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:


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

Can Stress Trigger TMJ Disorder?

Sleep and TMJ Therapy Can Stress Trigger TMJ Disorder
You bet it can! When we are stressed, we do not sleep well and this can lead to plenty of clenching and grinding of the teeth. If this goes on long enough, the grinding/clenching can actually damage your jaw joints and displace the discs in the joints that are designed to protect the jaw bones.

In the past few months my office has seen many new patients to the practice and their chief complaint has been pain due to clenching/grinding of the teeth. The stress of dealing with quarantine and the Covid-19 isolation is really getting to people. Many people are worried about their jobs right now and I have met many who have not left their house except to come see me here at the office. They feel like they cannot wait anymore in dealing with the pain.

So why is all this stress so difficult on people? Well, what I personally see is that people are clenching their teeth together more frequently than they normally would. This is actually a fairly normal reaction to stress. It’s just like if we lived 1000 years ago- going into battle we clench our teeth and take a defensive, or offensive, stance in preparation for an attack. Well, stress does the same thing to our body- our sympathetic nervous system is activated- this is the ‘fight or flight’ response as our body prepares to handle an attack (stress). We clench our teeth, our blood pressure goes up, we are unable to sleep, cortisol increases, and we prepare to handle whatever comes our way. Unfortunately, when this happens day after day after day, the body burns out and starts to fall apart. By the time I meet up with this person, he or she is simply frazzled and feels like they have been hit by a train.
The mechanics of this stress is quite interesting. When you clench your teeth, the jawbone or condyle, gets ‘jammed’ high up into the jaw socket and pushes harder on the protective discs that cover the jaw bones. Then you end up with a slipped disc. We all know what a slipped disc in the lower back can do- leg pain, back pain, numbness. In the head, this pain can often be much worse. My new patients are reporting head and neck pain, arm and hand numbness, dizziness, tinnitus (ear ringing), and even various tics. These symptoms are extremely common with TMJ disorder, however, lately they seem to be on the increase.

So what do you do about it? With most of the people that I meet, they want to understand what is really going on and wish to deal with the problem. This is when I order an MRI of the TMJs to figure out if there is any displacement of the little disc in the joint. And in 95% of those cases, the discs are indeed out of place. So basically, what I tell them, is that the discs were probably out of place all this time and the stress kind of pushed them over the edge due to clenching on the joints and more pushing on the discs. For this problem, we have various paths of treatment if they wish to treat the problem. For those people who do not wish to identify or treat the source of the problem, what often can help is a nightly hot bath with Epsom salts and lavender to stimulate the parasympathetic nervous system- i.e. the ‘calming’ nervous system. I personally do a bath like this every night after a long day of seeing patients and hunching over the computer. Another thing that helps a lot of people is to just get out there and walk- every day of the week! Get out in the fresh air and if you have sunshine, well, that’s even better. Sun will help produce Vitamin D on the skin and the Vitamin D will help you sleep better at nighttime. After all, Vit D is not really a vitamin, it is a sleep regulatory hormone. Who knew? Anyway, more on that in a later blog. Another thing that might help is massage therapy and even meditation.

An interesting observation is that the stress is actually helping people to identify an underlying issue that has probably been there for all these years and they really did not know it was there. Perhaps this is a good thing in a way- people are identifying a health problem, due to the reaction to stress, and are dealing with it now rather than waiting until later on when it is more difficult, not to mention more expensive, to treat. So listen to the signs- if your jaw pops and clicks, you have more head and neck pain, then perhaps it is time to figure out what is going on. As I tell all of our patients every day- listen to your body! It knows what is going on. Stay safe. Stay healthy.

The Case of PPE and PSP (Personal Safety Protocol)

The Case of PPE and PSP (Personal Safety Protocol)

Everybody already knows what PPE is don’t they? It’s Personal Protective Equipment in case you are not aware. But today I would like to talk about my own philosophy on PSP- Personal Safety Protocol. Having been a dentist for over 30 years, I am acutely aware of bacteria and viruses in our environment. My own protocol has been like this for many years now. Every morning that I come to the office I will enter the office wearing sweats and a T shirt. In the office I will shower and change into what you see me wearing- pants and a dress shirt. During the course of the day I will wash my hands about 50 times, which leads to dry skin, which then I take care of with lots of Meyer’s clean day lotion- I just love the stuff!

There are a few changes that have been instituted for your own protection when you come to our office. First, we want to make sure you can be nearly ‘contactless’ upon entering the building. The front doors have a button to activate and open them- these are at the handicapped level. Just today, I called the management and asked them to put a foot button at each door as well because I have noticed people actually kicking the button that is at knee level, and the buttons have already been damaged because of that. It will add to our costs, but it also adds to your safety as well. Then, once in the building, you do have to push the elevator buttons to get upstairs- I recommend you use a knuckle to do this, not the fingertip. Knuckles are rarely used to rub eyes and face so I believe this should be safer for you. And when you come to our office, the door is wide open so it is contactless. In addition, we removed the cloth furniture from our waiting room and only have our patients sit in the leather chairs which are disinfected after each visit. We do ask that ONLY the patient or the patient with a parent come into the office. We no longer can have multiple visitors. Another thing that we are doing is we have you wash your hands before and after the appointment and use a pre-procedural rinse that kills bacteria and viruses for the time you are here. It’s a wonderful technique that I believe adds more protection and safety for your visit. And as always, ALL of our operatory chairs are disinfected after every patient and a new plastic disposable head cover is used on the headrest.

At the end of the day, our cleaning crew disinfects our floors. Also, we previously fogged the office every month, but now do this procedure every two weeks. Sure, it’s a bit of a pain, but I sleep well knowing that we do everything we can to protect you. And, just to add more, we are waiting on our UVC light which should be here any day. This will be used to further disinfect masks between patients which is required since our supply chain for masks is still unstable. Once again, we are doing all we can to protect you and your family when you enter our office.

And now back to my day- when I finish here, I change back into my sweat pants and T shirt, drive home after using a wipe to touch the elevator buttons, and leave my shoes in the garage or foyer area. Then I wash my hands and head up to shower and toss the sweats and T shirt into the laundry basket. I have done all of this for many years to protect myself and my family, but since so many of our patients are asking what I do personally, I figured I might as well go through the whole thing.

I am sure some of you will tell me this is a bit too much, a bit of ‘overkill’ as they say- pun intended here folks- ‘overkill’ of the bacteria and viruses. Get it? Good. I, however, feel that I want my office to be as safe as possible for my team and our family of patients who trust me with their health every day. By being perhaps a bit OCD about personal safety and keeping our office as safe as possible, this means there is one less thing you need to worry about during your day. Rest assured that when you enter my office that ALL of us are acutely aware of the struggles and stresses you are all going through and we want to make your visit with us safe and comfortable. Just this week I have had dozens of patients tell me they appreciate all that we are doing and how obvious it is that we are doing so much (Does this mean they think I really am OCD? Hmm…). I may be a little OCD, but at least I admit to being so and I’m darn proud of it these days. So with that I wish you all a safe transition through these difficult times and may you stay healthy and happy. All the best.

What Is An ALF Appliance And What Does It Do

ALF (Advanced Lightwire Functional)

The ALF (Advanced Lightwire Functional) appliance was developed by Dr. Darick Nordstrom about 40 years ago. In working with an osteopath (bone doctor), the ALF was developed with the principles of osteopathy in mind. There principles include promoting movement of the fluids within the skull especially, but these devices also will re-align distorted bones within the skull as well. Our bodies require symmetry and balance in order to work effectively. A good example of this is when your hips are not in alignment- this can cause the legs to be of different lengths which means walking becomes difficult and painful. The same can be said for the bones inside your skull. When the cranial bones are distorted, this can cause nerve impingement which can lead to head and neck pain.

Many of the patients who are treated with the ALF appliances have originally sought treatment for migraines, tremors, vertigo, neck pain, and even seizures. The principle of the ALF is that it will re-align the distorted cranial bones so that the structures within the skull can function more efficiently. Think of it like if your car has been in an accident and the frame has been bent. If you continue driving the car, you notice that the ride is rough- the car vibrates and simply does not run well. This is what happens with distorted bones in the skull- blood does not pump well, cerebral spinal fluid does not move well, and lymph cannot drain as well. And when the cranial bones are distorted, oftentimes the eyes are not level so the patient learns to tilt their head a bit to make their eyes line up with the horizon, and this will have the effect of pulling on their neck. So any distortion to the cranial bones will pull the neck to the side- and this is where dystonia comes from!

With children, the ALF is a valuable tool in preventing many future problems. The research from many years ago confirms that 95% of all children are born with distortions to their skull from birth trauma (that’s right – 95%!). As the years go by, their faces look more uneven – the ears, eyes, eyebrows become uneven. The ALF appliances work to make the bones in the skull more even, more balanced, over time. In addition, most children these days have very narrow dental arches and their teeth are crowded. The ALF can also have the effect of expanding the upper and lower arches to make more room for the teeth, which can prevent the need for extractions! That’s right- instead of pulling teeth out, more room can be gained for the teeth and this will avoid bigger problems later on!

One of the hottest topics these days in dentistry is dental sleep medicine. There is research that now links sleep disordered breathing (waking up a lot at night, snoring, sleep walking, etc) to heart disease, diabetes, and now cancer. There are many dentists who recommend using dental sleep appliances which open the airway and reduce snoring. These appliances to help however, they do not treat the underlying cause. Another issue with these devices is that they tend to create an open bite, i.e. the back teeth no longer touch. This can all be avoided using the ALF appliance. An experienced ALF practitioner can use these appliances to widen the dental arches and make more room for the tongue, which promotes better breathing and will stop snoring in most cases. As you can see, the ALF is an amazing little appliance that is designed for better health- for all ages!

The Case of the Screen Without the Saver

Sleep therapy VA The Case of the Screen Without the Saver

There is now a fair amount of research that indicates children should greatly limit their amount of screen time, hence the title of the blog- more screen time will not save you anything! More screen time means more damage to the body as there is less sleep and less healing. Let me explain. Research is now showing that when exposed to the screen of our TV, phone, and even that little alarm clock, the body does not produce serotonin as well. The light of the screen is telling your body that it is time to wake up, not time to shut down and rest. So here we have countless people who watch TV in their beds at night and wonder why they cannot get to sleep and get a good night’s rest. The screen is not saving them. The screen is not helping them sleep. The screen is actually harming your health!

As many of you already know, much of my training over the years has been in dental sleep medicine. There is now a great body of research in this field and we have learned that sleep is incredibly important to good health. One of the biggest problems we are facing now is that most people seem to have fragmented sleep. What this means is that many of us wake up multiple times each night and this is detrimental to our well being. Our hormones that control the body are not able to recharge like they should and the lack of deep sleep does not allow the body to heal.

So now let’s talk about the average child’s nighttime rituals. Well, mostly it seems to involve a little box with lights and it makes a lot of noise. It seems that many children are on their Android or Apple phones well into the nighttime, talking to their friends, gaming, and reading up on social media. This means that their bodies are being told to wake up. 100 years ago, BC (Before Cells), when the evening came around a child might read a book for a while with gentle light and they would slowly drift off to sleep. Today, that same child might be on their phone up until the time of bed, only to find that they cannot fall asleep. So they toss and turn all night, waking up frequently, and when the morning comes they are too tired to function. Unfortunately, I see this every day.

After enough years of poor sleep, it’s no wonder children are showing more signs of ADD, OCD, and health and behavioral problems. Fragmented sleep is now rampant in our society and there is no sign that it is getting any better. In fact, new research is showing that the current generation of children will not live as long as the previous generation due to the decline in overall health. Could all this be due to poor sleep? Yes- it certainly is contributing to poor health. Every day I counsel my patients to get outdoors and get in the sun and the fresh air. Do they do it? Heck no- they would much rather play games on their phone and log in to social media.

Dear readers – it is time that we re-think our behaviors and make changes that will help us live longer and healthier. Get outdoors! Get some sun on you! All it takes is 20-30 minutes to stimulate Vitamin D production which will help regulate the sleep patterns better. We routinely have our patients check Vitamin D levels and in almost all cases the D is virtually nonexistent. So make sure your ‘D’ is good, get outdoors, and have some fun in the sun!

The Case of the Miraculous MRI…Maybe

The Case of the Miraculous MRI…Maybe TMJ Joint

As you all well know, I like to document our treatment by using an MRI to determine if the discs in the jaw joints are out of place, and to what extent they are out of place. This gives us a great way to track progress and determine if the discs have improved over the course of a year in treatment.

Recently, I had a patient who was one year in treatment and it was time for a new MRI to see if the discs had improved in position to make sure we were on track basically. Her symptoms were most certainly a lot better- i.e. much less pain and better range of motion. Unfortunately, the original MRI showed very prominent displacement of the discs in both joints- i.e. it was bad. The day that we reviewed that MRI I told her that her risk of needing the microsurgery to fix the damaged discs was relatively high, but we needed to ‘work the joints’ as I call it, for about a year to see what can improve.

The original MRI showed the right disc had ‘prominent medial’ displacement which is about as bad as it gets. And the left joint had both ‘prominent anterior’ and ‘prominent lateral’ displacement- again really a lot of displacement. Both discs did not reduce on opening – i.e. they were stuck there and probably had been like that for many years. Another thing that I order on my MRI’s is the angle of the jaw relative to the central axis to determine how out of alignment the jaws were. Those angles came in at 76 degrees on one side and 62 degrees on the other- again, not a good situation but very important information to have to compare for the future.

Back to the story at hand. At one year into treatment, I ordered the new MRI for comparison purposes and told the lady to go back to Novant imaging- the same  people who did the first MRI so that we could get a good comparison done. You already see where this is going: She went to a different imaging center for the new MRI and the report came back stating there was no longer any displacement, nothing was out of place, all was well. Hey folks- I think I am pretty good at this, but not that good!  In all the years I have been doing this work, I have never had such severely displaced discs go back into proper position completely- in other words it’s simply not likely. It’s the same odds as winning the lottery, imho.

This is why good data is so very important. When using an imaging service for the MRI’s, it is really important to maintain consistency and use a company that does these images all day long. Most imaging companies only do MRIs of the TM joints once in a while, whereas I send oftentimes 3-4 patients daily to this one place- and they have become very good at reading and producing good data. So when I got this new report for this woman, I knew right away that the results were nearly impossible and if indeed the report was correct, this classifies as a small miracle! And since I have not seen such a miracle in the past, it was not likely that the discs recovered as much as the report stated- i.e. they did not read it well.

As I sat back and thought about this turn of events, I understood why the lady went to another location for the imaging- it was near her home and they were in network- i.e. insurance paid more. But then as I further reflected on the situation, it made me realize how easy it can be to entirely misdiagnose a TMD case. If the radiologist cannot read an MRI properly, that means there are many cases out there that are being misdiagnosed. So imagine  if this lady had originally gone to a TMD doctor more near her home and if she had the imaging done at the same place as she had done, then it is likely they would have missed the problems and her course of treatment might have gone a lot differently.

This is why TMD treatment seems to be a ‘hit or miss’ kind of thing. Over the past years I have had countless new patients show up here telling me they have been to ‘dozens and dozens’ of specialists- Mayo clinic, Harvard, UCLA, and Hopkins as well. A good MRI proved that the discs were displaced and allowed us to begin proper treatment. Without that MRI to prove what I thought to be true, treatment would never have begun. So therein lies the rub as they say- taking a shortcut on diagnosis does not benefit anyone.

The Case of the Happy New Year

Sleep TMJ Therapy VA The Case of the Happy New Year

Here we are starting a new year folks- it’s 2020! As I look back on what happened in 2019 I realize that our practice has hit some new highs that really need mentioning. My team and I have helped thousands of people over the years to improve their health and well being and I am extremely proud of my team for making this happen. I feel very blessed to have such a group of people that I call friends, and even family. Together, we have made a positive difference in many, many lives and I am truly thankful they are with me.

And now for 2020: we are going to help more people this year than ever before. I am currently heading to another dental sleep medicine program this coming weekend and it is geared up for both myself and my team members. This is one of those ‘few and far between’ programs that is designed to have the doctors train at reading various graphs and sleep studies while team members learn about how the lack of sleep affects a person’s life and how we can really help them get better.

As for me personally, I am in the middle of my studies to become a Diplomate of the American Board of Dental Sleep Medicine. This is quite a large amount of work. I fly to Boston every couple months, study articles and reports, write a synopsis of everything I study, and I just passed my first exam. This program is being done through Tufts University and already has given me new insights into how to better treat our patients.

One interesting thing that I learned from the Tufts program is that more emphasis needs to be placed on the TMJ and how dental appliances might help or hurt the joints. I have already brought this up with the directors of the program and they are considering making a few changes here and there. I personally believe that the ALF appliance that I use every day is the best course of treatment for sleep apnea because it makes very slow, very gradual changes that improve the shape of the jaws for better breathing. These days, when I deal with sleep apnea patients, I offer them the dental sleep appliance if they just want something to get by for now, or, alternatively, I offer them the ALF appliances to actually fix the apnea. That’s right folks- I am talking about really fixing the apnea situation once and for all. What the ALF does is that it widens the upper and lower dental arches which makes  more room for the tongue, and it slowly lowers a high palate which means you can breathe better through your nose. This is really important because nasal breathing promotes the formation of nitric oxide which helps you to heal better.

This year I am planning to teach in a few locations to help spread the word about what our practice does. If all goes well, I will be teaching in Warsaw, Poland, in the fall and plan on showing many of my own cases done in this office. It should be a fun journey and I am quite sure the doctors that I teach will be able to help their patients in a better fashion. Overall, it’s going to be a busy year with much more education and changes in our sleep protocol that will improve more than ever before!

The Case of the Thanksgiving Thoughts

The Case of the Thanksgiving Thoughts

As another year comes to its end, I am just sitting here thinking of how very blessed I have been. I truly am thankful for all the people that have trusted me over these many years and I am thankful that I have been able to contribute to the betterment of their lives. Although what we do is not an easy process- it does take time to unwind the pain that has been there for so many years- we have proven that this process works really well and we have many successes over these past years.

One of the main reasons that I believe we are so successful is because of my team- they are the best!  I am very lucky to work with a team of seven people who run this office like the well oiled machine that it is. These folks are hard working and really understand that our patients need to feel cared for and appreciated at the same time. My team members exude confidence in what they do and the patients really pick up on this. Our patients know that my team knows what they are doing and know that I trust what they do! By having such a highly trained group of people working with me, I am able to focus on taking care of 20 patients each day and never have to rush through our discussions and planning sessions because I know that my assistants are just down the hall taking great care of another patient and I know that my front desk team is handling everything else. This great group of people makes sure that my day is productive and the patients are well handled at all times.

I would like to also point out that I am ever so thankful to the many patients of ours who have referred their friends and family to our office over the years. It is truly remarkable to meet a new patient only to have them tell me they are related to Mary or Sam who I treated years ago! As I look back on just today for example, I can look at the schedule and feel thankful that so many of our patients said “Thank you Dr. Brown” as they report feeling better as each month passes. It is I who is thankful for all those people who have put their trust in me and will give me the time it takes to make them feel better.

And so another year comes to an end, another chapter in the life of ‘Sleep and TMJ Therapy’, and a few more gray hairs show on top of my head!  ?  The journey has been amazing and shows no signs of slowing down anytime soon and I am right there having fun every day of the week! Thank you all for all that you do!

The Case of the Initial Exam and Consultation

TMJ diagnosis The Case of the Initial Exam and Consultation

The purpose of this blog is to inform our potential new patients how we do the initial examination and consultation, so you know what to expect when you come in for your visit. First of all, many of our new patients already know that they have some kind of TMJ problem- i.e. their jaw joints pop and click or get stuck open or closed. Many of them also have pain in their joints as well. This is usually what prompts a person to call and come in to see our office. And so when that first visit happens, it is a screening process to determine whether or not you really do have an underlying TMJ problem and whether or not you are in the right office.

When a patient first comes to our office, they will find the exam a bit interesting because they sit in a bar stool, not a dental chair. After a few minutes to review their symptoms, I will actually ask the patient to sit up straight and look directly at my nose to give them a focal point. I will then look at that person- I look at the eyes/eyebrows/ears/nose/shoulders/neck/etc to determine if there are any imbalances present. And in almost all cases I see that the ears and eyes are not level. This means that the bones inside the skull- the cranial bones- are not level or balanced. After the initial observations, then I will glove up and start pressing on many of the muscle groups that are attached to the TM joints. If these are a bit sore or painful, it leads me to believe that the discs are out of place. If you have popping or clicking in the jaw joints, this also means it is likely that the discs are out of place and further examination is needed to determine the extent to which those discs might be displaced.

If I suspect an underlying jaw joint problem, then I will order an MRI of the TM joints. This means that we are not ‘fixing’ anything on that first visit. Diagnosis is critical! If you follow me on Facebook I am constantly preaching that you MUST take the time to figure out the real problem and document it carefully. So, 95% of the time, I will send you to another location to get an MRI of the jaw joints. This requires that you schedule your MRI with either Novant or Inova Radiology and you will either pay them directly, or your insurance will cover this procedure.
Once the MRI is done, it takes a few days for the radiologist to review it and come up with a report. At that point, you are ready for visit #2 with our office- the next consultation and the MRI review. This is the visit where I will personally review the findings of the MRI and show you what your joints look like on the imaging that we pull up on the computer. I have direct doctor’s access to both Inova and Novant imaging services so I will be able to show you exactly what is going on. It is important that you as the patient understand your situation prior to treatment. At the MRI consultation visit we will discuss the options you have on your course of treatment and I will provide you with the information you need to make an informed decision. At that time, you will understand the appliances that are recommended and what they will do to help your condition. Again- at this appointment we are not actually ‘fixing’- we are talking and planning. If you are ready to begin treatment right away, we will take the actual impressions that day to make the appliance(s), however, most people want to know what insurance will cover. That could take weeks or even a month or so since insurance companies do not react very quickly.

As you can see, this is not simply a process of walking into my office and I get right down to fixing the problem. It takes time to diagnose the problem and to document it carefully. Now we have a baseline to work on getting you better! Ideally, we would like to have a three dimensional x-ray as well, but most patients want insurance to pay for that, so we do not take the x-ray unless they are really ready for treatment.

There you have it- two consultations visits to gather information and formulate a plan and from there we are able to begin the actual treatment.

It’s TMJ Awareness Month!

It’s TMJ Awareness Month!
As November rolls around, I have been made aware that it is officially TMJ awareness month. So, what is this TMJ thing? What does it do? Why is it so important? Well, it all begins with a little piece of tissue that is on top of your jaw bone and is supposed to cushion the jaw as you open and close. It’s sort of like a knee cap on your knee, but it’s on top of your jaw bone. When this little piece of tissue slides off the jaw bone, it can literally wreak havoc with your entire body! Let me explain. First of all, TMJ refers to the Temporo Mandibular Joint. Inside this joint is where the top of the jaw bone (the condyle) resides, and on top of the condyle rests the articular disc. There you have it folks, all the anatomy you need to understand TMJD (temporomandibular joint disorder).

So now let’s talk about displaced or slipped discs. Imagine that your doctor informs you that you have a slipped disc in your lower back. The light bulb goes off in your head and now you understand why you have pain in your legs and/or back. It just makes sense because we have all heard about slipped discs all our lives. Very few people, however, understand that slipped discs in the jaw joints can cause all sorts of health issues like headaches, migraines, neck pain, back pain, and even tics and numbness. Most of the patients who come to my office have already been to ENT’s, neurologists, regular MD’s, dentists, and even psychologists to figure out what is going on.

A really good way to figure out if you have TMJ disorder is to measure how big your mouth opens. Measure from the tip of the upper front teeth to the tip of the lower front teeth at the most you can open your mouth. This should be around 50 mm. If you only open to 35 or 40 mm, the odds are that the articular discs are likely out of place and will block your ability to open your mouth widely. And if those little discs are out of place, they are going to pinch blood vessels and nerves that travel through that joint- and there are so many of them!

So many people suffer needlessly from slipped discs in their jaw joints. It is relatively easy to take the pressure off the joints and promote healing, however, many people do not deal with the problem while it is easier to fix. Many folks wait until it is quite painful and are hoping there is some kind of quick and magical cure for this problem. There really is not- it takes time and patience to give the discs a chance to get back into proper position. Many times, we are able to move the discs into a better position and that is when the patient notices the relief they have been wanting for so very long.

By being aware of the TMJ and the various problems slipped discs can create, you can help yourself and others who are close to you. If you or someone you know has popping or clicking in the jaw joints, this indicates that the discs are out of place and need treatment. In my office, the first thing we do is assess the situation and see if a problem actually exists. If there appears to be a problem with the TMJ, then an MRI of the jaw joints is ordered to determine how displaced the articular discs might be. At the next appointment we review the options and show the patient the MRI findings. From there, a plan for treatment is developed. Generally, we work with our patients for a year or so to help the discs get back into proper position. This is Phase I as we call it and the goal here is to help those discs get back into place if they are able to. From there, we will figure out how to finish up, so you no longer need to keep up with our office on a regular basis. Our success rate is extremely high, and as with all things, the sooner you deal with the problem, the more likely we can get you better. So now you know a little more about TMJ disorders and what to do about it. Schedule a consultation for a screening so we can assess the situation and get to the root of the problem.

Here are some of the symptoms you might want to look for to help you in understanding TMD Disorder:

  • Locking of the jaw and inability to open or close your mouth
  • Pain in and around the ears
  • Jaw pain and tenderness
  • Headaches and/or Migraines
  • Neck/Shoulder/Back pain

Some of the causes of TMJ Disorder include the following:

  • Poor posture- in today’s modern society we are notoriously hunched over a computer all day and this is highly contributory to TMJD
  • In the event of an injury the discs are more likely to be knocked out of proper position
  • A misaligned bite or previous orthodontic treatment that did not pay attention to the articular discs
  • Teeth grinding and/or clenching
  • Bony defects like arthritis

In my office we also coach our patients through the process of treatment and teach many different exercises to alleviate tension through the head/neck region. These exercises ( are posted on our website and include head movements, tongue exercises, and even meditation.

Spread the word about TMJ Awareness Month by sharing this blog!

The Case of the Apnea and the Attack

sleep anpea disorder VA treatment The Case of the Apnea and the Attack

The heart attack, that is. When a person has sleep apnea, their entire body no longer functions the way mother nature intended. The hormones do not recharge properly, the body does not have the ability to heal correctly, and you just plain feel awful most of the time. As someone who has in the past suffered the effects of sleep apnea, I can testify that it really is not much fun waking up tired, waking to a head ache, and feeling like you just cannot get out of bed some days. And now that I treat these cases, I hear these things every day in my new patients. They feel awful and just don’t know what to do about it.

Well folks, at this point I might as well add on another little concern. When a person has sleep apnea, their body is simply not getting enough oxygen for the body to heal. They are in a state called ‘hypoxia’- which simply means the oxygen is too low in the body. There has been a fair amount of research into this area and we have now learned, much to my chagrin, that sleep apnea now directly correlates to cancer risk. OH CRUD! The research indicates that the low oxygen allows the cancer cells to thrive better than they can in a high oxygen environment. So now, let’s review all this. Sleep apnea not only leads to heart disease and high blood pressure, but it also correlates to diabetes, and now to a high risk for cancer.

And now let me add on some other observations that I made recently. Just yesterday I went to the grocery store to buy more organic non dairy creamer for my team (they refuse to put the regular junk into their coffee) and I just started looking at the other shoppers- 90% of their were actually obese. I was thinking- is this the new norm? Is this what people look like now in general? I recall a photo from Facebook a few weeks ago. It showed a picture from the beach at that time. NO ONE was overweight-everyone was generally normal sized if not thin. A few months ago I noticed that more than half of the beach goers were extremely overweight over at Fenwick island- near Ocean City, MD.

As I thought about all this, things started to come together even more. Hmmm- sleep apnea means that your hormones are not able to re-charge properly so the hormones that control eating are out of whack. You can’t control your eating habits very well due to the apnea, this makes you eat more, you feel like crap from over eating and now you can’t even sleep well at night. What a vicious cycle this is! Pretty soon you are on medications to control the high blood pressure and the weight and now you have to worry about cancer as well! It really stinks having sleep apnea, doesn’t it?

So what can you do about it? Well, because I see so many apnea patients each day, I try to have a nice little chat with them about what is going on because I think understanding the problem is the first step toward fixing it. One of the first steps toward a real fix is exercise- simple as that. I now tell, not ask, all my patients to get out there and walk at least 20 minutes each day. This is where they start the process. Of course, we do a sleep study and analysis of their sleep patterns, but this needs to begin with something in which the patient takes charge of their condition, and I think walking is a great start! From there, we have lots of work to do, but let’s keep it simple for now and I’ll see you in the next blog.

The Case of the Xray vs the MRI- Who Wins the Battle?

Sleep TMJ Therapy Xray MRI Falls Church VA

When it comes to TMJ disorder, there really is no contest here. The Xray AND the MRI are critical to a really good diagnosis. First of all, when the jaw joints pop or click upon opening and closing, it is likely that the articular discs are out of place. The discs are made of soft tissue, basically like cartilage, so only an MRI would tell you if they are in the proper position or out of place. Over the years I have learned that the MRI is quite difficult to get done properly unless the MRI center has a lot of experience at doing this. I only allow our patients to go to Novant imaging for that reason. They have a dedicated Tesla coil for this imaging and know what I expect. In addition, I only have my colleague, Dr. Nick Patronas, do the reading. I really do not allow any other radiologist to look at the MRIs because I have found that Dr. Patronas does the best, most concise reading that I have ever seen. And this is what allows me to know the status of the discs in the joints. This is the view of the ‘soft’ tissue.

The view of the ‘hard’ tissue, i.e. the bone, is done through the xray. Xrays are designed to view hard tissue and will not allow you to see the disc tissue. The distinction is quite important. Xrays are indeed radiation so you want to limit how much you allow in exposure to the patient. The MRI, however, is magnetism so really no worries there. When it comes to xrays, you want to be sure you get a lot of bang for your buck here- i.e. minimal radiation exposure but maximal information gain. For this reason, I am luck to have the VA Tech i3D machine. It basically does 3-D imaging of the head/neck region so I can view not only the jaw bones (the condyles) but I can also see the cranial bones and the cervical spine. This is a lot of information that helps in the diagnosis and treatment for our patients.

So as you can see, dear readers, the twain are indeed not at battle with each other, yet they must coexist together on the same plane (wow, that was rather eloquent if I must say!). With both the xray and the MRI, we are able to view both the hard and the soft tissues in the jaw joints and the skull. With this knowledge comes a better understanding of what is happening in the TM joints and then we can better formulate a plan to help you. I often have people ask why they cannot just do an MRI, or just an xray, and this is because the two work together – i.e. no battle!

The Case of Not Knowing What You Don’t Know Until One Day You Find That You Didn’t Know It

TMJ disorder treatment VA The Case of Not Knowing What You Don’t Know Until One Day You Find That You Didn’t Know It

This was sort of a frustrating one that happened the other day. A perfectly lovely woman came in for a consultation for TMJ disorder, because that’s what I do, and her comments were very interesting. She explained that she went to someone else nearby for a TMJ consult and the doctor was bragging that not one of his patients ever needed surgery! She was surprised that I told her that surgery was always a possibility and that is why I do an MRI to understand the status of the jaw bones, the joints, and the discs. She also told me this other doctor never does MRI’s because he does not feel it to be necessary. To me, this was a dangerous position to be in- not being aware of the status of the joints and just assuming all was well. You know what happens when you assume (you make an ass of u and me).

Well, dear readers, as you well know, we ALWAYS do an MRI. And as you already know, the reason for this is that we must establish a good baseline to compare how we are doing during the course of treatment. It is important to document the position of the discs in the joints so that we know if things are improving. In almost all cases, the discs do improve and this is what we want to see.

The problem with not documenting with an MRI is that if the condyles (jaw bones) are eroding away and you do not track the progression of the disease process, you are not doing well by that patient. In so many of our new patients, the MRI shows long standing degenerative arthrosis and condylar erosion. So let’s imagine you go to the dentist who does not do an MRI. Even though the patient might be feeling better over time with the appliance therapy, the erosion continues and gets worse, yet the patient does feel better overall. Without the proper tracking mechanism there could be catastrophic failure one day. What that means is that the eroded jaw bone is so damaged that if the patient fell down on the ice, slipped in the rain, got hit in the head with a soccer ball, well, you get the picture, then that already eroded jaw bone could snap or break. And this means a major surgical procedure to fix it.

It would have been so much, much easier to just do an MRI at the beginning and redo that MRI every year or two to make sure things are ‘holding their own’ and not eroding. As you all know by now, I see about 100 patients each week who have TMJ disorders. Of those, 1 person or 1% will need surgery. That’s a pretty good percentage I believe. But I do have many other patients who I am ‘tracking’ over time. They have some erosion of the condyles due to the displaced discs, yet they do not want to do surgery or simply cannot do surgery for whatever reason. My job is to keep them well informed of their situation by periodically doing the MRI and monitoring the status of the discs, the joints, and the condyles. This way, if and when we see erosion or break down occur, we can discuss the surgery option and let the patient decide what they want to do. That’s all I’m saying folks- track the progression and keep the patient informed. You never want to learn that you did not know something that you should have known.

The Case of the Way We Work and Why it isn’t Working

sleep tmj treatments The Case of the Way We Work and Why it isn’t Working

Every day in my practice I meet new patients who have what is called FHP (Forward Head Posture) and realize this is starting to become the norm, not the exception to the rule. We are all so attached to our little phones and hunch over them all day long that our necks are now out of place all the time. Just yesterday I had spoken to a young lady about her rolled shoulders and head craned forward as she texts her friends and watches videos. She then straightened up nice and tall…for about 30 seconds…and then re-hunched (this should be a real word!).

A few weeks ago I was at Dulles Airport on my way to Toronto and was noticing how most people were hunched over their machines- phone or tablet or computer. I thought gee, maybe I could invent a device that they rest their head into to make the ‘hunch’ more comfortable. Think of something like a chin rest where you lean forward and rest your chin into a cup like device so that the neck does not get too sore for the hours upon hours of doing your work or just surfing on your devices. Would I really make such a device- no! Just kidding folks.

As each day goes by and I meet my usual 3-4 new patients, I am noticing a trend. More and more of them are slouching over at our initial consultation meetings. Most of these folks are on the computer all day long and it just becomes a habit to hang their head forward. This forward posturing will also tend to make your jaws slide forward, which in turn will close down the distance between C-1 and C-2 in your neck, which will adversely affect the TM joints. When I see this happening, I explain to the person how they really need to work on posture and be aware at all times. It’s not easy, and I am the first to admit that it kind of feels good to lean forward while on the computer, but hey, it is not the healthy way to go!

So, dear readers, take a look at yourself in the mirror. That’s right, stand up and take a good look at yourself from a side view. Are you bent over? Do you look like the hunchback of Notre Dame? Maybe you could even take a look at your fellow workers and help them as well. Maybe, just maybe, you all should look at each other and practice good posture and getting that neck more upright. I even have some neck stretching videos on my website that will help- check them out. So take a good look and make yourself better!