When it comes to recommending surgery to one of my patients, it is always a difficult decision. The problem with telling a patient they need to do surgery is that by the time they come to see me, quite often the discs are in really bad shape and the pain has been there for quite some time. What this means is that the discs are usually damaged and quite often the condyles (the heads of the jaw bones) are also somewhat damaged as well. It’s kind of like saying your car needs engine repair and it already has 150,000 miles on it, so it’s a bit worn out. Not the best analogy but that’s what I have for you.
Let’s get a little more into what we have to consider. The TM joint is a three-dimensional structure, which is very unlike other joints in the body, like a finger or a knee, which just bend in one direction. So with the TM joint, you have to consider all angles- literally. When you have surgery performed to put that little disc back on top of the condyle, you must consider where the discs have been displaced and is it really possible to get them back into proper position. Think of a baseball – the interior part of the baseball is the condyle and the disc is the leather covering on top of the substructure. Can the surgeon really get the covering back on top of the baseball? If the disc is really damaged, sometimes it has to be removed, yet there is no way to get the whole thing removed- it is simply too close to the cerebral artery so the whole thing cannot be safely removed. So this is the other consideration: Can my surgeon get enough of the damaged disc either put back in place to give the patient relief, or if removal is necessary can he get enough removed to take the pressure off the nerves and blood vessels to get the relief needed? Doing this kind of surgery is not like putting a new muffler on your car – it’s not a definitive thing that is totally predictable.
When you are considering TMJ surgery, you must be aware that the surgeon is cutting through tissue, through blood vessels, and near nerves. All of this usually goes just fine and with a success rate of around 94% (yes, we have a case study on this) there is little to worry about, however, it’s always those 6% of the cases that I have concern with. The interesting thing with what I do is that as a dentist, my patients expect me to get the job done, and get it right the first time. This surgery is actually a medical procedure – it’s done at the hospital by a board-certified surgeon- and due to it’s complexity may have complications. And again, although very safe, the patient has to be aware that post-surgery there might still be some degree of discomfort here and there. There might also be some degree of numbness on the side of the head due to the incisions and scar tissue that forms. And for some people, it just may not work at all. This is because there was just too much damage to begin with.
This is why I wrote today’s blog: I want my patients to understand that surgery is never definitive, final, or the end of all treatment! After surgery you are going to go out into the real world and keep on using those joints. They can and possibly will, break down again which means that even though you have had the surgery and you feel great, you still need to come back every year post treatment to check the joints and make sure they are doing OK. So if the discussion of surgery is on the table, please read all of this carefully and ask any questions before you consider the procedure.
Recently, a young woman in her 20’s was diagnosed with a fairly severe TMJ disc problem. Basically the discs were already degenerating and eroding away and no one knew why this had happened. I suspect it was birth trauma, but no one knows for sure. I treated her conservatively for many months, trying to get the discs to recapture into position, but it was to no avail. The new MRI clearly showed that I met her too late in the game and surgery would be the best option. When I discussed all this with the patient and her father, it was obvious they were not thrilled. Heck, who wants to hear that surgery is the only option? The father was very upset that insurance would not pay 100% of the hospital costs, nor would they pay for the surgeon’s fee. I figured I would never see them again after that visit since they were quite noticeably upset, disappointed, and distraught. They knew from day one how much damage was there, but they expected me to work a miracle and fix everything non surgically. My consent forms are quite clear- surgery all depends on if I meet the patient soon enough before the damage becomes extreme. In this case, it was a pretty bad situation.
So I wished them well that day, thinking they would find some other doctor who would tell them what they wanted to hear: You do not need surgery. Well, as it turns out, the father diligently went to his insurance company and got the names of 20 TMD specialists who could do the surgery, and it would be covered at 100%! Yippee! And being the very diligent father, he took his little girl to ALL of these so-called participating providers who knew what they were doing. Well folks, as it turned out, 10 of the doctors on the ‘list’ had never heard of TMJ surgery (yet according to the insurance company they did). Another 8 had no idea how to do the procedure (even though they were on the provider list as well). And the other 2 had perhaps done a couple of these procedures. The father already knew that my surgeon, Dr. Gregory, had done thousands of joint surgeries over the years with a success rate of around 94%. Needless to say he was appalled that there was so little understanding about what needed to be done.
A few weeks later I was shocked to see the young woman on my schedule. She and her father had come back to discuss having the surgery with Dr. Gregory. The father basically told me he was disgusted with what the insurance company tried to do- they tried to save money by having an inexperienced surgeon do surgery on his daughter. To me, this borders on criminal intent. The insurance carrier wanted someone to do this surgery when he/she had no right to do this. Did they figure that it might work out anyway? I was shocked when the father told me how he went to all those doctors only to learn that taking the short cut might damage his daughter’s future.
Ultimately, our young woman had Dr. Gregory do the surgery and her pain was literally gone that same day. I have seen her for multiple follow ups since then, I took out her sutures, and she said she feels much better now. Although I am very much against surgery for my patients, I must admit that 1 or 2 out of the 100 patients per week really do need it. This week alone I met several new patients that were fairly warned that surgery might be needed, but I will do all that I can to avoid it and manage their cases non surgically. I am always sorry to report that the insurance company is not really there to help you get better. They exist solely to make profit for their shareholders and are simply a for-profit entity. There is no ethics involved when talking about insurance companies so I do not understand why patients look to their insurance for ‘proper’ care and consideration. The father and daughter learned a lesson from all of this, but so did I! Now when discussing surgery, I explain that you are very welcome to go get other opinions- I wholeheartedly recommend it! However, please be aware that due to the lack of knowledge in this area, you will most likely find doctors who will not recommend the surgery and that is the way it is.
Today is Wednesday, November 21, 2018. The time is 06:30 (that’s like 6:30 am in the morning) and I have been in the office since about 4:45 am working on my MRI’s, reports, letters, and emails. As I sit here, I am thinking how incredibly lucky I am to have a wonderful family -both at home and here at the office. My kids are growing up, three are in college, and the youngest goes to high school this coming year. They are doing great. At the office, my family consists of five wonderful women (and also my beautiful wife, Barb) who do most everything needed to run this office, along with our new guy, Brendon. My team is not my staff- my team is like family to me. We have our squabbles, we have verbal exchanges that leave some of us quite exasperated, but at the end of the day I think we all know that we made a very positive difference in so many peoples’ lives.
Just a few days ago I saw a woman who we have only worked with four months. The day I met her, she was in such pain that she cried constantly, could barely open her mouth, and the family had mostly given up on her and was ready to institutionalize her for the rest of her life. This is pretty sad for a 50 year old woman. When I saw her the other day, she came in with her hair done up nicely, a little bit of make up on, and she could smile easily. I give thanks to Dr. Darick Nordstrom for all the training in the ALF appliance that he has provided over the years. The ALF appliance gave this woman her life back. She now has a chance at a real future and a real life. Thank you Darick.
I would like to thank Dr. Brendan Stack as well. He was my mentor, my tutor, my predecessor, as well as a pain in the butt! He and I would frequently get upset with each other if we did not agree if the appliance should be 5.5mm high, or 5.4mm high. That’s right folks, we were quite anal about things back then. I miss him now that he has retired from the practice, and yet I am still so thankful for all that he pushed me to do. He told me on day one to become the best ALF doctor in the world and I have striven to meet that challenge. I spoke to him yesterday just to chit chat and he sounded great. I even invited him to come back to the practice- he just laughed and said those days are over.
At the office I must give special thanks to Venus- MOM (My Office Manager) who keeps me in check and on point at all times- she is simply awesome. To Meghan, very special thanks for handling the schedule and the marketing programs- I think she has the toughest job trying to juggle patient schedules for the times people want. I thank Karina who has been with me since the days of Dr. Stack- she is perhaps the best assistant I have ever had. She takes the time with the patients and shows how much she cares at every visit. Then there is Jessica – a truly excellent assistant who is extremely dedicated to the job and supports all that I do, even though we have our differences, we still care about each other and our team. My third assistant, Ruth, just seems to adore being with our patients- she has become a truly valued member of our team. And finally, we call him the new guy, Brendon has taken the art of dealing with insurance companies to a new level-he helps our patients get the coverage they deserve and advocates for them at all times. I am very thankful for my team- they show what excellence is truly all about.
And to bring this all together – my wife, Barbara, not only takes care of the house, the children, the cars, and the dog but she comes to the office every week to make sure all is running well here as well. This takes pretty much all the stress off of me so that I can do what I do. I cannot tell you what that means, dear readers, to be able to come to the office each morning and just focus on the patients and not have to even think about the rigors of daily life. Heck, I don’t even gas up the cars any more- Barb handles all that too!
So on this day of November 21, 2018, I thank God for all that I have and all that I have become on the day before Thanksgiving. I truly have so much to be thankful for. I wish you all a most excellent holiday with friends and family!
Today’s blog is all about good cranial rhythm and how things are supposed to flow inside your skull. So as you can well imagine, your skull is just packed full of all sorts of things like the brain, obviously, but there are also many veins, arteries, nerves, and even lymphatic drains. Every day of the week I meet new patients who have severely distorted cranial bones- and many times I do not even need an x-ray to confirm this, I can tell just by looking at them. When the ears and eyes are not level, this is a giveaway that internally the cranial bones are quite distorted. Well, dear reader, just imagine a car that has been in an accident – because the frame of the car is now bent, the brake lines are crimped and electrical wires are now bent so they do not function very well. The same thing is happening inside your head- if the cranial bones are bent, fluids cannot flow very well. Simple as that, ‘nuff said,’ right?
Not exactly done yet, are we? Now that we can see the cranial bones and how they are not level, we need to delve more into the real problem. From my own observations, most of the time the bones inside the skull are bent or crooked because of trauma from birth. Let’s face it, birth is a rough process – whether or not you are delivered normally or by C section. Here you are, this little tiny body inside the womb of your mother, all crunched up and upside down, and then you travel through the tight opening of the birth canal or get ripped out via C section. This makes that tiny body go all crooked and bent, and much of this damage stays with us all our lives. And then one day, as you get a little older, you notice the jaws popping and clicking and wonder what that is all about.
Let’s fast forward a few years. The joints have been popping/clicking and once in a blue moon the jaw just locks up tight and won’t open or it won’t close or a searing sensation of pain shoots through the entire left side of your jaw. You tell the dentist and he or she makes an upper nightguard to help with the problem. Unfortunately, the nightguard is one of those rubbery things that just make you grind your teeth even more, but fortunately there is less pressure on the jaw joints so you tolerate it.
The real problem with such a device is that it really slows down cranial motion. What this means is that inside your skull the cerebrospinal fluid needs to pump and flow all over the brain and spinal cord. When you wear the upper device, this locks up the cranial bones and things do not flow as well. This also applies to the lymphatic system. You have all heard of lymph nodes and how they drain the crud out of your head. Well, now imagine that the cranial bones are locked up tight from the upper device and things are no longer flowing well. According to University of Virginia hospital center, the lack of lymphatic drainage in the brain can lead to ADD, OCD, and autoimmune disorders. So why in the world would anyone wear an upper nightguard? Sure, it might stop damage to the teeth but I think I would be more concerned about damage to my brain and the rest of my body!
As many of my very dear readers already know, you simply should not lock up the cranial bones because the body will most likely pay a price for this later on. It’s kind of like saying your car’s engine needs lubrication or else the various parts will seize up. It’s the same with your bones inside your skull- they need to keep moving in order to stay healthy. It is a simple concept, but not well understood. So keep those bones moving and keep up your health!
This is a true story folks, and it all happened within the course of only two weeks. For one of our dear patients I called her neurologist to discuss her case- I tried to explain the displaced discs in the jaw joints and the distortions to the cranial bones and how this can certainly affect the entire body. Heck, I even offered to bring x-rays to the doctor to show him my cases and how I am able to make the cranial bones go level over time. But, alas, he wanted nothing to do with me. He told me he was going to ‘treat’ the patient with Botox. I then told him that this was not really a ‘treatment’- it was more like ‘masking’ the pain without getting down to the real cause of the problem. Total strike out with this guy. He told me he did not believe in what I was doing and had never heard of such a thing -slipped discs- and that was that!
Literally that same day I spoke to another neurosurgeon about another patient. Once again, I tried to explain that the slipped discs in the jaw joints were wreaking havoc with her entire body. The neuro calmly told me that although she did not understand any of this, what I was doing was simply using a ‘sensory trick’ as she called it, in order change the proprioception (how things were sensed) so the body did not feel the same way. In my mind I was losing it! In just two days I was shot down by two neuros! This one thought my appliance therapy was just a magic trick into getting the patient’s body to think things were different. She had no understanding that the displaced discs would cause all these problems with head and neck pain. There was nothing left to say when she explained the patient would be ‘treated’ with Botox. End of that conversation.
Now, it was a week or so later when this new patient showed up and was referred to me by, of all doctors, a psychiatrist- go figure! I called the doctor and asked him what I could do to help and he literally told me that he had sent this guy to many different doctors and no one could figure out the pain. The patient had been told he was crazy and it was all in his head (well, that part was sort of right). When I met the patient, it was really obvious what was going on- his left ear/eye/eyebrow were all very high relative to his right side. My dear readers already know what this means- the cranial bones are distorted! This was a true structural problem. I called the psychiatrist back and told him all this- he thanked me profusely because he really thought the problem was structural, and I told him how very right he was. Of course, there is more to the case and we need an MRI to diagnose the whole picture, but I was really impressed with this doctor- he opened his eyes to something that was not taught in medical school.
So as I close this blog an old song by the artist ‘Meatloaf’ comes to mind: “Baby, two out of three ain’t bad” – well, in my case it’s more like one out of three ain’t bad, but the way I look at it is that I can now help another one who would have been put on drugs for the rest of his life. I can work with one more doctor who has opened their eyes just a little bit more in the effort to take better care of their patient. So in this very poorly understood world of TMJ disorders, maybe, just maybe, the tide is turning and a few doctors out there are listening.
The month of September is Dystonia Awareness month. So little seems to really be known about dystonia and it seems most practitioners have difficulty in diagnosing and treating this awful and debilitating disease. Almost every day of the week I see a patient or two with dystonia and it pains me to meet them and see how much they have suffered and for so many years. As it turns out, in many of these cases there is likely an underlying TMJ problem, i.e. the articular discs in the TMJ’s are out of place.
In just about every case of dystonia that I see, the discs are out of place and cause damage to the surrounding tissue, nerves, blood vessels, etc. If I told you that you had a slipped disc in your lower back, it would make total sense in explaining the leg and back pain that you are experiencing. Well, if the discs in the jaw joints are out of place, this can cause serious health problems. When we alleviate the pressure on the articular discs, headaches go away. Back pain subsides. Neck pain abates, and the neck can gradually go back into proper position. That’s right, dystonia can be fixed, but it will take time depending on how much damage is present and how long it has been there. That is oftentimes the key: How long and how much damage is there? If the damage has become so extensive that nerves and muscles are damaged beyond repair, then the hope for resolution is not as high and that must be recognized.
Because our office sees so many dystonia patients, we know how to diagnose what is wrong from our viewpoint and then work with the physical therapist or osteopath to help re-align the neck over the course of time, which might be years in some cases. I have a number of patients who are in their 60’s and have had dystonia for decades. I tell them that if we can unwind the problems, it could take several years of treatment. For example, this week I saw perhaps 8-10 dystonia cases and most were close to a year in treatment. They all had improved a fair amount, but it was obvious that the discs were still out of place. In some of these cases, we choose to do the TMJ surgery to fix the displaced discs, in other cases there is just too much damage and we will keep them in appliances forever to maintain the stability we have gained. Don’t get me wrong, many of them get a lot better, but the underlying damage is still there so these patients are likely going to be wearing devices for a lifetime as I adjust the appliances and keep them stable. I guess it’s not too bad considering they are doing better.
One major issue when dealing with dystonia is that you cannot simply make a TMJ appliance that is up to final height at the very beginning. I see this too many times, a new patient comes to see me and is wearing a device that is 10mm high made by their dentist. This is so wrong for so many reasons, but basically such a height so fast will actually hurt the cervical spine because what you do to the front of the face will affect the back of the head. What should be done? You need to raise the appliance slowly over time, work with a body worker to handle the changes, and as the months go by raise the appliance to a proper height that provides comfort and support.
As you can see, dealing with dystonia is multi-faceted. It takes time. It takes patience.
In today’s blog I would like to discuss how parents are not at all aware that their child completes much of their neurologic and physiologic development at a very early age. Most of their faces are done growing by around six years old, so shouldn’t we take care of abnormalities that are blatantly obvious by that age?
You see, dear readers, although this little guy looks cute, he is probably hurting and does not even know it. How do I know this? Look at how his left ear is higher than his right, his left eye is higher than the right and the sclera (white) of the left eye is different as well from the right side. Even his ‘dimples’ are not level. When the body has this degree of unevenness, we know the cranial bones are distorted. Such distortion leads to improper venous/CSF (cerebrospinal fluid)/lymphatic drainage and multiple health problems later on as you know from previous blogs.
It seems that very few of the dentists and physicians out there would take the time to explain to the parents that this young man would benefit from ALF appliances, and maybe even a bit of osteopath work as well. Early intervention is critical at this point in this child’s life, I firmly believe, in order to reduce his problems later on in life. The circles under his eyes indicate there might be some issues with sleep disordered breathing. All this absolutely must be addressed NOW, but it is not likely that it will be. So few doctors are aware of what is really going on. So few doctors are trained how to treat this child. And so few doctors have even the slightest clue as to what their delays are costing this child and his family.
Parents- please – just look at your child. If you see such obvious distortions, find someone who will help you deal with this problem before it becomes too late. The children out there need help and maybe, just maybe, your observations can help them get better sooner.
Photo Courtesy of unsplash.com
This past week I had another family from Texas show up in our office. For some reasons, we now have a number of families coming here from Fort Worth and Dallas. Most of them tried someone local, yet apparently things did not work out too well. As you know, dear readers, I see lots and lots of patients with Tourette’s and I think the word is getting out about this. As I write this blog, I had just checked on one of our patients who just had the surgery to fix the discs. Since he was a Tourette’s case, I just had to know right away if the discs in the joints had medial displacement (as you already know, this is my theory on ALL Tourette’s cases). Sure enough, the surgeon confirmed the discs were not only medially displaced, but VERY medially displaced. To date, this has happened every single time- in ALL Tourette’s cases the articular discs are medially displaced.
Do I have enough evidence to write a paper? Perhaps. Do I have the time and money to make such a study happen? No way. So here I am in a bit of a dilemma – I could probably afford several thousand dollars to do some kind of study, but I have absolutely no time at all. I would much rather help as many patients as possible. I figure this is the way that I can stimulate interest in our treatment modalities and try to get these kids off the meds that are only beating them down anyway.
So back to the Texans. With several families coming from Fort Worth, they eventually bumped into each other and started talking about me and my team. As you already know, I use osteopaths and physical therapists every day so these kids from Texas needed this therapy as well. The problem was that I did not know anyone in Fort Worth to refer them to. I gave one family a name that I had heard of and it turned out the therapist was a flake! She wanted to come to the family’s home and rearrange their beds and furniture for the best ‘energy position’. ARRRGGGHHHH! Needless to say, that did not work too well. So after a while, one of the mom’s found us all a great osteopath who they all now see and everyone is happier and feeling much better.
Although today’s blog was not too well organized, I am glad that it got the message across: We just might have a true causative factor for Tourette’s folks! One day I hope publish a study about our work and the results- it will be an eye opener for sure. And, many thanks to the families from Texas too!
I know you are all used to sitting in the doctor’s waiting room and are prepared to just ‘wait’ like a good little boy or girl patient, but that’s not the case in my office. Many years ago I started something new and different in my office- it’s called ‘not waiting’. As an example, yesterday our 1:00 pm patient showed up 10 minutes early. We sat her within a minute or two and saw her BEFORE her appointed time. She barely sat down when one of my assistants asked her to come on back and since you were early we would see you early. One thing I realized many years ago is that time is a precious commodity, and not only should we not waste our own time, we should also not waste other people’s time.
Maybe this goes back to being just plain polite with others, showing respect, or even really showing that you care. But it goes both ways. I will admit that it drives me insane when one of our patients is late time and time again. In other words, they just could not show up on time if they had to! As an example, the other day I remembered that Cindy Lou Who (not her real name) was always late for her 3:20 appointment, and sure enough she showed up 15 minutes late, which made her 40 minute appointment cut short a good bit. She just showed up like it was nothing that she missed nearly half of her appointment and expected to be seen anyway. This has happened many times with her. Of course we still saw her. Of course we took good care of her, but it still irked me that she did not respect me or my team enough to make the effort to be on time. Perhaps I take it personally and expect too much from others. But, dear reader, I am here in my office at 4:30 am, typing this blog so that I can review my charts and MRI’s for the day and be ON TIME and AWARE of each appointment. That is what I do so am I expecting too much when I ask that you the patient be prepared and on time as well?
For certain patients who are like this -i.e. they could not show up on time for anything in their life- we treat them like they are booking an airline flight. They are required to pre-pay for that appointment and if they no show, then they lose their money. And if more than half late for the appointment, their money is gone. Simple as that. I honestly hate being this way, but how else can I make them respect the time, and us as well?
The other issue with the chronically late is that the next person on the schedule who really does respect our time is cheated on their time if I run late because of the person before them. That is just not right at all! These days we tell our patients to please be early for their appointment, and it works sometimes, but not always. We do have a lovely waiting area with coffee, tea, and water bottles, so there is no reason not to be a few minutes early. The funny thing is that our patients notice that the waiting room is always empty- we planned it that way actually. We don’t want anyone waiting, so we don’t make them wait. What a concept! No waiting in the waiting room!
In truth, we do have some people wait because of the person before them who was late and now demands their full time. I am working on a solution for that- maybe one of these days I will figure it out. Until then, I will keep waiting for a solution!
Any time an organization is able to help so many people get better, it is important to spread the word so that others can learn as well. This has been my mission these past 4-5 years since I took over Dr. Stack’s practice. I have taught in a number of countries and have been able to stimulate a lot of interest in alternatives to drugs and aggressive surgeries by using our specialized approach to treating craniofacial pain.
Recently, Dr. Stack and I did a podcast with a group called ‘The Misdiagnosed Life’. We were interviewed and had a great discussion around why the articular discs can cause such havoc in a person’s life and what to do about it. Our interviewer, Beverly Butler, was intrigued to hear that slipped discs in the jaw joints can cause so many problems. She really seemed quite taken aback when we explained how we treat patients with chronic head and neck pain, back pain, migraines, and even movement disorders like Tourette’s and Parkinson’s. By treating the jaw joints and the slipped discs, we can oftentimes greatly reduce a patient’s level of pain and other seemingly unrelated symptoms. We have such an amazing effect on so many lives that we feel we need to teach others what we do. Please enjoy the podcast.
Below content a credit to: themisdiagnosedlife.com/big-mouth-health-common/
Neurological disorders and other health issues such as difficulty sleeping, facial and/or body tics, headaches, head jerks, pain and many other symptoms…
It’s often said that a TMJ problem is caused by talking too much, but is it really? And what does a TMJ problem REALLY mean to your health especially if you’re suffering from a neurological disorder? Dr. Brendon Stack and Dr. Jeffrey Brown discuss this topic in this week’s show.
Dr. Stack is world famous in temporomandibular joint disorders and he discovered 40 years ago that a person with a TMJ or temporomandibular joint disorder can often have neurological disorders and other health issues such as difficulty sleeping, facial and/or body tics, headaches, head jerks, pain and many other symptoms, and these symptoms go away most of the time when their joint is put back in proper alignment with their head and jaw.
Dr. Stack developed a device that the person wears once they are examined and the problem identified that helps to realign the person’s jaw and as a result, most if not all of their problems go away even problems they didn’t associate with their jaw. Dr. Stack has retired but Dr. Brown has taken over his business and after treating thousands of patients with great success he is continuing to treat patients and teach other doctors this technique so more people can get the relief they so desperately need.
In this past week I have had over a half dozen patients call to tell me that the ENT, their MD, or their pediatrician said the frenums- see pictures below- do not require ‘trimming’.
If you look at the picture on the left, that little bit of tissue just above the two front teeth is called a maxillary frenum, or frenulum (I’ve heard it both ways). The pulling of that tissue is what is keeping the front two teeth apart, but even more onerous is the fact that this tissue is holding back the entire upper jaw from proper ‘face forward’ growth. So if a person is only six years old or so, and this is when their body and face are really trying to grow, this frenum might be preventing proper development. Now imagine how this can affect the airway. Since the upper jaw is not able to drive forward which would open the airway, this little guy will be more likely to end up with sleep apnea when he is older since that jaw is being held back and not allowed to grow forward to full potential which would open the back of his throat and airway more.
Similarly, on the right side photo, the tongue is being held down by that frenum. It simply cannot reach the roof of the mouth and get a good seal up there. This means more mouth breathing will have to occur and since that tongue is held down, there is less chance for good nasal breathing so nitric oxide is less likely to be formed. (You all remember my blog on nitric oxide, don’t you?) I have found that due to a lack of education in this area, many doctors do not ‘get it’ that these frenum restrictions will hold back a child’s jaw growth during their important years of development!
In a recent article written by an MD (a REAL doctor in other words), it was stated that there is a current trend toward frenum trimming/cutting/reductions/etc because of monetary reasons. To me this is just insulting because I do not ever receive a kickback of any kind for sending a child to the ENT surgeon for this procedure. I make no money at all by providing such a referral. In fact, I actually lose money in some cases because the cost of doing the procedure sometimes means that the parents cannot afford my services until they save up after the cost of the frenectomy procedure! So whoever wrote that article probably needs to re-think their thoughts!
I truly wish that I had the resources to do a proper study on how children develop with or without the frenum trimming procedure. However, that would be malpractice on my part, wouldn’t it? Since I already know that these children will have more face forward growth if the frenums are reduced, why in the world would I want to compare to children who maintain restrictive frenums? Why would I want to see another child suffer from breathing and developmental problems when I already know the better path for them to take? So as a parent, please take the time to look at this aspect of your child’s growth and help them to grow better!
In many of the patients I have seen over the years, they have suffered from migraines for a very long time. When I first meet them and explain that from what I have seen most migraines are TMJ related, they balk and say ‘no way’ or ‘it’s not possible’. Most of them have been to neurologists and have received a battery of medications that just dopes them down and prevents them from getting restful sleep. Most of them are irritable and look like the life has been sucked right out of them. Little did they know that in many cases it’s just a displaced disc in the jaw joint causing the problem!
If you have the stomach for it, and would like a little glimpse into the anatomy of what we deal with every day, please check this out:
This is a dissection video so it’s not for the faint of heart- don’t go there if it might gross you out. Basically, if you do decide to look at this video, you can clearly see that the head/neck region is jam packed with all sorts of blood vessels, nerves, and muscles that all intertwine. So just imagine if you lost a few teeth and your jaw bone now collapses up into the jaw joint. This will effectively ‘pinch’ all those vessels and nerves and muscles and things and can readily lead to migraines. It’s not all that difficult to understand really. So now imagine, yours truly comes along and opens up the bite with either the ALF or the lower gelb style device. The pressure now comes off all those pinched up nerves and blood vessels, things flow properly, headaches are gone. This is what I see almost all the time folks! It ain’t rocket science!
Now you understand where the mix up comes in. Patients go to a neurologist because they think this is the kind of doctor that can help them with their headache, but little do they know that a slipped disc in the jaw joint can cause their pain. In addition, the neurology doctors, although well intended, are not versed in the art of TMJ management. They are well versed in the art of prescribing medications of course. I am not saying that ALL migraine cases are TMJ related, but with the ones I have seen, most seem to have a TMJ component to them.
In the past few years, several local neurologists have actually referred their patients to me! Some of them have realized that when that patient can only open to 25 mm or their joints are popping like crazy, they have a definitive underlying TMJ issue. One of our patients got better so quickly that her neurologist actually threw a party for her to celebrate her victory over the pain. That is the kind of neurologist I enjoy working with- someone who is open minded and really ‘gets it’.
So if you are someone who suffers from headaches and/or migraines, take a moment to figure out if it just might be TMJ disorder. It can’t hurt to figure it out, and who knows, it might be the actual answer to your problems!
This past week I have seen a number of new patients come into our office and I am hearing the same old story: “I went to a neurologist…I went to the ENT…. I went to my GP…. I went to my acupuncturist” and on and on and on. And then I sit down directly in front of them and just look at them. That’s when the same thing happens again and again -they all seem to have the left ear higher than the other, one eye is higher than the other, or you can visually observe their jaw pops out to one side when they open their mouth. It is sometimes so painfully obvious that these people have cranial bone distortions that I just shake my head and wonder why this was missed with all these other doctors.
I guess that these people have been to their doctors and the symptoms are being treated, not the root cause. You see, dear readers, when a person’s face is very obviously distorted- and you can see this very easily if you take the time to look – then this is why they have that head or neck pain. Just like if a car has been in an accident and the car’s frame is bent, well, that’s just like a person’s skull being bent. When the frame, or skull, is bent then the vehicle or the person just cannot travel down the road very well. Things are shaky and if that vehicle is a person, then pain usually happens over time since things are no longer lined up properly and the body is fighting with itself just to walk down the road. Does that make sense? I certainly hope so!
Next year, in 2018, I will be teaching to a handful of general dentists and I hope that they will stop being a regular dentist and take a look at the whole person instead of just the teeth. It is so important to realize that if the hips are out of place, then likely the skull will be a bit twisted as well, and this can lead to lots of discomfort throughout the entire body. So, when the dentist is preparing to crown all your back teeth, stop and have your whole body assessed for any irregularities that might prevent those crowns from working as well as they should. When the hips are not level, this might affect the shoulders and the neck which would mean things are not balanced well enough to do all those crowns. So buyer, or patient, beware when you make major changes to the system!
First thing – I hope you appreciate that I make the effort to at least try to come up with these inviting and interesting titles! Just kidding. I do hope that by blogs are not too boring and do help you a bit to understand what TMD treatment is all about. In today’s blog I would like to discuss someone who I just met the other day. She lives in New England and she came here to the DC area to see me after some very frustrating treatments. I did my exam and discovered that her right jaw joint was crunching like crazy- sorry for all the big words- and it sounded like broken glass in the joint. Then I noticed her left ear/eye/eyebrow were all quite elevated relative to the right side. Her xrays that she brought showed severe condylar (jaw bone) degeneration as they were totally flattened out and sharp on the edges.
Now the interesting portion of our program begins. She reported she already had both discs surgically removed from the TM joints- ooopps! She was not wearing a surgical splint to protect the joints so she was likely bone on bone inside the joints (the condyles were worn down due to this) – another ooopps! So here she comes along and wants me to fix all of this. OK folks, I’ll admit I can figure out what is going on, but to fix what is so terribly damaged might not be possible and I told her this. She showed me photos of how someone had put brackets on her teeth in an effort to pull them together. She came in with one of those huge binders holding all her data and I was amazed at how she had been to California, Florida, and all over the US talking to various doctors.
It was most interesting that she said she would gladly consider surgery if I thought it might make a difference. It was then that I explained why the previous surgery did not turn out so good: her condyles or jaw bones were not even at all. It’s kind of like saying the front-end alignment is way off on the front tires of your car. Just putting on new tires won’t help in the slightest -you need to align the front end first! Well, your body is the same – those cranial bones and jaw joint sockets need to be level and aligned to get a good surgical result. This lady had surgery done, yet none of the doctors involved had spotted the misaligned cranial bones, so nothing could work properly anyway! After hearing all this, she said she now understood why her shoulders were uneven, why her back hurt, why her face looked distorted, and why there was so much pain!
As all of you dear readers already know, the previous doctors focused in on her teeth and barely even noticed the joints. They completely missed the distorted cranial bones. Even if this lady wants to do surgery, I told her there is no point in doing this now- maybe later if we can level out the bones and get the joints functioning better, then perhaps it might be something to consider. So that’s it for today folks -the message is that you need to take the time to analyze and diagnose, but isn’t that the same message I put out there every day? You get it. You got it. Good.
Well folks, I am sitting here at my desk on December 29, 2017, at around 09:00 – that’s around 9am or so. As I reflect back on the year, I realize we had some ups and downs, but overall we did great and really have made a difference in many peoples’ lives! I am grateful for my team -these ladies have worked hard and have well earned a few days off to relax and enjoy. I have felt many personal gains this year as my studies into osteopathy and cranial bones continues. I am honored that my friend, Dr. Logan Cooper, will be in our office every Friday from now on. Our patients really appreciate his work and are happy he is on board. We now can have our patients experience a full body adjustment with him, then jump into my room to balance their appliances to that new position- it makes a big difference!
This coming year I will be teaching in Toronto on various ALF and general TMD therapies. I give all credit to my mentors: Dr. Brendan Stack and Dr. Darick Nordstrom who have been instrumental in my training. This year I lectured with both of these famous people and I must say it was quite an honor! Dr. Stack and I go way back in our training in the area of TMD. And earlier this year, Dr. Nordstrom called me out of the blue and asked me to co-lecture with him in Norway -that was a great experience! The only bad part of the trip was that I only could go for three nights so I stayed in the hotel and went to the classroom each day and never made it to Oslo- it was a whirlwind of a trip!
A similar experience happened going to Dubai this year. I taught at the dental school and visited with a VIP patient and left after only two nights there. The 17 hour flight had my head in such a spin that I had no idea what day of the week it was. But it was a great opportunity and I think we made the people there much more aware of what TMD is all about. I will never forget how I ran around on stage for three hours doing my lecture and ended up being so soaked in sweat that I was embarrassed and simply could not drink enough water to cool down! The trips to Norway, Korea, and the local DC trainings were all great and helped to spread the word.
On the home front here in the US, we made a lot of changes to our protocols in order to help our patients even more. I changed my MRI order to include other images to look for concussion problems along with instabilities in the jaw bones that would affect our surgical cases. We also now take a specific xray prior to our MRI consults so that I can better explain how the cranial bones will affect the treatment plan. It’s kind of like having your mechanic explain that the front end of the car might need an alignment before you buy those new tires. This makes our treatment planning process smoother and much easier for our patients to understand.
I am really happy to have a most excellent network of doctors to work with every day. My surgeon, Dr. Eugene Gregory, has done surgery on thousands of joints with an extremely high success rate. My ENT buddy- Dr. Michael Abidin- is doing frenectomies and tonsil removals on our patients who need these services. I have local dentists like Dr. Rodney Mayberry and Dr. Eva Pleta who understand our work and are very careful and precise with our patients. You already know about the wonderful Dr. Logan Cooper who does some brilliant physical therapy and osteopath treatment. Now, I also work with a top notch chiropractor near the Baltimore area- Dr. Jean Thompson – this lady knows her stuff and every single patient I send to her is impressed with her skill set. And last but not least is our very local (in the same building) Madhura Gurjar- a physical therapist who has a really good handle on the difficulties in treating TMJ patients. Overall, I am very lucky to have all these doctors on board.
Another fun (or simply crazy ) project is that I wrote a bill for the Virginia legislature that if it passes will force insurance companies to cover TMJ treatment. Right now, they weasel out of paying by calling our treatment ‘experimental’. Well, dear readers, there is nothing experimental about having someone get rid of headaches that have been there for decades. If all goes well, I will propose the bill to the legislature and answer any questions they might have. I generally cannot stand politics, but in this case, if it helps you folks get the coverage you deserve, then it will be worthwhile!
As you can see it has been a busy year. I am actually going to try and take a vacation next year -it is much needed! To all my readers, thank you and God bless you all!
Today I would like to write about why breathing is so important to the human body. Too many people in this country have become mouth breathers and this creates many problems for their bodies. When we breathe through our mouth, the air is not as humid as if we breathed through our noses. In addition, that same air is not warmed up, which is better and safer for our lungs. Another consideration is that breathing through the mouth does not allow the air to be well filtered like it would if it went through your nose. For all these reasons, and more, mouth breathing is not a good thing to do!
I have attended classes over the years taught by Patrick McKeown, of the infamous Buteyko Clinic out of Ireland. Patrick is a most brilliant practitioner who is able to help athletes and regular folks to breathe better so that their bodies heal and stay healed. Just one of the things Patrick teaches is that you should have longer breaths- what this means is that instead of breathing in and out at a fast rate, try to breathe in and then hold that breath, then breathe out and wait a bit before doing the next breath and make the in between breath intervals longer. Although the process is quite complicated, in simple terms (which are about all I can handle), let’s say you only have 10 million breaths available in a lifetime. So don’t use them up all at once- make them longer and increase the intervals between breaths so that you live longer.
Another thing that is taught at the Butekyo Clinic is something called ‘control pause’ breathing. What this is all about is that you take in a breath, breathe it out, pinch your nose, and time how long before you need to take that next breath. If your CP (control pause) is less than 20 seconds, more than likely you have some sort of breathing problem- apnea, asthma, snoring, fatigue, etc. If your CP is 20-40 seconds you are in decent shape, but a trigger could make things worse- allergies for example. If your CP is over 40 seconds, you are in good shape- no worries mate! So what is your CP? Mine happens to be in that 20-40 second range. I have sleep apnea so this correlates. Oh well. This means I need to lose weight, get in shape, and take better care of myself.
Many thanks to Patrick McKeown of the Buteyko clinic for all his great information and helping people achieve better health!
We will be hosting a live Facebook video with Ed Harrold on December 19th.
Ed Harrold will have tips on better breathing!
Facebook Live on December 19th: https://www.facebook.com/jeffbrownofvirginia
Sometimes you just have to come up with an analogy to make a person understand what is going on. And sometimes you have to come up with more than one analogy to REALLY get them to understand. In my little world of treating TMJ disorders, I make it a point to try and get our patients to understand why they have a problem long before I explain how to treat it. Recently, I revamped my MRI order with the radiologist to include measuring condylar angulation relative to the central axis. What that means in English is that I am having the radiologist measure how ‘in line’ the jaw bones are relative to the middle of the skull. It’s kind of like if you take your car to the mechanic and they explain whether or not your front end alignment is ‘in line’ or not!
The reason for the front end alignment angular measurement is that I need to know if surgery may be an option one day, and this helps me to understand how effective it might be. Let me explain. The articular disc sits on top of the condyle (jaw bone) and if the two condyles do not work in unison with each other -i.e. if they are tipped differently, then putting that disc on top of the condyle may or may not work too well. Just like the wheels on the front of your car- if one is turned right and the other is turned left, then two new tires will just wear out very quickly. If your mechanic is honest with you, he/she will not sell you two new tires- he/she will explain that a front end alignment will make your new tires last so much longer.
Well, dear readers, this is where you need a good TMJ mechanic (please excuse the analogy). If you begin treatment and those condyles are angulated at 67 degrees on the left side, and 87 degrees on the right side, then surgery is far less likely to work and the patient should know this. For this reason, you need to explain to the patient that we need to use our ALF appliances for a year or two to get the cranial bones re-aligned. With all good luck, this will level out the sockets for the jaw joints and allow the condyles to reshape and re-align to a more balanced angulation. It’s good to be balanced.
This is one of my short series on “It’s all about me today”. Look folks, I cannot work miracles. It’s as simple as that. Example: About a year and a half ago I met a new patient whose discs were terribly out of place and I felt really good that I could help him. Well, we never heard from him again. My team does reach out to see if the consult went OK, if there were any questions, or if there was anything we could do to help him figure this out. He made no effort to call back. My guess is it was all about money most likely. Well, the other day he called the office and basically demanded to come in at that time because his jaw had ‘locked open’ as he said. He was in pain, could not eat, and just plain miserable.
My schedule was totally booked up and as you know, dear readers, I do not double book for any reason – I respect your time and that’s how it is, so I will not jam someone into the schedule. Needless to say, he was not happy that we were not willing to just drop everything and see him immediately. This is what irks me I guess- he put off treatment for whatever reason and just because he wants to be seen right away, he figures we have to stop seeing the patients we are already scheduled to see. This thinking is kind of rude I believe. We gave him plenty of chances to take care of the problem while it was so much easier and yet he decided not to take advantage of the opportunity.
Maybe part of the problem is that he just did not understand how serious the damaged discs can be when they are badly displaced? Maybe it was all about money. But, if money was the issue, and now the problem is a lot worse, it’s only going to cost a lot more to fix the problem at this point in time. It’s like if your mechanic says “Hey lady, there’s an oil leak you should deal with” and you put it off. Then one day the whole engine is blown and the car is ruined. You should have dealt with it back then but just did not want to pay the price and now it’s exponentially more expensive!
As I started with earlier- please help ME now- deal with the problems before they become more difficult and more expensive and we are all upset with what we now have to deal with. If your jaw joints hurt, pop, click – LISTEN to the signals- they are telling you they need help and you need to do something about it. Inevitably I will get a call on the holiday from one of these folks who I met, talked to, made a plan with, and they simply did not care to deal with it, yet on Thanksgiving day, they will call me and expect me in the office. Will these folks ever change? Doubtful. Thanks for listening to me rant and rave today!
Don’t you just love it when a story starts out with ‘It was a dark and stormy night’. Well, not today folks. It was a bright and sunshiney morning at our office and I was looking forward to meeting the new patient on our schedule. She flew in from Canada to come see me since several people had told her she had no choice. I must admit, the visit with her was frustrating, angering, and just plain maddening at times. It truly was a conundrum! Let me explain. The moment I sat down at my bar stool, and she sat down at hers, I could tell what was wrong. Her complaint was that she had been to many practitioners and showed me her appliances. Dear readers, I tried to be nice, I really did, but on the inside I’m both laughing and disgusted with what I saw. She showed me all upper appliances, and they all were designed to let the jaw slide back into the joints. It was wrong in so many ways.
As many of you already know, you never, ever, make an upper appliance on a person who can only open to 30mm – sorry, I forgot that little tidbit earlier – she could barely open her mouth. So here she has this upper device that locks in the maxillary bone and blocks cranial motion. Not a good idea. We talked about all this and I think she understood what was going on. And then I showed her the very obvious cranial distortions- her mastoid on the left and sphenoid on the left were terribly elevated compared to her right side. And today she looked worse than her ‘before’ pictures that they did a year or so ago. In other words, wearing the appliances on her upper jaw had made things worse and more distorted.
Then to top it all off, her tongue was all scalloped, she was tongue tied, and her palate was very highly vaulted. This means she could not get good nasal breathing going so her body could not heal very well. These are the things that need to be discovered and noted in a very first initial visit folks! Needless to say, I did my best not to berate the other doctors who had seen her in the past…heck, I’m nowhere near perfect…but if you say you are going to treat these patients, at least know what you are talking about!
So in this initial 45 minute exam, I was able to give this young woman some good guidance. Maybe I over whelmed her, maybe she will never come back again because I overloaded her with information. Maybe she will return and allow me to further diagnose once the MRI has been done. A lot of maybe’s here.
As a patient, I can only imagine going to so many doctors and getting such a divergence of opinions and treatment plans. The one thing that upset me the most was that NOT ONE of them did an MRI to understand what was going on internally, and then some idiot surgeon was suggesting surgery because that is what he does! This patient (as the MRI showed later in the day) has anterior displacement of the discs in the jaw joints, so if the surgeon moved her jaw forward, this would put the jaw so forward that it would actually pinch the discs even worse and make the situation more painful. Not a great way to treat your patient, is it?
As you can tell by now, I am a bit frustrated with the various approaches toward TMJ treatment. To help out, I have just written a bill for the Virginia State legislature to have insurance companies cover this treatment more completely. TMJ disorder ruins peoples’ lives and if there was better insurance coverage, more people would be healthier and lead better lives. That’s my mission folks- stay tuned for more!
As many of you dear readers already know, I wear a sleep appliance at nighttime because I have sleep apnea. A few years back, I used to snort, gasp, stop breathing, and snore every night. It drove my wife crazy! Then I had a sleep test – after falling down and crying when I read the report, I knew I could not wear a CPAP since so many of my own patients tell me they cannot either, so I had a sleep appliance made. It’s great, I wear it every night, and feel 120% better with it than without it.
The interesting thing about CPAP is that it truly can save your life if you can handle wearing it every night. Did you know that our own government has dictated that a successful use of the CPAP is defined as the patient wearing it 4 hours per night, 5 days per week. That’s right folks- it’s considered successful by our government if you wear it 20 hours per week. So during the work week you are doing fine if you can breathe about half the night and on weekends you take a break from breathing basically. I am not sure what the logic is in that, but when it comes to the government there might be no logic involved. The reality is that you are supposed to get 8-9 hours sleep per night, which tallies up to 56-63 hours per week. So according to government standards, you are doing fine if you get around 1/3 of that amount when using the CPAP.
I have a problem with government statistics in this case. I believe that sleep is very important to people at all ages. Without good sleep, your body does not recharge the hormones needed to be healthy. Without good sleep, you are more likely to develop diabetes and heart disease. So why would anyone cut corners on good sleep? When I wear my appliance at night, and I wear it EACH AND EVERY night, I feel well rested the next day and can handle being in my office for my normal 10 hour days (that’s right folks, I don’t have a life). Would any of you like to go to a TMJ doctor who uses a CPAP and only gets about half the normal sleep they are supposed to get?
The message here is that if you think you have sleep apnea, or your bed partner, or your Mom or Dad have concerns that you might – get a sleep study done! You just might save a life. And if the CPAP keeps you alive enough, go for it, but keep in mind that compliance is not all that great whereas a properly fitted sleep appliance might provide for some better relief. Sleep well!