To be honest, no one knows everything there is to know about dystonia- what causes it, how to diagnose it, how to treat it. There is so much speculation that we could go on for hours discussing all the various issues. However, there is one thing that I can say I have observed for sure. In almost every case- that’s about 95% of the time- the articular discs in the jaw joints are out of place, i.e. they are displaced. Unfortunately, most of the doctors out in the real world have no understanding of TMJ disorders- it’s not in their wheelhouse. They tell me this is one of those ‘in between’ medical and dental problems- kind of like the middle of the desert on a horse with no name (reference: 70’s band called America). Anyway, you get the picture. So I really cannot fault anyone for not knowing where to turn when it comes to dystonia.
As many of you dystonia sufferers already know, you go to the chiropractor to get your neck snapped and when that does not work you go to the physical therapist to get the neck and the back worked on. When none of that works and by now your head and neck are bent to the side, you go to the neurologist for Neurontin or whatever drug du jour they recommend. Don’t get me wrong folks- the doctors are ALL trying to help you get better based on their knowledge base. Then after years of pain, embarrassment, and even thoughts of depression and giving up, they google their symptoms. And lo and behold, little old Dr. Brown shows up on their screen. At first, they think it’s snake oil when they see my videos, but then they delve more into the website and realize that this guy just might be legit. Then they get the nerve up to call my office and talk to my team and realize that the ladies they are speaking to really understand them and want to help. It’s looking more promising now folks.
And one day that person shows up at my office after years and years and thousands of dollars gone, and I examine them. Most of them are not able to open their mouth fully. The xray shows that most of them have severely distorted cranial bones as well. And then the MRI is ordered and this shows about 95% of the time that the discs in the jaw joints are out of place! It’s a home run on the diagnosis board! But then the reality kicks in. I have to explain to Cindy Lou that it is highly likely there could be permanent nerve damage from the neck and head being bent to the side all these years. I try not to say ‘I wish I met you a few decades ago’ but that is often what I am thinking. So now we move forward. That person will need a splint to take the pressure off the jaw joints, most likely. And now that the pressure is reduced, this is when good physical therapy will really make a difference.
You see, dear reader, I believe the dystonic starter event began many years ago. It is possible that a slight accident or hit to the jaw could have ‘popped’ the disc out of place and this is now causing the skull to tip to the side, which then pulls on the neck. Please check out the xray below of one of our cases. This patient was not even diagnosed with dystonia, but I believe we can call this perhaps a ‘pre-dystonia’ patient. When I met her, her complaints were head and neck pain. The MRI showed definitive displacement of the jaw joint discs. We treated the discs and cranial bone displacements for about a year and as you can see in the xray on the right, she now lines up a lot better.
Of course, I cannot promise everyone the same results, but more often than not I am able to improve the situation and give the person a better life. So if you or anyone you know suffers the pain, the embarrassment of dystonia, be sure to tell them to consider that the discs in the jaw joints just might be the culprits, or at least highly contributory to their problems.
Over the years I have made perhaps a few thousand ALF appliances for my patients and still get this question almost every day: What is an ALF and what does it really do? Let’s start off with what ‘ALF’stands for: Advanced Lightwire Functional. I suppose it really is still considered an ‘advancement’ because so few people have heard of it, although it has been around for 40 years and I have used them for the past 10 years or so. So why is it so ‘advanced’? I think the reason for this is that with the ALF you oftentimes do not need the heavy duty palatal expander which can actually harm the teeth and the bones if not done correctly. And it is most certainly an advancement over the old appliances like the Herbst and old style braces. In fact, most of the time we do not need braces when I use the ALF.
As for the term ‘Lightwire’, yes, the wire is very light- in fact it is .025 Elgiloy if anyone is interested. Compared to many braces wires, this is pretty darned light indeed. I personally wear the ALF appliances and can hardly tell they are there. If you are so inclined, you can look up Elgiloy wire on the Internet and see that it is a popular orthodontic wire. When used correctly, it helps to actually align the bones in the skull to make them more symmetrical which is critical to good function and good health. In fact, leveling the cranial bones is what I mainly use the ALF for.
The term ‘Functional’ refers to what the wire does- which I said in the above paragraph- it gets the bones in the skull in better alignment so you can improve your overall health. I adjust the appliance every couple months to make sure we expand and level at the same time. All of this effort makes more room for the discs in the jaw joints and helps to reduce intracranial pressure for so many people who experience head and neck pain.
The only other part of the ALF that demands your attention is the turbo. The turbo/lifter/riser is a blue filling material we put on top of the lower second bicuspids to stimulate the eruption or lifting of the teeth. This makes your teeth just a smidge taller to better support the TMJ (temporomandibular joint). This is what helps to correct the TMJ problem and the ever so ubiquitous displaced disc. So many people have slipped discs and this can cause severe head and neck pain, so when we grow your teeth up a bit taller, it reduces the pressure on the discs which alleviates much of the pain.
So now that you understand the ALF a bit better, you can understand why I really enjoy working with this nice little appliance. It does take time to make things happen, but as with all good thing, it’s worth waiting for.
Due to popular demand, and believe me, people are asking a lot these days, I would like to explain what turbos are all about. When we do braces at our office, we put little plastic lifters – from here on we will call them turbos- on top of a few teeth to determine the height we want the teeth to be in order to support the jaw joints correctly. How about a little background on this concept?
When I meet a new patient in my office, in most cases I discover that their back teeth are not tall enough to support the jaw bone in the proper position in the jaw socket. So because of this, what often happens is that the protective disc (made of cartilage) that is on top of the jaw bone, becomes dislodged and can then pinch upon blood vessels and nerves in that area. Here is the source of so much head and neck pain in so many people. Unfortunately, I meet many adults who have had this problem for many years and now are in desperate need of help. When I meet a child with similar issues, it is oftentimes much easier to help them because at a younger age the teeth move better and the bones align easier. At a young age, almost certainly the wonderful ALF appliance can open up space for the discs and make the joints better. And the little turbo allows the teeth to erupt taller which in turn protects the space needed for the discs in the joints. Hopefully this is making sense.
Now, continuing with the idea of the turbo. The turbo basically creates a ‘fulcrum’ or a lifting point so that the adjacent teeth can now grow taller. The taller teeth then support the jaw bone better in it’s socket. Again, I hope this is making good sense: taller teeth = better jaw support. The taller teeth effectively protect the disc space in the socket and that slipped disc now has a chance to go back into proper position. Once you get a handle on this, it all becomes quite elementary, Dear Watson.
So through the use of turbos, we allow the vertical height of the teeth to change over time in order to establish the height needed to support the jaw joints. It’s a process and it takes time to get there, but it is always well worth the effort. Granted, sometimes the discs are already too damaged to help them, but we always must give it a try. And considering that 90% of the time this process works well, then it is worthwhile!
So in today’s blog, dear readers, I will present to you a fairly simple rule of physics: No two objects can occupy the same place at the same time. It’s pretty simple, admittedly. But now let’s get into the example that I have in mind for you. As you all know, I do complicated orthodontics in my practice every day. What that entails is ‘growing’ or ‘lifting’ or ‘erupting’ the teeth taller so that the jaw joint is properly supported and does not collapse further. As you can see in the picture below, there is a little white thing called a turbo buildup that creates a fulcrum or lifting point to get the teeth to raise up taller. All very important things to do.
What is unfortunate, and I saw this in last week’s orthodontic class, is that without that little turbo to stimulate the teeth to grow taller, you basically end up forcing the jaw bone (the condyle) to jam into the socket and impinge on the disc space. So when you use orthodontic elastics to pull the teeth together, without a turbo there, you just jam that condyle into the socket and displace the discs because two objects cannot occupy the same space at the same time. Since the jaw bone is much harder than the soft disc, that little disc just slips out of the socket and becomes displaced and now will pinch blood vessels and nerves in that area. And now you have TMD (Temporo Mandibular Disorder). When I think back over the years about all the orthodontic training that I have done, I realize that this concept was never taught to us. We were always taught, actually, that the teeth have little or nothing to do with TMD. In truth, however, the teeth have EVERYTHING to do with TMD issues.
When you do braces and drag the teeth through the bone to line them up nicer, you are actually putting forces on the cranial bones and these bones can readily distort. I see this every day of the week. Then, on top of all that, if there is no fulcrum to lift the teeth against, and all you do is elastics to pull the teeth together, you can indeed jam the condyle into the socket and displace the discs. A very simple law of physics is then violated: two objects – the condyles and the discs- are now occupying the same space at the same time. End of discussion.
In an interesting twist of terms, a study done out West called the TuCASA study – the Tucson Children’s Assessment of Sleep Apnea- it was discovered that there is a negative relation between AHI and immediate recall. What this means in English is that a high apnea index correlates to poor recall in children, i.e. they do not remember what they studied in school all that well. The apnea also correlates negatively to Full Scale IQ, Performance IQ, and even math achievement. Nocturnal hypoxemia (lack of oxygen at nighttime) also correlated to poor non verbal skills as well.
From a behavioral standpoint, children with apnea and snoring also present with hyperactivity, attention deficit, concentration difficulties, and even impulsiveness. So now what is happening more and more is that children are being mistakenly diagnosed with ADHD when what they really have is an apnea problem.
A five year followup study done by the same TuCASA group has shown that those children with untreated OSA- Obstructive Sleep Apnea- had problems with attention, were more aggressive, had lower social competency, communicated more poorly, and decreased adaptive skills. What this means to doctors is that they need to be more careful in putting a label on a child because treating their condition using medication might make the sleep apnea even worse.
Let’s just imagine that a doctor prescribes Adderall -a combination of amphetamine and dextroamphetamine- for what they perceive to be ADD/ADHD. And let’s also imagine that the child has sleep apnea which is undiagnosed. So now this child is suffering from being medicated while being unable to breathe well at night. This is typical of so many children these days- they are on meds for ADD/ADHD- yet they have an underlying sleep apnea issue! These children have difficulties at school, problems making friends, and often cannot communicate well due to sleep deprivation, not due to some diagnosis of ADD/ADHD.
This unfortunately is an all too common occurrence these days- putting a child on meds when what they really have is sleep apnea. Doctors need to pay attention to this a bit more and run a few more sleep studies to figure out what is happening before they write an Rx for medication. In my own office, I will frequently meet a young new patient who is sitting in the chair and jumping all around at the same time. I am then informed that little Johnny has ADD and taking meds for it. As I observe the child, it becomes obvious that sleep apnea might be the culprit- the child has deep circles under their eyes, the tongue is scalloped, the palate vault goes up high. Then when I ask if they snore, it seems most of the time the answer is YES. This is a child who needs help and they need it now.
As we can all see, it’s time to take the time to observe and study how are children are sleeping. I am starting to see more practitioners and parents order the sleep studies, and this is a good thing. This will help to make a better diagnosis and help that child to sleep better. And as we all know, sleeping well is critical to good health. So here’s to your good sleep and your good health.
PS- much of this information is from:
‘Obstructive Sleep Apnea in Children: A Critical Update’ Journal: Nature and Science of Sleep
Did you know that there is a very large nerve that innervates much of the skull? It is called the trigeminal nerve and it looks kind of like this:
As you can readily see, this is one HUGE nerve and it covers a lot of surface area in your skull. It also just so happens that this nerve goes right through the temporomandibular joint (the TMJ). Now imagine if the articular discs in those joints are out of place and rubbing on the trigeminal nerve. Since this happens so often, the slipped discs that is, it would explain why so many people out there experience headaches on a regular basis. In my own practice, I see 4-5 new patients on an almost daily basis and 90% of them come in with headaches, which is unfortunate. The good news is that in 95% of those cases, the articular discs (the cartilage on top of the jaw bone) are out of place and are pinching nerves and blood vessels in that area. And since the trigeminal nerve is so omnipotent (that means it’s all over the place) it is likely being affected and this can cause all sorts of issues with headaches. Just like if you had a pinched nerve in your lower back due to a slipped disc, the jaw joint discs can cause the same problem which leads to pain. This is why when I begin to treat the situation, many of those headache and migraine symptoms slowly go away.
Almost every week I meet a new patient who has been to many different doctors over the years and when I tell them it looks like the discs might be out of place, they tend to be very skeptical. So I have to explain to them, don’t worry, you don’t have to believe me, but would you believe it if we did an MRI and had a board certified radiologist confirm the slipped discs are a problem? Most everyone believes this, however, over the years I have had a number of potential patients express that perhaps the radiologist just might be lying for me. Oh well.
So let’s get back to those slipped discs, shall we? When the discs slip out of place, they are then basically pinching the nerves and blood vessels in that area. Hopefully that makes a bit of sense. And, when I come along and make an appliance to take the pressure off that slipped disc, it tends to go back into position if it is able to and the patient feels better. It’s really that simple. Of course, in some cases that disc is just too damaged to go back where it belongs and surgery is indicated, but it does not happen often.
The message, dear readers, is that headaches and migraines are often due to a physical cause and once we identify that cause, treatment can be rendered. And the fact that 80-90% of the time this treatment works quite well, does indeed confirm that diagnosing the displaced discs is important to your course of treatment. So if you have head pain, like so many people do, please take the time to figure out what is going on.
Recently, I wrote a little blog about how perhaps, just maybe, we should take the time to analyze WHY a patient requires a biteguard/nightguard device. Last week I went to the office of a friend of mine and I mentioned how I am seeing so many new patients these days who tried the biteguard and it did not work too well- it made their symptoms worse actually. The problem with this approach, as I told him and his team, is that if the biteguard masks over underlying TMJ disorders or sleep apnea issues, then the appliance may be causing more problems than it is worth.
In some of my more recent studies, I was reading about this in:
Journal of Dental Sleep Medicine
Balasubramaniam et al.
The Link Between SDB and TM Disorders: An evidenced based review
SB may mask an UARS problem
Now, in English, and without all those abbreviations, this article explains how there is a definitive link between SB (Sleep Bruxism) and UARS (Upper Airway Resistance Syndrome). What this means is that a person clenches/grinds perhaps to open their airway so they can breathe better. The research actually now shows that more than half the time a person will clench or grind their teeth because their airway needs to open more. So now, ipso facto, (don’t you just love that term? 😉) if we as the dentist make a biteguard without informing the person that they have an underlying sleep bruxing problem that might be causing apnea that maybe, just maybe, we are contributing to the decline in their overall health? Hmmm…makes you think a little, doesn’t it?
What I actually explain to a potential patient is that I understand the purpose of the bite guard, however, the more current thinking is that there very likely could be underlying issues that must be identified prior to having you wear this device. As a TMD practitioner, I am acutely aware of this and do my best to identify why you are clenching or grinding, and if you might have sleep issues as well.
The bottom line folks is that prior to wearing a bite guard of any kind, you really should take the time to identify what else might be going on. In my practice, I will frequently meet a new patient who feels they spent a lot of time and money on their appliance, only to discover it made things worse. Well, dear readers, sometimes that is because they wore the appliance at night, and this allowed the slipped discs in the jaw joints to move a little into a better position. Then, the next morning they take out the appliance, bite down into a bagel for breakfast, and they get a searing shot of pain from the jaw joint. This occurs because now the disc has moved a bit from having the guard open up the jaw space, and now you bite down and bang really hard into the disc- that plain hurts! So here we have a case where the appliance is effectively masking over a TMJ disorder that really needs to be dealt with. I basically explain to this person that their bite guard just helped us identify they have a TMJ problem.
Now let’s look at the other side of the equation: sleep issues. If you have an Upper Airway Resistance Syndrome issue- the airway is so narrow that you wake up frequently at night. It’s not apnea, but close enough to cause all sorts of health problems. So here you are wearing your biteguard for nighttime use. The bite guard sort of opens the airway vertically, sort of. This then can mask over the underlying sleep problem, and this is now a dilemma. Did you know that sleep apnea directly correlates to cardiovascular disease, diabetes, atherosclerosis, and even cancer? YUP- that’s right. So if you want to mask over this absolutely MASSIVE problem, who is responsible? Is it your dentist? Is it you? Is it both of you who should take the blame? And believe me, one day someone will likely take the blame. And if you are a general dentist who made that nightguard and did it in good faith, of course, won’t you feel really bad if your patient walks in one day and reports they have severe sleep apnea and diabetes and heart disease? And, won’t you feel even worse if their lawyer calls you up and asks: Dear Doctor: did you not diagnose the underlying apnea and TMJ problem prior to fitting in that biteguard for Mr. Smith?
Need I go on folks? If this blog can reach enough people and they are really listening, then perhaps these people will save themselves lots of issues when they hear their dentist say these words: Dear patient, you need a nightguard.
Almost every day I point out to a patient that they have a calcified stylohyoid ligament going from behind their ear to the hyoid bone in their neck. Check out this xray:
In my practice I see such a bony formation every day of the week. Maybe this is because my practice sees so many patients who have neck, back, and head pain. Maybe this anomaly is becoming more and more frequent in people. Who knows?
Let me explain. There is a ligament (which is soft tissue and will NOT show on an xray generally) that goes from the styloid process behind your ear to the hyoid bone in your neck. It will not show on an xray unless it has calcified into bone. It generally calcifies when the neck is damaged or out of alignment and needs more support. Think of it like this: Your body recognizes that your neck is not stable so it is trying to form ‘struts’ or supports to stabilize the neck. When this calcification process takes place, many people can feel it in the form of difficulty with swallowing pills or vitamins, and even swallowing many foods can be difficult. If you look up ‘Eagle’s Syndrome’ this is what we are talking about in many cases. This calcification makes it more difficult to swallow food and pills and can be quite annoying.
So what do you do about it? Mostly, nothing. In the very old days, my mentor, Dr. Brendan Stack, might have his ENT surgeon cut the bones away, but that was really painful and the patient had to take off a lot of time from work. It was quite cumbersome. These days we mostly recommend that you do physical therapy to get the neck into better alignment with the hope that the bone is no longer necessary, and it just might dissolve away over time. As long as you can manage this quirky little bony formation, I believe that is the best approach rather than an invasive surgery. This is one of the strong reasons that I have our patients see the PT –physical therapist- to keep the neck aligned as best as possible.
Since this annoying little bone keeps showing up in my xray studies- every day it seems- I thought it would be prudent to show everyone how prominent it really is and that in most cases being aware of it and doing PT is good enough- for now.
In my little world of TMJ disorders I have been acutely aware of the negative effects of wearing upper (maxillary) nightguards for many years now. Years ago, my osteopath doctors explained that the upper hard acrylic devices will actually slow the pumping effect of the blood and CSF in the brain. This, of course, is potentially quite harmful to the body. Being a pragmatist, I did not believe them and asked for articles that confirmed this. Well folks, the closest we got to that was when UVA Hospital confirmed that our brains do indeed have a lymphatic system and if the beta-amyloid ‘crud’ does not drain at night, then you end up with ADD, OCD, and even auto immune disorders. This is what the osteopaths were talking about all this time- they kept telling me that upper hard guards slowed cranial motion. Go figure!
In the Journal of Dental Sleep Medicine, an article entitled ‘The Link Between Sleep Bruxism, Sleep Disordered Breathing and Temporomandibular Disorders: An Evidence Based Review’, posits that an upper nightguard/mouthguard causes an ‘aggravation of AHI and snoring’. This means that the upper biteguard makes snoring and sleep apnea worse. Also documented is a 30% increase in Respiratory Disturbance Index (RDI) when a maxillary guard is worn at night. There was also a 40% increase in snoring with the upper device. Sure, you want to protect the teeth and joints at night, but at what price?
As so many of you already know, sleep is critical to staying health. Without proper sleep our hormones and cells cannot recharge. Our brain cannot function properly unless we get enough sleep. So why would you wear something on your upper teeth that might make sleeping that much worse? Logically, you would not. However, as a dentist, this is what we were taught in school and this is what we use to treat sleep bruxism and grinding. It actually took me a long time to figure out that my upper appliances might be making things worse for my patients. It was a long time ago when I figured this out and ever since I have avoided these upper appliances. Now, even the Journal of Dental Sleep Medicine supports this position. If any of you dear readers are dentists, please heed my warning- take the time to analyze the situation of your patient. Don’t just slap an upper appliance in their mouth and call it good! There very well could be an underlying sleep or even a TMJ problem that needs to be looked at and addressed.
In recent months, as I explain to the new patients that the biteguard they just paid $500 for may not be as great as they thought, I have had their dentist call me and honestly berate me for saying such a thing. Well folks, the research is out there – we all just need to take some time and learn what this research is telling us. If any of the dentists out there want to talk to me about this, I welcome it. Let’s talk how to best treat your patient, what kind of therapy is best, and how to make them live better. Thank you for your time.
It seems like almost every day I meet a new patient who wears a device called a ‘nightguard’. There are so many issues with this ‘nightguard’ thing so let me just get right to it. First of all, in almost all patients who clench or grind their teeth the articular discs in the jaw joints are out of place. The displaced disc will inherently cause an inflammation or irritation in the joint area and many people will tend to clench or grind to help alleviate that irritation – just like if you popped your kneecap out of place in high school and coach tells you to ‘walk it off’- you are trying to pop that disc back into place and it just won’t go. In addition, some of the research is now suggesting we clench or grind to stimulate our dilatory muscles in the throat to open the airway. So if you have an airway problem that is going undiagnosed, the nightguard might be covering up this problem that you really should be aware of and you really should treat. Get it? Good.
Now let’s discuss the two types of nightguards- one is for the upper jaw and one is for the lower jaw. The lower nightguard is perhaps the less invasive of the two choices because it basically adds vertical height to the lower jaw and protects the teeth while opening up the space in the jaw joint and protecting the discs inside the joints. But, and this is a big but, the next morning when you take out your nightguard, and if the discs have moved around because the nightguard took the pressure off them all night, and you bite down on a bagel, you just might bite into a disc and damage it even more. If you are a dentist reading this blog, please think about this. Your patient might have displaced discs, might have sleep apnea, and although you mean well, it might be wise to analyze the situation a good bit more. It might be wise to figure out WHY they clench and grind.
The other type of nightguard, the upper version, actually is less favorable than the lower and for more reasons. Of course, it might mask over an underlying TMJ or sleep apnea problem and this is not good- my analogy with my patients is that if you have a broken leg you need a cast, not a bandage on it. Yes, this oversimplifies things, but you get it. The other issue with that upper nightguard is that when you bite down, it tends to push the jaw bones back into the joints which can damage the discs. Also, it blocks proper tongue position on the roof of the mouth because that is where the acrylic base of the nightguard lies. The other problem with an upper nightguard is that it tends to slow down cranial motion. What this means is that the brain moves with each pumping of the blood and this movement is what helps to keep it healthy. So a hard acrylic appliance might slow down this important motion.
As you can see, it might be prudent to delve deeper into why that patient grinds and clenches their teeth so much. Is there an underlying sleep disorder that is not being diagnosed? Are the articular discs in the TM joints displaced? I know we were all taught in dental school that you just put in a nightguard to protect the teeth, but if the problems run deeper than that, perhaps it might be time to take the time to figure things out.
In today’s blog I am going to make a correlation with a bit of a stretch. I am going to put together the opinions and beliefs of several types of doctors and the research that correlates with those doctors. In other words, I am going out on a limb today. This blog actually started many years ago. I was at one of the ALF Academy meetings where a bunch of us ‘ALFers’ get together every few months and discuss cases (this was before the Covid shutdown when people would actually travel and see each other personally).
At that meeting, one of our osteopath doctors stood up and mentioned to me that my ALF appliances actually help the lymphatic system in the brain to drain better. Being the skeptic that I am, I balked at this and told the osteo doctor to ‘show me a paper’, ‘show some proof’, yet there was none. It was not until just a few years ago that UVA Hospital in Charlottesville, Virginia, did some very impressive research showing that the brain did indeed have a lymphatic system and it did indeed need to drain the Beta Amyloid particles at nighttime, or else this could lead to ADD, OCD, and even autoimmune disorders. These brilliant researchers are changing the medical textbooks as we speak.
Now back to that limb I mentioned. My osteopath doctors at subsequent meetings basically said the same thing- the brain needs to drain the debris, the crud, at nighttime or else the lymphatic system gets backed up and causes health problems. They reiterated how the ALF helps to align the cranial bones, freeing up blockages, and thus allowing the lymphatics to drain better. When you think about this, it kind of makes sense. I have made thousands of ALFs over the years and every day can see that the bones in the skull (the cranial bones) line up better – i.e. they become more balanced and even. The body wants symmetry, and the body wants balance. Think of it like this: I am a front end alignment specialist. I help you get your skull lined up better. In almost all cases of using the ALF appliance, I notice the cranial bones aligning better over time. This is what my osteopath doctors were saying- cranial alignment means better lymphatic drainage. It kind of makes sense, doesn’t it?
As far as my own personal observations, when I use the ALF appliances for my patients, I notice that most of them begin to sleep better over time. Also, their cranial bones tend to line up better- my follow up one year xrays show so many patients where their bones look more in alignment and they feel better in general. Of course, I cannot promise this to happen, but it does in so many cases. And of course I have many xrays to show this. Is this something new perhaps? Not really. Dr. Darick Nordstrom invented the ALF many years ago and I have been using it for years now and see, and expect, the bones to line up better. For my practice, this little appliance has been such a great addition and I use it every day to improve the lives of the people that I see.
The technique that I learned for doing regular braces has changed greatly over the years. When I first learned how to do braces, all that we did was to make the teeth straight, so they looked good. Then, I met Dr. Brendan Stack, and that changed completely. Dr. Stack explained to me that he noticed how well patients felt when the back teeth were erupted taller to better support the jaw joints- the TMJ. Since the earlier days of my training with Dr. Stack, I have since changed my approach and my belief in how braces (or aligners like Invisalign) should really be done. Please allow me to explain.
One of the best ways that I explain to our patients when it comes to braces is by telling them to imagine that they have a couple back teeth taken out. When this happens, the jaw bone (condyle) will actually now go deeper into the socket and can pinch the protective disc on the top of the condyle. Now let’s think the opposite way- if you were to grow the back teeth just a bit taller, this would create more room for a disc that might be out of place (which happens with so many people). So what I like to do is to take an xray and determine the position of the condyle in the socket and see if it looks like there is enough space for the disc on each side. If it looks like we could use a bit more space, then I will do the braces like you see below in the picture. Notice what I call the ‘turbo’- a plastic buildup that creates a ‘fulcrum’ or lifting point. The wire is straight when placed into the brackets and it will tend to erupt those back teeth which will provide more support for the TM joints.
Granted, such a technique is so much more complicated than regular braces, and something like Invisalign is not capable yet of erupting teeth, but the 3 Dimensional orthodontics works extremely well. Having done hundreds of cases in this fashion just in the last few years, I have seen a huge success rate. Admittedly, when it becomes complicated like this, it will cost more, but in the long run the cost has proven to be worthwhile for everyone!
Let me also be quite clear- braces in general do NOT treat TMD issues and in fact usually make things worse. Braces are designed to simply make the teeth look straight. It is important to note that you must first work with the joints and the discs and find the position that is most comfortable to the patient – this is done with appliance therapy. Once the cranial bones are more level and the discs are in good position, only then do you consider braces to establish taller teeth to support the jaw joints.
I have taught this technique all over the world now and must admit that it takes some extra training to do this, but again it’s well worth it because now you can help that patient more than ever before. By getting the condyles in proper position, this protects the very fragile discs in the TM joints and helps to alleviate the many symptoms of TMD: head/neck pain, migraines, dizziness, blepharospasms, and even tics. Doing three dimensional braces is a great thing to help your patient have a higher quality of life.
Recently, we have had a slew of people calling our office asking, “Can I have a TMJ / TMD problem with no pain?” They go on to explain they have nothing wrong with them except for a popping and clicking noise in the joints. Well, dear readers, the popping and clicking in those jaw joints are simply the early warning system that our body uses to tell you to deal with the problem before it becomes more serious. Let me explain: the popping/clicking indicates that the protective disc on top of the jaw bone has slipped off from where it belongs and now it is moving on and off the top of that jaw bone. This is not a good situation- it’s kind of like if you have a red light on your dashboard that says the oil is low in your car- the car is still driving just fine, but you are now being warned that a problem is imminent, and you should deal with it. Most of us will probably take the car to the shop and get the oil topped off. What I find unfortunate is that most humans do not listen to their own bodies. Just because it does not hurt, yet, does not mean you should ignore the warning signs.
The human body is designed to keep on functioning even when it has problems. Your jaws are designed so that you can keep on eating, in order to survive, even when they have a problem! This is why your body gives you signals that something might be amiss. Now you just need to listen to the signals and deal with the problem. I must admit that every day of the week I meet and talk to a new patient and they tell me “Well, it’s been popping for 20 years now but the pain just started”. I tell them that the body presented a warning sign years ago, no action was taken and the jaw joints are now in worse shape. Sometimes they admit they were told to see a TMD specialist but never went. Some mention that they told their dentist about the popping and clicking, and they were told to wait or ignore it since there is no pain. This frustrates me however, I try to remind myself that TMJ Dysfunction was not taught in depth in dental school. Some doctors do not know much about they symptoms of TMD or what to look out for. As part of the dental community, we need to share our findings and constantly learn so we can provide the best care to our patients. Also, we need to do a better job listening to our bodies!
Over the years I have connected with many dentist and physicians and we have spoken about the symptoms of TMD and what to look out for. This is how a majority of patients find my office. These doctors are familiar with our treatment and they know what the warning signs are. If your doctor tells you that you have a TMD problem, they are doing you a great service. See a specialist and treat the problem before more symptoms arise.
For now, I will continue my own journey of educating my patients and colleagues and give them the best care possible. In turn, they are already educating their friends and family about TMJ disorder. It’s a slow journey, but maybe one day the world will understand this is something that should not be ignored.
In my little world of treating craniofacial pain disorders, it has been an interesting journey this year. For a month or so at the beginning of the Covid scare, people stayed away as they figured out the best path to take. Then, after only a month or so of being sequestered from the world, they came to see us in record numbers. I can only surmise that the stress dealt to us from the Covid changes caused a lot of people to experience pain this year. And as they began to seek help, they realized how important it is to deal with TMJ and sleep problems.
Even though people were concerned about ‘going out’, they still came to see us this year in order to improve their health. As an office, we have been more than extra careful in protecting our health and yours. Every night of the week my cleaning crew is in here disinfecting all surfaces and every other week they fumigate to make sure all nooks and crannies are clean. We wash our hands so many times each day that my whole team now needs hand lotion several times a day. And because of this our paper towel usage is through the roof! We even have our patients wash their hands upon entering and leaving our office- and I think this is making a huge impact on our safety levels. There has not been one reported case of Covid transmission being caused by this office. Not one.
We did, however, have two potential scares this year. Both happened because a patient was going to travel and did the Covid test- and they turned out positive. Luckily, our protocols were strict and no cross contamination occurred. All of my team were tested and the tests came back all negative – demonstrating our safety protocols were correct. Although the changes we have made this year were not too major (we have done mask/glove/hand wash/disinfection for a long time anyway), I do believe we did what was necessary and I feel totally comfortable in my office. I am truly proud of the way my team has been strict on our protocols and feel that they have made our office a very safe place to come to!
As we wrap up 2020, I can honestly say it was a bit of a rough year for all of us- the worries, the scares, the changes, and the new ‘awareness’ have changed how we interact with others. I am wondering if wearing a mask is the new norm for 2021. Will we have to disinfect everything for the entire coming year, or will we go back to whatever was ‘normal’ one day? Will workers go back to real offices or are we now entering a new economy of virtual office work? If virtual becomes the new norm, what happens to flying to another city for a continuing education program? It’s going to be interesting, dear readers, but rest assured, I will continue to be here since I cannot really do much virtually.
I am looking forward to 2021 actually. It holds lots of promise, lots of hope as well. Now that I feel very, very confident that my office is an extremely safe place to be, and our patients feel that way too, then I will continue to help and treat TMJ and sleep issues for people all over the world. Wishing you and yours health and happiness in the coming year.
This happens almost every day at my office. A new patient will come in because their jaw joints are hurting and they simply cannot figure out why things are so bad. It really can be quite the conundrum for them. When I start asking questions the truth comes out: The TM joints have been clicking and clacking and popping for many years now and no one told the patient that this is a serious problem! Let me explain. When the disc that sits on top of the jaw bone is slipped away from it’s normal position, it will rub against blood vessels and nerves that traverse through the joint. For some people the popping and clicking does not cause any pain at all…at least for now. For others, just a slightly displaced disc will cause tremendous and debilitating pain.
Let me tell you what I have seen over the years when it comes to displaced discs in the jaw joints. I have seen quite a number of people come to my office in a wheelchair and after just a few months of them wearing our devices they graduate to a walker and eventually are able to walk on their own. I have had many cases of patients with Tourette’s Syndrome where the appliances have made the person able to stop the tics and lead a normal life. Displaced discs also correlate greatly with migraines as well. Who would’ve thunk?
One of the problems with delayed treatment for slipped discs is that the longer they are out of place, the harder it is to get them to go back into proper position. This is why I would suggest that if you have popping/clicking/clacking/clunking in those jaw joints, try to deal with the problem before it becomes more serious. So many people explain to me that ‘it’s been popping for many years…and it only became a problem in the last few months. Well, my analogy is that if your car had a radiator leak or an oil leak and you could see the fluids on your driveway, then there was a serious problem. If you ignore that oil leak, the problem just gets worse until one day the entire engine seizes up and will not function. This is like the jaw joint- you have had the warning signs for many years- popping/clicking- yet nothing was done about it and now it’s an emergency and you want it fixed! And you want it fixed ASAP!
It is actually unfortunate that so many people out there have slipped discs and do nothing about it. What I hear in many cases is that ‘my dentist told me not to worry about it’ or ‘my PCP said it’s nothing to be concerned with’. Well folks, that’s wrong! The clickity clackity joints are telling you something and you really need to listen! The human body is actually quite remarkable. You are getting the warning signs well in advance of a catastrophic failure – what more could you want? If only more of the doctors out there understood how dangerous the slipped discs can be, the pain they can cause, the loss of quality of life, not to mention the problems they create with your sleep.
As I tell most of our patients here at the office: Please spread the word and help a family or friend. If they have joint noises, cannot open their jaw all the way, or it hurts or locks up now and then, get the jaw joints checked by someone who knows how to diagnose the problem and deal with it.
This month of November, 2020, marks a time when it’s important to be aware of TMJ disorders and what you need to look for in your journey to find relief. Many of the symptoms of TMD are very difficult to really identify as to what might be causing them. For example, many of our patients come to our office with migraines and they have had these migraines for many years. Did you know that a displaced disc in the jaw joint is quite often the cause for this pain? Yes, that’s right! In almost all cases of migraines the discs in the jaw joints are out of place. How do you figure this out? Well, an MRI of course! It’s kind of like if you went to your orthopedist and said “Hey Doc, my knee/shoulder/elbow/neck hurts all the time” Most doctors would immediately order an MRI to figure out what is going on. In my little world of TMJ disorders, that is always the go-to prescription to diagnose the problem, and in 99% of the cases that I see, the discs are out of place. Talk about a slam dunk on the diagnosis! From there you need to figure out a plan to fix the problem.
Another issue that I think is really important in spotting a TMD problem is that you absolutely MUST look at the cranial bones to see if there is distortion. You also MUST look at the cervical spine to see if the spinous processes are out of place. None of this is really difficult to do, it just takes the experience of the practitioner to understand how this is done. Let me explain. If you look at a person when they are sitting up nice and straight and their eyes and ears are clearly not level, then this means the bones inside the skull- the cranial bones- are not level. This is exactly why I see so many orthodontic failures – the teeth are being forced into a straight alignment when the bones of the skull are terribly out of place. It’s just like putting two new tires on the care when the front end alignment is way out of place – it just makes no sense. A car cannot complain of pain- it just wears out sooner when the alignment is incorrect. However, a human can indeed complain of pain when their teeth are forced to fight against a skull that is out of alignment. Make sense? I hope so. This is why most of the orthodontic cases that I see have to start over again. The bones of the skull need alignment first, and later on you can do braces or aligners to make the teeth look good.
So how do you go about finding someone who understands TMD? DO YOUR HOMEWORK! Take the time to call different offices in your area and ask if they treat TMD cases. Ask if they do an MRI to diagnose. Ask if they palpate the muscles. Ask if they examine the cranial bones for balance and symmetry. This is a great way to figure out if the doctor is really trained in this field and can help you get better.
This is a journey to improve your health, your well being, and your quality of life. Good luck and good roads ahead!
When we see a little kid sucking their thumb, many people think that it looks harmless and sometimes even cute. Little do they know that thumb sucking leads to all sorts of damage to the skull and the airway! In today’s blog I would like to go into some of the reasons why you should figure out why thumb sucking needs to be addressed at an early age.
One of the first problems that occurs with thumb sucking is that the upper teeth will be pushed forward while the lower teeth are pushed backward. This has now created an orthodontic nightmare that will require extensive treatment. However, a bigger concern is that thumb sucking will cause the palate to become more narrow, which creates an even bigger issue: breathing difficulty! You see, as that rogue thumb pulls the upper teeth forward, it also causes the palate to ‘mold’ around the thumb and the palate becomes more narrow which means the tongue can no longer reach to the roof of the mouth for good nasal breathing. Breathing through the nose is very important to good health because when we breathe through our nose, we create a molecule called nitric oxide which helps to repair the body.
Another aspect of thumb sucking is that it pulls the upper jaw forward and creates an anterior open bite, i.e. the front teeth are so far forward that the lips cannot close and get a good seal. This creates an environment of dehydration and the lips, tongue, palate, and other tissue become more dry over time. You are then more prone to infection because saliva is unable to keep things moist like nature intended. Saliva itself is antibacterial in nature so with less saliva, there can be more infections.
The bottom line with thumb sucking is that it can be deleterious to the dentition- the teeth- and to whole body health in general. The thumb sucking behavior needs to be stopped early on to avoid heavy duty braces later on.
In our modern society, most of the young people I meet really, really want braces or Invisalign or something to make their teeth look more cosmetic. This is where I need to segue into some of the reasons why doing orthodontic work may not be the right path to take. When a new patient comes to my office, I like to sit in front of them, facing them directly, as we both sit in a bar stool and stare at each other. Yes, it’s awkward, but when I tell them there is a reason for this they understand and appreciate it. What I am trying to do is to figure out if we can make braces work, or if the concept of orthodontics simply does not make sense. And, dear reader, most of the time doing braces simply does not make sense. Let me explain.
Research has long since proven that around 95% of the babies are born with cranial bone distortions that go both unrecognized and untreated. What this means is that the eyes and the ears are not quite level/even and the bones of the skull are somewhat distorted. In other words, just about all of us have these distortions. And so if you want to do braces and these cranial bone distortions are present, more than likely the braces will force the teeth where they do not want to go and the cranial bones will simply distort the teeth and move them later on anyway, even with retainers. As an example, I met a 25 year old young woman the other day who has been through two rounds of braces already and could not understand why her upper front right tooth and the three behind it had flared forward- a ‘bucky beaver’ effect- but ONLY on the right side. I told her I could easily put her back in braces, but the teeth will likely flare out again. When she asked why, I gave her a mirror and she was made aware that her right eye/eyebrow/ear were all higher than on the left side, i.e. her cranium was distorted and if we were to force her teeth to come back down into alignment with the others, they would just flare back out again because the cranial bones would push them out.
So with all my orthodontic cases, I explain these things to the patient and they are usually quite glad to realize that the relapse would likely be unfavorable if they did proceed with braces – unless those distorted cranial bones were leveled! Enter the formidable ALF appliance. Today, in lieu of doing braces, in many cases I am able to improve the appearance of not only the teeth, but the face in general. This is done by using the ALF appliance. This little device is incredibly efficient in leveling the bones inside the skull, and by making these bones more level, the teeth will often level out as well and go straighter. The ALF sits behind the teeth and gently pushes them a bit forward, while the counter force of the lips pushes them back. In other words, the teeth are pushed from the front and pushed from the back and end up lining up better. It’s a great way to avoid braces or to minimize the time you spend in braces, but it’s a healthier way to go too.
If you have any interest in a ‘better way to go’, please look at my website and read the blogs – many of them talk about how ALF treatment works. And of course, once the bones and joints are lined up better, we can always put on a few braces here and there, or even use clear aligners, to give you the nice looking smile you want!
My team members asked me to write about these topics the other day. It seems that many potential new patients who suffer TMJ disorder are calling about what arthroscopy and arthrocentesis actually mean and if they are a candidate for such a procedure. First, let’s clarify each procedure and then I can talk on the merits of whatever path you choose to take.
When a procedure called arthroscopy is performed, this means that you are using little needles to actually go into the joint in order to perform a procedure. Arthroscopy is considered to be a minimally invasive procedure to go into the joint in order to examine what is going on or to perform a procedure. So basically when you say you are having arthroscopy, it just means the procedure is a minimally invasive technique using needles and that is about all that it means.
On the other hand, arthrocentesis is more like using arthroscopy to flush damaged cells and debris out of a damaged joint. This technique -in the TM joints for example- involves putting a needle into the top of the joint, flushing something into the joint, and using a needle at the bottom of the joint to suck up the junk that is being flushed out. Sorry for the graphic explanation, but it does allow you to understand it quite readily, at least I hope it does.
Now let’s talk about why someone would consider doing these procedures. When a person is told they ‘have TMJ’, what that more likely means is that they have TMJ disorder, i.e. displaced discs in the joint with joint irritation, inflammation, maybe arthritis as well. Then they go to someone like an oral surgeon who says ‘Let’s use arthroscopy to perform arthrocentesis and clean out those joints’. The problem with this is that you are not actually fixing the real problem- the displaced discs. The arthrocentesis procedure is used to flush out the mediators of inflammation and hopefully make the joint feel better for a while. This is the problem- it does not actually FIX the problem. It just masks the problem and makes it feel better for a while. This is why TMJ treatment gets a bad rep- the doctor is just leaving the damage there and charges the patient thousands of dollars and never really fixes anything.
So now you ask: Why do they do this? Well, the answer is that this is what they were taught in dental school- lavage (clean out) of the joints is simple and logical. They are not really taught that they should probably actually open the joint and fix it right the first time. The surgeon that I work with has done TMJ surgery on thousands of joints and explained this to me many years ago- he said that surgeons were taught to do arthrocentesis because the open joint procedure is riskier and more difficult. Well, maybe that is the truth, but would you like to be cut open multiple times or would you rather just do the open joint procedure and be done with it? I have personally worked with my surgeon for so many years that I would rather have him take the 20-30 minutes to properly plicate the disc back into it’s proper place, rather than leave a displaced disc rubbing around in that joint. Leaving a displaced disc can lead to arthritis and lots of inflammation which can eventually lead to degeneration of the jaw bone and the socket. So, it is basically our belief that leaving a damaged disc rubbing around in the joint will only lead to more problems over the long run and cost more time and money to fix later on- i.e. you are only delaying the procedure that should have been done the first time. So, as I pose to these potential patients: Why not just be sedated ONCE and get it over with? This minimizes the cost, minimizes the drugs, and mitigates future degradation of that joint.
And of course, I hear EVERY DAY of the week that TMJ surgery does not work, and it causes more problems than it is worth. Well, like any type of surgery you must have a really good surgeon and thankfully I do! I know all of you dear readers remember my blog about the doubting Dad – just say you do. This blog was all about a young woman who needed the surgery and he Dad said he would find someone on his insurance list who would do it for a discount. He discovered that of the 20 so called ‘TMJ Surgeons’ on the list, 10 never heard of such a surgery, 8 had never done one, and 2 surgeons had only done a couple of these procedures. This is a clear case of lack of experience, whereas the surgeon I work with has done thousands of these procedures and has a documented success rate above 90% on symptom resolution. I guess because so few surgeons have done and understand the procedure this is why it is considered not so successful.
To sum it all up, arthroscopy is the procedure used to perform the actual arthrocentesis – the cleaning out of the joints. I hope this blog has helped you to understand more. Thank you.
So many people grind and clench their teeth these days that it is almost becoming the norm in the patients that I see. There are several theories about why we grind our teeth, with perhaps the most common being that we are under stress and take out the tension on our teeth- this can happen during the day or the night or both. This theory is that grinding ‘feels good’ and helps us to calm down. I am not really sure this is the truth or not. The other theory on grinding/clenching is that it stimulates the muscles that dilate (open) the throat during a sleep disordered breathing (apnea) event. When I see sleep studies, oftentimes there is a grinding event that occurs during an apnea, so possibly this is the case. Much of the research is leaning toward a link between sleep disordered breathing and grinding, but we still have a long way to go to confirm this.
What in the world does ‘torus’ mean, you might ask? Well, tori refers to more than one torus, simple as that! Whoops, sorry folks, let’s tell you what a torus refers to, and for sure it’s not a Ford Torus. When a person grinds their teeth heavily, the bone attached to the grinding muscle tends to become more dense. Just like if you were a weight lifter you build up bone in your legs and arms where you work those muscles. Most tori bones form either behind your lower teeth, mostly toward the front region, or on the roof of your mouth. Some of these tori bones form in front of the upper teeth as well.
And who really cares about these tori bones? You should! When the tori bones form behind the lower teeth, they are effectively pushing the tongue backward and can compromise the airway to some extent. In some cases these tori bones are so huge that we need to have the oral surgeon remove them to make more room for the tongue. This is a bit of a rough surgery as the surgeon has to chisel these bones away. As you can see in the photo below, the large tori bones behind the lower teeth are pushing this person’s tongue back into the throat. This can be contributory to sleep apnea and many health issues due to sleep disordered breathing. By cutting away the tori bones, the tongue can then move around much better.
Sometimes my patients ask me: Is there any way to make the tori reduce or avoid them in the first place? My answer is that if they are due to sleep disordered breathing, then do a sleep study and figure out if sleep apnea is there. By dealing with the sleep problems, these bones might not form in the first place. Maybe wearing a bite guard would help if the problem is due to stress. So many factors, so many things to think about! I hope this blog about tori has given you something to ponder. Thank you.