escalating Tinnitus. He was referred from his ENT doctor, as are many of my Tinnitus patients. The tenderness of his jaw, neck, and facial muscles, along with his admitted history of teeth clenching indicated muscles that were in crisis and potentially a driving force behind the Tinnitus.

I starting him on treatment including a combination of muscle injections, dry needling techniques, self-muscle massage, and an oral appliance. This has reduce Barry’s Tinnitus by at least 50%. As a result he is no longer using the Xanax on a daily basis, something that he had come to rely on for a number of months! With the optimism that has been created I will likely continue to see Barry for another month or two to reinforce the achieved benefits.

If your Tinnitus search has reached the end of the line, exploration of a possible muscle origin may not be a bad option.

Tags Dr. Tannebuam, Tinnitus, Tinnitus symptoms, Tinnitus Treatment, TMD, Treatment Options for Tinnitus

Woman with severe Migraine Headache holding hands to head

Case Studies Facial Pain Headaches Women & Pain

Headaches & Facial Pain Caused by Emotional Distress

Caring for the Caregiver

Case Study: Joan

Joan was referred to my office due to her daily headaches and facial pain that had continued to get worse despite taking over-the-counter medication on a daily basis and treating herself to a few massage sessions. She had seen her family doctor who had assured her that there was nothing terribly wrong, that the headaches and facial pain were a result of stress, and that she should start exercising more frequently and try to get more sleep.

Joan came to me when she could no longer tolerate the pain. After careful listening and a full examination, it was clear to me that her pain likely had a muscle origin. For Joan, along with countless other people in America and across the globe, her aching facial, jaw, and neck muscles were undoubtedly the result of an ongoing burden that had begun to dominate her life. Joan’s particular burden was that six months prior, her husband had suffered a debilitating stroke and she had become his sole caregiver.

Joan’s world had changed overnight. She was now a full time, worrier, cook, chauffeur, appointment maker, and sole provider of her husband’s physical and emotional needs. Although she took on these responsibilities with love and commitment, it was clear that she had been unprepared for the enormous challenges she faced. As the weeks and months passed, friends and family retreated to their own worlds, and she was left to fill the voids in her husband’s life, knowing that this job came with an unknown future.

As a result of her daily caregiver obligations, Joan’s sleep suffered, her independence all but disappeared and her ability to exercise and stay healthy dwindled to almost nothing. Suddenly her neck ached, headaches emerged, and she found herself gritting her teeth during the day as she tried to maintain patience and deal with the physical effort it required to get her husband showered, dressed, and fed.

Joan’s headaches and facial pain were clearly the result of muscles that were in crisis as a result of a ‘brain under siege’ and muscle fatiguing behaviors (clenching/raised shoulders…) that were prompted by the realization that she was alone and unprepared for an unknown future. The more Joan and I talked, the more I realized that not only was she suffering with pain, but she was lonely and depressed as well.

To help address Joan’s sore and painful jaw, face and neck muscles, I set her up with number of common therapies. These included “physical self regulation techniques” which help patients identify and change the behaviors that they have developed as a result of ongoing life challenges and stressors.

Just becoming aware of when the brows are furrowed, the lips are tense, the shoulders are raised, the jaw muscles are braced, or the teeth are clenched is the first step. I then taught her a number of exercises and breathing techniques that reduce muscle tension and can lead to significant pain relief over time. To complement these self-care efforts, we added medications, muscle injections, oral appliances, and physical therapy.

Though as a result of these efforts Joan felt somewhat better (in spite of the fact that nothing had actually changed in her life), there clearly was more that had to be done to help Joan not fall back into her acute pain state once formal treatment in my office stopped. That is when I introduced her to the Caregivers Survival Network, founded by Adrienne Gruberg.

By joining The Caregiver Survival Network (CSN), she became part of a community of other caregivers eager to interact, share stories and be a source of support. She found a lot of free services geared exclusively to a caregiver’s needs and links to other organizations and websites for caregivers, as well. As a result of taking advantages of the ideas and services shared on the CSN, her feelings of being alone started to dissipate and I feel that Joan is on the mend both physically and emotionally.

If you are in a similar situation, or know someone who is, please direct him or her to http://www.caregiversurvivalnetwork.com/

Tags Caregiver Survival Network, Dr. Tanenbaum, Facial Pain, Headaches, Referred Pain, TMJ Case Study, Women & Pain