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Tag: Dr. Tanenbaum

Categories
Nightguards & Oral Appliances TMJ

Can Mouth Guards Cure TMJ?

Patients will often come to me suffering from symptoms of TMJ and looking for solutions that don’t involve medication or surgery. Symptoms such as facial pain, headaches in the temples, inability to open to the mouth widely, sensitive teeth, or aching and throbbing jaw muscles can be unbearable. There are numerous remedies, for jaw related symptoms that include massages, home exercises, physical therapy, modified diets, and changes in daytime behaviors/postures. At times an oral appliance is an important part of care. These devices are commonly used for the treatment of TMJ problems and can be used in a number of different ways.

What is an oral appliance?

An oral appliance is a device that fits over your teeth with the intent of reducing tooth wear, tooth mobility, tooth sensitivity, muscle pain and soreness and joint pain and instability. At times but not frequently these devices are designed to “align the jaw.”  They can also be used to discourage some of the daytime behaviors many patients don’t realize they’re doing, such as resting their teeth together, clenching their teeth, or biting their nails or cuticles. These appliances can be worn at night and/or during the day

In general the intent of these appliances is based on the problems experienced by patients.

Night guards: Most commonly these appliances are chosen by dentists to address tooth wear, soreness, and mobility that occur as a result of night clenching or grinding of the teeth. Many patients that develop tooth wear do not even realize that they have a problem and often deny grinding their teeth at night. These devices when used in patients without active symptoms (just wear of the teeth) don’t require much adjustment and should be brought by the patient when they return to the dentist for tooth cleaning visits. Typically these devices are custom fit so that they are retentive, not too thick, and modifiable over time. Over the counter devices sold in pharmacies and online are for the most part inadequate, as they are often too thick, poorly retentive, and inadequately cover all of the teeth. As a result these devices can often prompt more clenching, and/or allow tooth shift.

Night appliances to address TMJ problems: Based on the specific jaw problem that is diagnosed (muscle soreness, morning temporal headaches, limited jaw opening in the morning…etc) oral appliances at night are designed to reduce overuse and loading forces to the TM Joints and jaw muscles. The biting surface of the appliance is therefore designed and modified to most efficiently address the problems at hand. Most commonly the biting surfaces are flat but, at times, inclines and ramps are used to confront unstable joint ligaments and displaced discs. When used in patients with active symptoms, these appliances require frequent modifications requiring patient follow-up visits.

Day appliances to address TMJ Problems: At times there is necessity to have a patient wear an appliance during the day. For the most part these appliances are needed when there is extreme instability in a TM joint that has led to clicking, locking, and pain problems. These appliances are not worn all day and virtually never during chewing. At other times, oral appliances worn during the day hours can be used to get in the way of day behaviors and/or remind patients that during the day the jaw should be hanging in a rest position with the teeth apart.

How about oral appliances to re-align the jaw? This concept of jaw re-alignment to address a TMJ problem remains controversial. To date there is no science to support the concept that a poor bite or mal-aligned jaw is responsible for the emergence of TMJ symptoms. At most a bad bite or mal-aligned jaw may be a risk factor but with no more weight than other risk factors such as; female gender, gum chewing, clenching, night grinding, or stress. As long as there remain millions of people with bad bites and asymmetric jaws without symptoms this concept has to be viewed with skepticism. In addition, if an appliance were to be made to re-align the jaw, it would require the patient to bite or rest on it when in the mouth to hold the jaw in the ‘better’ position. This action of course would violate the principle that the jaws should hang at rest during the day. Clearly this option must be chosen with great care.

From an overall perspective the concept of curing a TMJ problem with an oral appliance is probably a bit of a stretch. Their use however is a critical part of TMJ treatment!

These appliances are extremely helpful in reducing the damage from night clenching or grinding. They work by diminishing the forces exerted on the TM joints and by diminishing the amount of contracture that can be generated in the jaw muscles.  Night guards are most effective when custom fit, and adjusted over the course of time. Or you can purchase a generic set at a drug store. Obviously, custom-made night guards that have been conformed to your individual bite-print are more effective in treating TMJ symptoms, but the trade-off is that they’re more expensive.

  • Bite Splints: This form of therapy uses a mouth guard to physically correct the bite, rather than just relieve pain or reduce damage to the teeth. Bite splints are best for you if you have more extreme TMJ symptoms that need correcting in order to have a hope for any long-term relief. The primary difference between a bite splint and a night guard is that bite splints are worn around the clock, 24-7. It’s a full commitment to correcting the misalignment issues that are causing your TMJ.

So, can mouth guards cure your TMJ? The short answer is: Yes. In some cases, particularly with corrective bite splints, you can realign your bite over the course of time and eliminate those painful TMJ symptoms. In other cases, mouth guards can relieve your symptoms to the point where you feel very little pain or discomfort at all.

If you or someone you know is experiencing persistent or acute pain in the face or jaw, we invite you to set up a consultation with one of our Orofacial Pain specialists in the NYC metropolitan area. Our office locations and contact information are below.

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BOTOX® TMJ

BOTOX® For TMJ Pain

Does It Work?

Despite the press advocating BOTOX® for TMJ pain problems, my clinical experience using it over the past 15 years suggests that it represents another supportive treatment at best and may not live up to the hype over the long term.

To start the discussion let’s focus on who is even a candidate for BOTOX®, a chemical agent that can be used to partially reduce muscle contracture. Since most of the commonly seen TMJ problems are orthopedic in nature, patients typically experience muscle and joint pain, limited jaw motion, difficulty chewing, and at times joint clicking, popping and locking.

Those patients whose problem is mainly mechanical – whose jaws click, pop, and lock – are typically not good candidates for BOTOX® injections. BOTOX® for TMJ pain and for people whose jaws have become more prominent due to excessive teeth grinding are more likely to get relief.

If you look at the common muscle problems we encounter with TMJ, the vast majority of patients will get better by:

  • Education, behavior, and diet modification
  • Postural awareness
  • Home exercise
  • Massage
  • Short-term medication

More stubborn problems will get better by adding:

  • Oral appliances
  • A prescription for physical therapy
  • Trigger point injections and/or acupuncture

That leaves only a small percentage of patients who would benefit from using BOTOX® for TMJ pain. It can be very effective in alleviating persistent jaw muscle pain resulting from the accumulation of lactic acid and other irritating substances. What makes people grind their teeth? Teeth grinding for most people is the result of negative emotions (stress), daytime overuse behaviors that fatigue the jaw and/or restless sleep associated with frequent arousals, and at times tooth clenching and grinding. Even when BOTOX® for TMJ pain is used in this select population of patients, success can only be achieved if what caused the problem in the first place is controlled or eliminated. It’s not an easy task!

People who opt for BOTOX® for TMJ pain typically need injections over a period of 9-12 months. If you are among the select few who are candidates, you have reasons to be optimistic. Patients for whom first-line therapies have failed report reduced suffering. Although still clench or grind their teeth they feel less pain as a result.

BOTOX® For TMJ Pain – The Take-Away

BOTOX®does have a place in the management of jaw muscle pain, but it is important to understand that it’s far from the remedy it is made out to be by those trying to sell it as a cure for TMJ problems.

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

If you or someone you know is experiencing persistent or acute pain in the face or jaw, we invite you to set up a consultation with one of our Orofacial Pain specialists in the NYC metropolitan area. Our office locations and contact information are below.

Categories
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:

  1. The patients’ TMJ symptoms often did not respond sufficiently to treatment if the migraine headaches were not under control.
  2. Migraine headaches that are under control by the use of medication can become more problematic when an acute TMJ problem is present.
  3. 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:

  1. 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.
  2. 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.
  3. 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.

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.

can a mattress cause tmj? donald tanenbaum dds
Categories
TMJ

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.

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.

Categories
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

Categories
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.

 

  1. 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.

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.

TMJ, TMJ Arthritis
Categories
TMJ

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.

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.

Categories
TMJ

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

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.

Woman with Facial Pain
Categories
Women & Pain

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

  1. 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.
  2. 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.
  3. 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.

Migraine Headache, Tension Headache
Woman with severe Migraine Headache holding hands to head
Categories
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/

BOTOX for TMJ
Categories
BOTOX® Bruxism TMJ

Case Study: BOTOX® for TMJ

At times we are challenged by patients with chronic pain and soreness in their jaw muscles. Though these patients have received benefits using oral appliances, performing home exercises and massage techniques, using medications and even going for physical therapy, they continue to suffer as a result of daily and continuous aching pain in their face. Though we may not fully understand why their muscles continue to hurt, the use of BOTOX® injections has restored hope for many of these sufferers

Consider the case of Carly a thirty eight year old female with a 20-year history of facial pain and tooth clenching activity during the day and at night. She was first treated while still in high school during the stress of exams and applying to college. Her symptoms however continued through college and into her adulthood often with acute flareups prompting the use of pain medications and muscle relaxants at bedtime. Despite professional treatment and ongoing self care she continues to brace her jaw muscles and clench during the day and wakes up with “my teeth plastered together.” As a result her muscles were paying a price!

With the knowledge that BOTOX® can be used to partially incapacitate muscles, not allowing them to contract forcefully, it’s use in this particular case was clearly indicated. Though not FDA approved for this specific purpose at this time, its use with patients has produced encouraging results. By preventing forceful muscle contraction over three to four months after injection, the sore and tender jaw muscles benefit from increased blood flow bringing oxygen and nutrients essential to healing. As a result Carly’s pain symptoms eased considerably and her days were  no longer consumed by constant massage and mouth opening movements to “loosen my face.”

Most importantly, Carly regained optimism that her problem could be helped though she would likely require additional injections to undue years of muscle compromise. As BOTOX® is not a cure, Carly understood that any efforts she made to keep her muscles out of trouble would go a long way towards maximizing the benefit of the BOTOX®. As a result of this understanding she continues to use her oral appliance at night and practices relaxation breathing techniques frequently throughout the day.

The end result is that Carly is feeling better and realizes that her life does not have to be filled with pain and suffering.

BOTOX® for teeth grinding is in the news! I was recently interviewed on ABC’s Good Morning America on the topic, Can BOTOX® be used to treat teeth grinding?  Click the link to watch the segment.

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TMJ

Can I Develop TMJ after Suffering Whiplash in a Car Accident?

Very often I get patients who come to me complaining of limited or painful jaw movement and are looking to pinpoint why. After tests, X-rays, and long discussions with the patient, they might casually let it slip that they were in a car accident recently and banged their head on the dashboard. The light bulb didn’t go off in their heads. They didn’t see a connection. But is there one? Can a patient develop painful or reduced jaw movement from a collision, even if they hadn’t made direct contact with their jaw?

According to a recent Canadian study, released in the Journal of American Dental Association (JADA), a population-based survey has revealed a strong connection between reduced or painful jaw movement and whiplash-associated disorders (WADs).

The questionnaire sent out to Canadians who filed personal injury claims over an 18-month period, and the responses determined:

  • A greater number of victims with WADs reported limited or painful jaw movement than those without WADs.
  • Those who experienced limited or painful jaw movement were greater among women.
  • Those who experience limited or painful jaw movement were greater among younger claimants.

The JADA study threw out respondents who had suffered from limited or painful jaw movement prior to the motor vehicle accident. It also excluded respondents who were hospitalized for more than two days, or who were pedestrians, bicyclists, or motorcyclists involved in the accident.

The message? If you’re involved in a motor vehicle accident and suffer from some kind of whiplash-related pain or injury, you might also be susceptible to symptoms similar to TMJ. In our consultations, we always ask patients details that may seem insignificant, but are backed by research. Some of these questions might pertain to your psychological state, work or life stresses, and yes; whether you’ve been in a motor vehicle accident recently.

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.

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Nightguards & Oral Appliances TMJ

Can Mouth Guards Cure TMJ?

Patients will often come to me suffering from symptoms of TMJ and looking for solutions that don’t involve medication or surgery. Symptoms such as facial pain, headaches in the temples, inability to open to the mouth widely, sensitive teeth, or aching and throbbing jaw muscles can be unbearable. There are numerous remedies, for jaw related symptoms that include massages, home exercises, physical therapy, modified diets, and changes in daytime behaviors/postures. At times an oral appliance is an important part of care. These devices are commonly used for the treatment of TMJ problems and can be used in a number of different ways.

What is an oral appliance?

An oral appliance is a device that fits over your teeth with the intent of reducing tooth wear, tooth mobility, tooth sensitivity, muscle pain and soreness and joint pain and instability. At times but not frequently these devices are designed to “align the jaw.”  They can also be used to discourage some of the daytime behaviors many patients don’t realize they’re doing, such as resting their teeth together, clenching their teeth, or biting their nails or cuticles. These appliances can be worn at night and/or during the day

In general the intent of these appliances is based on the problems experienced by patients.

Night guards: Most commonly these appliances are chosen by dentists to address tooth wear, soreness, and mobility that occur as a result of night clenching or grinding of the teeth. Many patients that develop tooth wear do not even realize that they have a problem and often deny grinding their teeth at night. These devices when used in patients without active symptoms (just wear of the teeth) don’t require much adjustment and should be brought by the patient when they return to the dentist for tooth cleaning visits. Typically these devices are custom fit so that they are retentive, not too thick, and modifiable over time. Over the counter devices sold in pharmacies and online are for the most part inadequate, as they are often too thick, poorly retentive, and inadequately cover all of the teeth. As a result these devices can often prompt more clenching, and/or allow tooth shift.

Night appliances to address TMJ problems: Based on the specific jaw problem that is diagnosed (muscle soreness, morning temporal headaches, limited jaw opening in the morning…etc) oral appliances at night are designed to reduce overuse and loading forces to the TM Joints and jaw muscles. The biting surface of the appliance is therefore designed and modified to most efficiently address the problems at hand. Most commonly the biting surfaces are flat but, at times, inclines and ramps are used to confront unstable joint ligaments and displaced discs. When used in patients with active symptoms, these appliances require frequent modifications requiring patient follow-up visits.

Day appliances to address TMJ Problems: At times there is necessity to have a patient wear an appliance during the day. For the most part these appliances are needed when there is extreme instability in a TM joint that has led to clicking, locking, and pain problems. These appliances are not worn all day and virtually never during chewing. At other times, oral appliances worn during the day hours can be used to get in the way of day behaviors and/or remind patients that during the day the jaw should be hanging in a rest position with the teeth apart.

How about oral appliances to re-align the jaw? This concept of jaw re-alignment to address a TMJ problem remains controversial. To date there is no science to support the concept that a poor bite or mal-aligned jaw is responsible for the emergence of TMJ symptoms. At most a bad bite or mal-aligned jaw may be a risk factor but with no more weight than other risk factors such as; female gender, gum chewing, clenching, night grinding, or stress. As long as there remain millions of people with bad bites and asymmetric jaws without symptoms this concept has to be viewed with skepticism. In addition, if an appliance were to be made to re-align the jaw, it would require the patient to bite or rest on it when in the mouth to hold the jaw in the ‘better’ position. This action of course would violate the principle that the jaws should hang at rest during the day. Clearly this option must be chosen with great care.

From an overall perspective the concept of curing a TMJ problem with an oral appliance is probably a bit of a stretch. Their use however is a critical part of TMJ treatment!

These appliances are extremely helpful in reducing the damage from night clenching or grinding. They work by diminishing the forces exerted on the TM joints and by diminishing the amount of contracture that can be generated in the jaw muscles.  Night guards are most effective when custom fit, and adjusted over the course of time. Or you can purchase a generic set at a drug store. Obviously, custom-made night guards that have been conformed to your individual bite-print are more effective in treating TMJ symptoms, but the trade-off is that they’re more expensive.

  • Bite Splints: This form of therapy uses a mouth guard to physically correct the bite, rather than just relieve pain or reduce damage to the teeth. Bite splints are best for you if you have more extreme TMJ symptoms that need correcting in order to have a hope for any long-term relief. The primary difference between a bite splint and a night guard is that bite splints are worn around the clock, 24-7. It’s a full commitment to correcting the misalignment issues that are causing your TMJ.

So, can mouth guards cure your TMJ? The short answer is: Yes. In some cases, particularly with corrective bite splints, you can realign your bite over the course of time and eliminate those painful TMJ symptoms. In other cases, mouth guards can relieve your symptoms to the point where you feel very little pain or discomfort at all. Stop in to our office and see Dr. Donald T. Tanenbaum for a consultation, fitting, and to end your suffering today.

Learn more about Dr. Tanenbaum’s unique qualifications and expertise, 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

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Jaw Problems

Case Study: Jaw Locking All Day With Tremendous Pain

A patient came to my office four months ago complaining that she woke up every morning with her jaw in a locked position. It was so bad that her morning routine starting by standing in the shower bathing her jaw with hot water until her jaw popped open. Then she could start her day.

Her problem however didn’t stop with this unlocking event. Her jaw would click and then lock numerous times during the day and she had no choice but to manually force it open. Each unlocking effort was accompanied with pain that intensified as the day passed. She also had to support her jaw with her hand in order to chew and she worried that her lockjaw problem would interfere with her ability to talk and fulfill her professional responsibilities as a teacher.

Remarkably her problem seemingly just started one morning. There was no history of trauma, no recent dental visits, and no underlying medical problems that could be responsible for the onset of the jaw clicking and locking. It just started one day and then took over her life.

Treating Locked Jaw

Just like a knee problem, the nature of my patient’s problem was related to compromised cartilage and unstable ligaments in the jaw joint. These problems are “orthopedic” in nature and require treatment that is similar to those used for injured knees and or ankles The treatment planned was designed to stop further injury, stabilize the joint and give the body a chance to heal.

The treatment for this patient had three parts:

• An oral appliance (orthotic) designed to prevent joint locking, relax the jaw muscles, and reduce joint inflammation.

• Exercises and physical therapy to help improve and restore proper jaw mechanics, muscle coordination, and stability of the ligaments

• Daytime behavior modification strategies to ease postural strains on the jaw and neck muscles and jaw joints

The Outcome

After four months of treatment, my patient has responded well with no morning jaw locking, no pain, better eating capacity and optimism that this problem was not going to compromise her ability to hold a teaching job. Though not ‘cured’, her orthopedic problem had stabilized and she was in her own words “better” and not in need of ongoing care in my office. Maintaining a home program would likely be all that she needed to stay comfortable and avoid future problematic situations.

This ability to help patients “get their lives back on track” never gets old and continues to be a source of my daily efforts when patients come seeking advice, guidance and care.

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.

creams for face and jaw pain tanenbaum
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Facial Pain Jaw Problems

Creams for Face Pain and Jaw Pain

Are there any topical creams that I can use to decrease my face and jaw pain?

A patient recently came to the office with a cream rub that she had been rubbing into her jaw and facial muscles. Although the cream smelled terrible, she thought it was helping. The question is then, do these creams work?

According to research performed on over-the-counter TOPICAL PAIN RELIEF products, creams designed to relieve muscle pain are generally safe, can provide short-term benefit but do not provide long-term relief. The reason these products have only limited usefulness is likely related to the fact that they do not penetrate deeply enough into the muscles.

The most common types of creams contain these basic ingredients:

• Menthol (a counter-irritant)

• Salicylates (aspirin)

• Capsaicin (a pain reliever found in hot pepper)

Menthol: Common products such as Flexall 454, Icy Hot, and Biofreeze contain menthol, wintergreen, or eucalyptus oil that makes the skin feel hot or cold and provides a distraction from the pain. Patients who come into my office tell me these products either provide temporary relief, or do not help at all. Generally these counter-irritant products are rubbed into the jaw muscles 3-4 times a day. When using these products on the face, care must be exercised to avoid contact with the eyes or lips.

Salicylates: The common ingredient found in aspirin, Salicylates are most effective when taken orally. Research indicates that the effectiveness of salicylates decreases to a significant degree when used as a topical cream. Bengay, Aspercreme, and Sportscreme contain this ingredient and are commonly used by my patients.

Capsaicin: A compound found in chili peppers, capsaicin causes a hot, burning sensation when applied to the skin. This topical rub actually depletes a chemical in nerve cells responsible for sending pain signals to the brain. Common products that use this compound are Capzasin, and Zostrix. These products, however, can be risky when applied to the face, as they can cause intense burning and irritation should they get in the eyes, or on the lips.

As expected, some patients swear by these products despite what the research reports. In my opinion there is likely some placebo effect taking place to account for at least 1/3 of the pain relief experienced by patients using these rubs. Additionally, the physical act of rubbing and massaging the facial muscles when applying these products can also provide relief by increasing blood circulation to the area.

In summary, self-help actions can go a long way toward reducing face and jaw pain. Despite poor scientific evidence, these creams can provide some degree of benefit and are recommended as part of an overall self care plan.

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

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Ear Pain TMJ

Causes of Ear Pain

Many patients come into my practice complaining of ear pain, when other physicians have found nothing wrong with their ears. The ear pain complaints heard most often are these:

• My ear feels full

• My ear feels stuffy

• I feel like something is dripping in my ear

• I feel pressure in my ear

• There is ringing in my ears

• I hear a hissing sound

• I hear a buzzing sound

More often than not, patients complaining of ear pain will see their general practitioner, internist, or an ENT (ear, nose, and throat) doctor. But if there is no evidence of an infection, and there is no fluid or inflammation in the ear (or other problems with ear function) the ear pain could be happening because of a malfunction in the muscles of the face, jaw, or TMJ (Temporomandibular Joint).

Because of the way our ears, face, and jaw develop inside the womb, the malfunction of one area can cause pain in the other. To figure out if your persistent ear pain is related to a muscular issue, pay close attention if the ear pain you’re experiencing:

• Increases when you eat

• Increases when you talk

• Increases when you open or close your mouth

• Is constant and intense

If these are the dominating symptoms, chances are the ear pain will not go away unless doctors can address the muscle and joints in the face that are causing it to begin with. Treatment that focuses specifically on the ear will not work if the ear pain is just a symptom of a different problem.

Dr. Donald Tanenbaum has been practicing in New York City and Long Island for over 20 years. He is uniquely qualified to diagnose and treat bruxism, TMJ and TMD problems, Sleep Apnea, facial pain, muscle pain disorders, nerve pain disorders, tension headaches, and snoring. Learn more about Dr. Tanenbaum here.

6 foods that can break your jaw donald tanenbaum
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Jaw Problems TMJ Women & Pain

Estrogen, Pain, and TMJ

Why is TMJ Disorder So Prevalent Among Women?

Not only is there a clear dominance of TMJ in women, but also the severity of the problem is often at a level virtually never seen in men. This scenario is frequently seen in the case of teenage girls, suggesting that the problems we are confronted with could be hormonal. Some research has unveiled a link between TMJ and estrogen, which could shed light on the dominance of TMJ in women.

Take the example of Mary, a 17-year-old female who came to my practice. Mary’s problems started when she was 12 years old with the onset of non-painful TM joint noises that did not interfere with eating or jaw function. Over time, pain emerged and her bite began to change, altering her profile and appearance. Before long her pain was so debilitating and her bite so altered, that there was no choice but to seek surgical treatment. Both TM joints had “dissolved away” and her jaw profile and bite had to be reestablished.

How could this happen with no history of trauma and no apparent underlying medical disease? The role of hormones, estrogen in particular, has been identified. Research has shown that Estrogen:

  • Impacts the body’s natural pain fighters (endorphins)
  • Increases inflammation in the Temporomandibular Joints
  • Compromises the strength and adaptive ability of all ligaments

These factors, coupled with lower endurance capacity in female jaw muscles, are all that is likely needed for difficult problems to arise. Additionally, research suggests there may be specific genetic predispositions that lead to unprovoked TMJ in women.

Though the treatment that Mary had received has restored function, jaw stability, and reduced her pain, there is still much to learn about gender specific jaw problems.

Dr. Donald Tanenbaum has been practicing in New York City and Long Island for over 20 years. He is uniquely qualified to diagnose and treat bruxism, TMJ and TMD problems, Sleep Apnea, facial pain, muscle pain disorders, nerve pain disorders, tension headaches, and snoring. Learn more about Dr. Tanenbaum here.

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TMJ

What is a TMJ Doctor?

Because many common symptoms of TMJ problems often can be the result of other medical conditions, those who represent themselves as “TMJ Doctors” (or “TMJ Specialists”) must be able to not only recognize common TMJ problems, but also must be adequately trained and have sufficient past experience to enable them to accurately diagnose the vast number of other problems that can produce these common TMJ symptoms:

  • Facial and jaw pain
  • Diminished jaw motion
  • Facial and temporal headaches
  • Jaw muscle spasm and tension

Whether the symptoms you are concerned about are due to a facial migraine, a nerve pain problem, disease in a salivary gland or sinus, a thyroid condition, brain tumor, or strained Temporomandibular joints and jaw muscles, the “TMJ Doctor” you see must be skilled in making what is called a “differential diagnosis.” From a patient’s perspective, that means you need to know with a degree of medical certainty that your ‘TMJ’ problem is truly due to a local muscle and joint problem, and not due, instead, to some underlying medical disease process.

In today’s world, particularly in communities with access to major medical centers, hospitals or universities, you should expect your “TMJ Doctor” to have an academic appointment or faculty position at one of those institutions. He or she should also be involved with teaching, lecturing, and/or publishing, as these positions and efforts are a clear indication that there is a commitment to learning and advancement of knowledge.

Most important, don’t be fooled by the ‘TMJ Doctor” who has high-tech computerized  equipment that (allegedly) determines whether your bite is bad or if your jaw is in the wrong position. Though imaging technology (CT scans and MRI’s) is often important in making an accurate diagnosis, the vast majority of all TMJ problems can be diagnosed accurately with a careful history and examination. The adage, “The diagnosis is in the history if the doctor chooses to listen” holds true in just about all these situations.

Lastly, because most TMJ problems respond to treatment over time and with supportive measures to heal the injured TM joints and muscles, treatment most commonly should not require changes to your teeth or bite. If your “TMJ Doctor” recommends ongoing bite adjustments (grinding the tooth surfaces with a drill), crowns to fix your bite, or extensive orthodontics as the primary focus of care, these should be looked at suspiciously, and you should definitely seek a second opinion.