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Woodbury | Hauppauge


Strategies To Solve Difficult TMD Problems Case Study – Part Two

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

Date: February 27, 2023

Why Didn’t Mary Get Better?

In Part One, we introduced “Mary”, a 52-year-old woman who presented to our office complaining of daily pain in her jaws that would vary in intensity from day to day but was always present and impactful to her life. She had been a patient in our practice ten years prior for a short period of time due to jaw tension and pain and periods of limited jaw opening. Our treatment strategy at the time included an oral appliance to diminish the impact of her sleep bruxism, efforts to help her control her daytime jaw overuse behaviors, and the healing effects of time – all of which seemed to be sufficient to address her symptoms.

However, when she returned to our office, she stated that the strategies, including a new oral appliance made by her dentist, had fallen short and that she had been “suffering from miserable jaw pain” for eleven months. In my previous newsletter, I invited you to consider the three types of pain that are common in the patients that are referred to our office:

  1. Somatic Pain
  2. Neuropathic Pain
  3. Neuroplastic (or Interpretive) Pain

Structuring A Plan Of Treatment For Difficult TMD Problems

In an effort to structure a plan of treatment that would ultimately bring her relief, we needed to better understand what had prompted the emergence of her more stubborn pain problems. The question was, “If Mary’s pain was not exclusively of somatic tissue origin – as it had been in the past – what component of her suffering was due to neuropathic influences or related to neuroplastic changes in her brain’s interpretation of pain?”

As we delved into Mary’s medical history, looking for clues, it turned out that she had bunion surgery two-and-a-half years before returning to our practice. The surgical outcome, unfortunately, was not as anticipated. Not only did her foot pain linger and frequently interrupt her sleep, but her walking gait had changed, as well. She had declined prescriptions offered by her surgeon to ease her pain because she, like many others, does not like the idea of becoming dependent.

Changes In Her World

Mary’s world changed in another way, too. During this time, she and her husband had opened their home to his father, who was suffering from dementia. As his dementia progressed, they became his full-time caretakers and were facing the difficult decision of keeping him in their home or sending him to a nearby facility, a move that would have an impact on their limited financial resources.

Along with the massive changes in her life, the impact of Mary’s pain had changed, too. Neuropathic pain in her foot had changed her walking gait and her breathing, which in turn increased the frequency and intensity of her daytime tooth contact and jaw muscle bracing.

This jaw muscle overuse led to the accumulation of lactic acid (a by-product of overworked muscles), setting the stage for the emergence of excessive nerve firing in her jaw muscles. Although very different in origin than the surgically-mediated neuropathic pain in her foot, Mary’s jaw pain was no longer a simple fix.

And, there was yet another layer to Mary’s pain. Her nightly sleep disruptions driven by foot pain, spiraling anxiety associated with the limitations of what she could do as a result of it, and loss of control of her daily schedule due to her father-in-law’s needs – all happening all at once – likely upset her neuroimmune system prompting the development of neuroplastic pain.

Mary’s Overwhelmed Brain

In essence, Mary’s brain was so overwhelmed it was no longer in a position to be able to accurately interpret or respond to incoming nerve transmissions. She was in pain and truly suffering.

Mary had come to our practice to address her jaw pain, but we realized we could not get her better on our own. So, this is what we did:

  1. Pain Education: We helped Mary understand the three types of pain and the role of the neuroimmune system in driving persistent pain. At the same time, we taught her what we call PSR or Physical Self-Regulation strategies. PSR strategies are designed to help pain patients pay attention to and learn to change postures and behaviors that reinforce their pain during the day.
  2. Collaboration With Her Surgeon: We collaborated with Mary’s foot surgeon and together helped her realize that non-narcotic medications could calm the irritable nerve tissues in her foot and jaw – and was in her best interest. We made sure she understood that it would take some time for the proper medication to be chosen and the dosage to be determined.
  3. BOTOX® Injections: In order to provide her some immediate relief from jaw pain, we injected BOTOX® with the goal of reducing the contraction strength of the muscles while at the same time reducing the excitability of the nerve tissue. Note: Because Mary had a naturally slim facial profile, we advised her that while it would likely be necessary to have a second round of Botox to ease her pain, ongoing injections would be avoided.
  4. Physical Therapy: To address Mary’s back and neck tension that had developed due to her foot pain, altered gait, and anxiety, we referred her to a physical therapist near her home.
  5. Sleep Medication & Counseling: A referral was made to a psychiatric nurse practitioner who prescribed medication for sleep and, more importantly, assisted Mary and her husband in making the necessary decision to place her father-in-law in a suitable facility outside their home.


As a result of these ongoing efforts, Mary’s jaw pain has eased considerably, and her foot pain, though still present, is no longer limiting her daily capabilities or compromising her sleep.

Mary came to our practice to address her jaw pain. But the key to getting her better was taking the time to understand her world – medically and socially – and implementing treatment strategies that she was capable of pursuing.

(read Part One here)

Your thoughts are welcome…



Practice News

We are pleased to announce the addition of our newest team member, Aimee Werfel, DDS. Dr. Werfel practices in our Manhattan office, providing care for our patients with Orofacial Pain and jaw-related disorders. She’s spearheading a wellness program to assist patients who suffer from persistent pain and poor-quality sleep, as well. This summer, we will welcome two more team members. Stay tuned!


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