The Case of: A little bit More About TMJ Disorder and Sleep

The Case of A little bit More About TMJ Disorder and Sleep VA

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.

The Case of Stylohyoid Calcification with Clarification

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:

Sleep TMJ VA treaments The Case of Stylohyoid Calcification with Clarification

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.

The Case of the Negative Effect of the Nightguard

The Case of the Negative Effect of the Nightguard Sleep TMJ VA Therapy Apnea

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.

The Case of the Notorious Nightguard

sleep apnea TMJ VA
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.

The Case of the Draining Debris

Stealth ALFSIn 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 Case of: The Case for 3-D Braces

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.

turbo tm joints VA

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.

The Case of The “Painless” TMJ Disorder

The Case of The “Painless” TMJ Disorder VA TMJ Jaw pain cracking popping sounds

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.

The Case of How We Wrap Up 2020

Sleep TMJ Therapy VA The Case of How We Wrap Up 2020 Image by Gerd Altmann from Pixabay

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.

Sleep TMJ Therapy VA The Case of How We Wrap Up 2020 Clean Image by zukunftssicherer from PixabayWe 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.

The Case of the Conundrum of the Clicking and the Clacking

Sleep TMJ Jaw pain VA The Case of the Conundrum of the Clicking and the Clacking Photo by Andrea Piacquadio from Pexels update

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.

It’s TMJ Awareness Month!

TMJ Awareness Month Sleep'n'TMJ Theray Photo by engin akyurt on Unsplash logo

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!

The Case of the Troubled Thumb

TMJ Therapy VA The Case of the Troubled ThumbWhen 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.

The Case of Avoiding Braces Without Really Trying

TMJ Orthodontics VA The Case of Avoiding Braces Without Really Trying

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!

The Case of Arthroscopy vs. Arthrocentesis

TMJ dysfunction treatment The Case of Arthroscopy vs. Arthrocentesis

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.

The Case of the Terrible Tori

Bilateral mandibular tori Sleep TMJ Therapy VA

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.

example 2 tori sleep tmj dysfunction therapy VAWhat 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.

example tori sleep tmj dysfunction therapy VASometimes 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.

The Case of the Quarantine, the Carbs, and the Kilos

sleep tmj therapy The Case of the Quarantine, the Carbs, and the Kilos

Today is September 9, 2020, and I wanted to do a blog about my experiences these past few months in regard to how our patients are doing with the quarantine and how we are slowly returning to some degree of ‘normalcy’. In the past months as Virginia has gone into the next stage of release from quarantine, more and more of our patients are showing up and telling me that the only reason they left their house was to come see me and my team and they felt quite safe doing it. Actually, the truth is more likely that they needed their appliances adjusted and felt it was necessary to come in. I was, however, quite honored at their comments. 😉

In the past few weeks, a handful of people have come in and told me that they have gone stir crazy and all they have been doing for months is watch TV and eat. One nice woman came in one day and said “Doctor Brown, all I do is sit in front of the TV and eat all day” “Last week I ate a whole baguette that was this long (and she reached arms out wide)” The baguette was apparently about 4 feet long. My first comment was that she must have been hungry, yet she responded she was not- she was just bored. ate a whole baguetteShe said she was too afraid to go to the mall, afraid to go to yoga class, and simply refused to return to the gym. My best advice was to get out on the trails and walk as much as possible. She then told me the trails were so busy with all the other totally bored people that she was afraid of doing that too! Now, I have known this woman for several years and when she says she is ‘afraid’ she really did not mean to the extreme, more like she was concerned. And now that she has put on over 20 pounds these past six months, I can see why so many people are packing on the kilos. They have nothing better to do than sit around and eat. Yikes!

Personally, I make it my mission to walk at least 2-3 miles every day- rain, sun, snow, sleet, or whatever those mail people do. I actually find it fun to get out there at 05:00 and walk the neighborhood around the office before I hit the shower. It helps me to clear my head and get ready for what is most always a busy and challenging day. And that is the other thing- as restrictions have lifted, our office is being slammed with all these new people seeking help for their pain. I have done this work for a long time and these past few months have seen a major uptick in pain cases. As it turns out, many of them were referred here some time ago and now that they have the time, they are coming in. The other side of the coin, I believe, is that the covid crisis has these people more stressed than ever and this has exacerbated their pain. Either way, it seems more people than ever are needing our help.

So if you are one of those people out there who are eating their way through the quarantine and the covid situation, do not feel bad. There are many folks in the same boat. Now that you know you are not alone, get out there and walk as much as you can. Enjoy the beautiful fall weather and let’s see you drop a few kilos!  Be safe and be kind to others on your journey.

The Case of the Mask Madness Mandate

The Case of the Mask Madness Mandate Dr Brown Sleep TMJ TherapyDue to the COVID-19 pandemic, most everyone is wearing a mask outside of their home. It is now considered rare to see someone without a mask over their face no matter where you go. Most businesses like grocery stores, restaurants, and doctors’ offices now require you wear a mask upon entering their location. And in many states this is even mandated by statute or code.  Let’s talk about some of the issues in regard to mask effectiveness.

The first thing to mention about masks is that you actually need to WEAR it to make it effective. Every day of the week I see someone walking around with the mask either around their neck, or it is hanging below their nose. A mask simply does not work if you refuse to wear it properly. These days I have seen many people wearing the ‘gaiter’ mask- i.e. the one that wraps around your neck and you lift it up over your nose to cover your face. The problem with this mask is that although it is better than nothing, it will not work nearly as well as the standard N95 does. In fact, here is what the Buff company says about their mask:

BUFF® head and neckwear protects against many of nature’s elements. However, while our multifunctional headwear products cover the entire front of the face (nose, mouth, chin, and neck), they are not scientifically proven by the Center for Disease Control (CDC) and the World Health Organization (WHO) to prevent you from: (1) contracting a virus/disease/illness or (2) passing a virus/disease/illness to someone else.

The CDC and WHO also recommend that in hospital type setting where patients are coming in with active COVID infections, the medical workers really need to wear a proper respirator/N95 mask. Unfortunately, these type masks have been in high demand and there are shortages of these types of PPE (Personal Protection Equipment) and many hospitals are having their employees use regular cloth masks. At this time, there is still a shortage of even the cloth masks and many hospitals are requiring their staff to reuse them. It has been shown in various studies that cloth masks are quite effective and the problem arises when they are worn so long that they become wet and soiled from saliva and nasal fluids. There has even been a case or two of Legionnaires disease showing up due to the mask becoming so saturated with fluid that the bacteria builds up causing an infection. Now, hospital workers are advised to clean their masks frequently if they are required to reuse them. Some things that work quite well to clean are disinfectants, alcohol, and UV light. One of the safest and most effective ways to take care of a reused mask is to simply let it dry overnight and most bacteria will simply die off.

In our office, my team members wear the N95 mask with a face shield when they are right next to the patient. If they are doing a major adjustment to an appliance, they take the device to our hood system in the center lab. The hood is a medical grade filtration hood that uses heavy filters to keep everything inside the hood and it even has an additional plastic shield as well.

Because of the concerns about fluid accumulation in the mask, there are some new products coming on the market. I just saw one this morning that looks like an astronaut’s helmet- it has a build in fan and fits over your head completely. Then there is a cloth portion that snugs up to your neck. I am not sure if this thing would work for claustrophobic people. Most of the other ‘new’ ideas involve making your own mask using things like regular cloth and even cutting holes in your socks so they become ear loops! Overall, these ideas are better than no mask but the bottom line still is that the respirator/N95 is still the best choice out there.

I wish you safety, good health, and a proper fitting mask.

The Case of How Invisalign is Related to TMJ Disorder

The Case of How Invisalign is Related to TMJ Disorder

I see new patients every day who are contemplating doing Invisalign, or aligners of some kind, in order to ‘fix’ either their TMJ problem or to re-align their bite when they already had braces done in the past. There is a chance that doing aligners might help them, but in truth there is a greater chance that moving the teeth with aligners will make things worse. Let me explain.

As all of my new patients know, they sit in a bar stool when they come to my office and I spend a moment or so just looking at them. I know at first it seems a bit odd having a dentist look at your eyes/ears/nose/chin, but it works! Then as I explain why I am doing this, they understand that I am not just looking at their teeth. I am looking at the bones of their skull to see if there are any imbalances, i.e. are there any distortions that might make doing those aligners a bit more difficult. What you have to realize is that if the bones in your skull are not level, and then you force the teeth to go level, you end up with the teeth and skull bones working against each other. This is why you are required to retainers when done with aligners- the cranial bones will take over and re-twist the teeth otherwise.

As an aside, dear readers, I actually stepped away from writing this blog for about an hour to meet a new patient to our office. She was super nice, super friendly, but in a super amount of pain- she had headaches, neck and back pain, tinnitus (ear ringing/buzzing), ADD/OCD, and sleep disordered breathing. The interesting thing is that she just finished Invisalign last year and came to me because she is grinding holes through her clear retainers. So, as usual, I sat her in the bar stool across from me so I could just look at her first. She actually turned a bit red in the face and said ‘no one has really just looked at me so intently before’ and I explained that I am just taking a critical look to check for any imbalances. Well, what I saw kind of surprised her. Her right ear/eye/eyebrow were elevated relative to her left side. Her upper right teeth were pulling upward as well. In other words, her cranial bones were so distorted that they moved her teeth and now the upper front teeth were crooked. So, the explanation that moving the teeth into a position just to look good when the more serious underlying issue- distortions to the cranial bones- was ignored allowed her to understand why she was grinding through her retainers. In English- doing aligners like Invisalign is like putting two nice new tires on the front of your car when the frame of the car is distorted and out of balance. The nice new tires will wear down much more quickly than they should because that distorted frame will pull and push on them unevenly. So I told her to go across to the nearby gas station and get a front end alignment.  NO.. Not really. But that was how it should have been done- first align the cranial bones and work on the airway (whoops, forgot to mention that to you folks-that’s another blog)  and then finally align the teeth to the position where the body seems to work well.

So, I digress, but when do I not? 😊 It’s my blog. 😉The moral of the story, as they say, is that you need to look at the whole person prior to doing any type of treatment. In my soon-to-be-released Orthodontic Oath, I make a check list of what the patient should know prior to initiating any form of orthodontic treatment- whether it is braces, invisalign, aligners, or similar. And one of the key components of that oath is that you as the patient need to understand that when teeth are forced into an arbitrary position just to look nice and straight, this may violate what the body allows and pain will ensue. Let me explain this some more. If, for example, the patient has what is called a maxillary cant, i.e. the upper jaw is literally bent higher on one side than the other- an uneven smile as they call it, then orthodontically you would bring down the teeth on the higher side so they are now more level across. Well, that is all fine and dandy, but if the cranial bones above those teeth are a bit distorted/bent, then this will pull on the jaw bone and can lead to TMJ disorder. In other words, we should try to identify if there is potentially an underlying TMJ problem BEFORE we move the teeth around. In so many cases, the cranial bones, the jaw joints, and the cervical spine are completely ignored for the sake of making the teeth straight.

In regard to the Orthodontic Oath, here is a rough draft- this thing is a work in progress and I just started it a few days ago, but here it is for your consideration when contemplating orthodontic treatment:

THE ORTHODONTIC OATH

As your orthodontic provider, I feel very strongly that you, as the patient, should be well informed prior to beginning orthodontic treatment (braces or aligners like Invisalign). It is important that you understand your status prior to the treatment, along with what might happen because of the treatment.

My Oath to you is to provide you with the following information prior to treatment:

  • You should be made aware of the condition of your condyles/jaw bones and whether or not there is wear and tear present, if the condyles are worn, or if they are set too far back or too high in the sockets. If they are not in the proper position, then the orthodontic treatment should be geared toward improvement of that position. Improper condyle position is one of the main causes for TMJ disorder so if the teeth are simply moved for cosmetic reasons, this will likely further damage an already compromised joint.
  • Your ROM (Range Of Motion- how big you can open your mouth) should be documented before treatment and at each and every visit to make sure your body is responding well to the treatment. Your opening should be at least 50mm or so at the beginning and should hold fairly steady during the course of treatment. If the range of opening decreases, it means there might be a problem in the jaw joints.
  • The discs in the jaw joints should be analyzed prior to treatment as well- i.e. are the joints clicking/popping? Is there pain on opening? Sometimes an MRI is required to analyze the joints more completely. If the discs inside the joints are not in their proper anatomic position, you are not ready for braces.
  • The dentist needs to inform you if the cranial bones (i.e. the bones in your skull) are out of place or uneven- and this is often the case in almost all patients that we treat. So, when teeth are moved orthodontically, this movement may make the distortions to the cranial bones worsen and could lead to head and neck pain eventually. In other words, sometimes the cosmetic treatment may not be worth it. Only you can decide if you wish to take the risk as long as you are well informed.
  • In almost all cases, it is very important to grow the teeth ‘taller’, i.e. erupt them taller in order to better support the jaw joints. If this is not being done, then you deserve an explanation as to why not.
  • You also need to be informed that certain teeth may already be compromised from past procedures like root canals, crowns, large fillings, gum disease, and even braces or Invisalign. These teeth may not respond favorably and may not move orthodontically and options may need to be discussed.
  • And finally, the proper way to treat a patient for orthodontics is to re-align the cranial bones FIRST, get the discs back into position FIRST, align the cervical spine FIRST, and then once all this is accomplished, consider proceeding with orthodontic treatment. This way, the teeth are more likely to stay in proper position and the patient will have less pain and sleep problems in the future.

The Case of the Mouth Breathing Mania

In too many people that I meet these days, both young children and older patients, I observe that the lower jaw is set back too far and it looks like they have no chin. It’s almost rampant how many children have this problem and yet so little is being done about it. When that lower jaw is set back then the airway, i.e. breathing, can be adversely affected.  These folks will breathe through their mouth in order to open the breathing passage as much as possible. This is what we call a compensatory effect- the body realizes there is not enough oxygen coming in so the person now breathes in as much air as they can through their mouth, instead of the preferred way through the nose. Here are some of the issues with mouth breathing:

  • Being a mouth breather will affect the person’s health as well. A mouth breather tends to initiate breathing in the upper chest, whereas normal breathing comes from the diaphragm. This means the body has to work harder to breathe and oftentimes the chest breather will take extra breaths or yawn to get in more air.
  • Mouth breathing is often erratic and not very smooth. This keeps the person in high sympathetic nervous system activity-i.e. in constant ‘fight or flight ‘mode – and this disrupts the normal digestion, sleep, hormonal recharging, mood, mental ability, and many other bodily functions.
  • Children who breathe through their mouth tend not to be well oxygenated and this affects their mental development. Many children wake up tired, want to sleep in all the time, and generally feel irritable all day long. For many of them, this lack of restfulness can lead to a diagnosis of ADD/OCD/ADHD. In reality- they are just sleep deprived.
  • Mouth breathing tends to force the body into a forward head posture position which then puts stress on the neck and back. Again- this is a compensatory position as the body tries to open the airway as much as possible. This then leads to long term back and neck pain which can lead to the need for neck/back surgical correction.

The message to parents is that they need to take a moment and just look at their child now and then. Are they breathing through their mouth? Is their head bent into a forward position? Do they snore at night or sleep with difficulty? All these issues can lead to sleep apnea, even in very young children. In turn, sleep apnea is now directly correlated with diabetes, cardiovascular disease, and even cancer.

Nasal breathing mouth breathingSo what can be done about being a mouth breather? First, get a diagnosis of what is going on. In  our office we have an xray that can measure the volume of the airway and this is a good start on the analysis. Also- you might want to have a sleep test done to see how efficiently the child/adult is sleeping. As for actual treatment, most sleep doctors will suggest you wear a CPAP to force the air down the throat and into the lungs. Some people do fine with this, and others not so much. From a dental viewpoint, the use of the ALF appliance has been extremely effective in actually fixing many cases of sleep apnea and sleep disordered breathing. The ALF expands the arches, making more airway space and allows the tongue better roof of the mouth positioning. In addition, it helps to level distorted cranial bones which allows for better flows in the skull- think blood, cerebral spinal fluid, and lymphatic drainage.

If mouth breathing can be identified at an early age, there is really good hope that the person can achieve better breathing, better sleep, higher functioning, and improved quality of life in a short period of time. Early diagnostics are the key to a better life!

The Case of the Concern About Radiation

The Case of the Concern About Radiation sleep and tmj therapy VA

Almost every day someone asks me about the radiation coming from our dental xray system. It is understandable that our patients have this concern, after all, we hear on the news that we need to be careful about sun exposure and the need for sunblock, so be careful about the radiation that you can really control- xrays. First of all, let’s talk about how xray units are measured. I prefer using a term called ‘micro-sieverts’ which is 1/1000 of a milli-sievert as far as dosing is concerned. Example: A normal whole body CT scan when done at your local hospital can expose you to around 10,000 microsieverts. That’s a lot of radiation! However, the radiation output for the 3-D imaging in my own office is more like 400-1000 microsieverts- that is substantially lower than a whole body scan. I am actually being very conservative with my estimate because the manufacturer of my xray unit insists that the radiation output is really more like 200-400 microsieverts.

The funny thing about radiation output is that it all depends on who you talk to. So far, I have not met with any consistency in these estimates. Did you know that you are exposed to around 400 microsieverts EACH and EVERY year just from being in your own home? That’s right- building materials put out radiation to a fairly high level. And if you have granite countertops, these things put out more radiation than a whole year of dental xrays! So when it comes to xrays at my office, I do not worry too much about the patient’s exposure because it is generally very little compared to all the background radiation around them.

By the way, I just read a report by Spring Hatfield, a dental hygienist, who reports that we receive 30,000 microsieverts of radiation yearly just from our food! The radioactive foods and drinks we ingest include Brazil nuts, lima beans, bananas, white potatoes, carrots, red meat, beer, and the annual dose you receive from food is equal to about 60 dental X-rays. So if you want a good snack it might not be so wise to wash down those brazil nuts with a cold beer!

The really important message here is that radiation is cumulative. This means that the more exposure you get, the more likely you will end up with a health problem. Like all things, moderation is the best approach. So when you do need xrays, it is always wisest to work with a doctor who uses digital xrays to keep down the amount of radiation you will be exposed to.

As you can see, the above information is really just a guideline to the amount of radiation you are exposed to on a regular basis. We are all constantly exposed to this radiation and just have to make the most out of our situation by being wise with how many times we get xrays and paying attention to the types of exposure we will be experiencing. Additionally – I personally believe in keeping radiation exposure to the bare minimum with children because their bodies are still developing and I think it is important to not overly dose them with radiation, even though it is so very little. Every person’s body responds differently so keep this in mind.

The Case of Treatment for Tinnitus

As many of you know, tinnitus can come in many forms. A person may experience hissing, buzzing, ringing or generally strange noises in their ears for no apparent reason. Sometimes the tinnitus can be so bad that a person is bed ridden and unable to perform their normal functions like going to work or taking care of their children. Other people find that the tinnitus wakes them up in the middle of the night and they are unable to get back to sleep. In our society, most people are already sleep deprived, so this is a serious threat to their general health.

It is generally recognized that tinnitus can be caused by several factors. One of the first correlations to tinnitus is actually in your neck. That’s right, when C-2 in your neck is out of place, this can often lead to the symptoms of tinnitus. As a TMD practitioner, I am well aware that when C-2 is out of place, this often will lead to displacement of the discs in the jaw joints as well, so perhaps the displacement of C-2 causes disc displacement in the jaw joints, which in turn puts inadvertent pressure on the ear. This might be how it all occurs, but there is no conclusive proof at this time.

The most logical cause of tinnitus, and the one factor that I have seen to be consistent over the years is that when the articular discs in the jaw joints are displaced, quite often this causes pressure on the ear canal and I believe is one of the leading causes of tinnitus. The reason I believe this to be true is that when the displaced jaw joint discs are treated, oftentimes the tinnitus goes away. If you check out the diagram below, you can see that the normal positioning of the articular discs should be just above the top of the jaw bone. Then, when that disc is slipped forward, or anteriorly, it will have the effect of pushing that jaw bone (condyle) much harder toward the ear canal. And since most of the time a disc is displaced anteriorly, I believe this is what puts the pressure on the ear canal and causes the tinnitus. And since I see tinnitus abating over the course of TMD treatment, there seems to be a strong correlation to slipped discs in my opinion. Sure, there could be other factors involved like damage to the ear itself from trauma, but most every time that I order an MRI after trauma and self-reporting of tinnitus, I see anteriorly displaced articular discs.

Normal Jaw Join Placement v Anterio Disc Displacement

So when someone reports tinnitus as a problem, it would probably be logical to check for displaced articular discs in the TM joints. It’s a great place to start.

In the sketch below, it can clearly be seen how many nerves are within and around the jaw joint. So if the jaw is pushed aside by a displaced articular disc, this can cause pain in the nerves and can disturb the surrounding tissue. Unfortunately, such problems are often overlooked by many practitioners. They are more often trained to treat the symptoms rather than delve deeper into the structural problem itself. With all the nerves that traverse through skull, it is important that the structure of the skull be examined carefully and the practitioner needs to look for any imbalances and displacements that might cause pain/tinnitus/twitching/etc.

TMJ Auriculotemporal Nerve diagram