Welcome to
the Stanford Health Library.
Thank you for
coming here tonight.
My name is Michele Jehenson
and I work at the orofacial
pain clinic at the Stanford
Pain Center in Redwood City.
So today's topic
is TMJ disorders.
TMD, I'm going to speak about
the nature of the disorder.
What a TMJ disorder really is.
I'm going to also talk about
who is at risk for TMD.
And finally, I will touch on
the common treatments that
are recognized as
evidence-based treatment for
TMJ disorders.
So, I guess it's customary to
talk about disclosures as
to if I'm affiliated with
any kind of pharmaceutical
company or anything like that.
I have no disclosures
to be done.
So, I wanted to first show
you the anatomy of a TMJ.
It's a joint that is
very unique in the body.
It's one of a kind.
There is a one disc, and
you can picture it as a donut.
So, it's a circular,
biconcave, just a donut,
just doesn't have the actual
hole in the middle.
So it's kind of like
a donut shape, and
it separates the jawbone,
which you see as the rounded
bone in the picture,
from the skull.
And particularly, the fossa,
the articular fossa, and
the eminence that you see
to the right of the fossa.
So the disc is flexible.
It's fiber cartilage, and
it offers a perfect interface
between the skull and the jaw.
It allows for smoother motion.
The joint is also particular
in a sense that not only
it allows rotation of
the joint, but it allows for
forward motion of the jaw.
So, if you put your hand
like slightly over your,
in front of your ear and you
open your jaw wide and slow,
you can see that initially,
it just starts rotating and
then you can feel it
actually advance forward.
And for some people, you can
actually feel it coming out
slightly, because even though
the jaw is seemingly fixed,
the suture that is in
the front, it allows for
certain flexibility in and
out of the joint itself.
So, what is a TMJ disorder?
So, a TMJ disorder
is defined by pain,
either at rest or
upon function.
It is defined by something
that is a painful noise.
It can also be just
a dysfunction,
like a limited range of
motion, or a jaw deviation
such as this, like when you
open you go to one side or
you are unable to go from
one side to the other.
Or a sudden unexplained bite
change, like you wake up and
your jaw is to the front,
or to the side.
Those are considered
TMJ disorders.
They can be associated
with headaches, and
ear aches, or ear pain.
So, the prevalence
is 5 to 12%.
Vast majority of them women.
And the age group is between
puberty and menopause.
And there's some research
suggest that there's a link
with hormones as
the cartilage and
the TMJ has
estrogen receptors.
So that would make sense since
the age group is, you know,
puberty to menopause.
So that leaves us to,
what is not a TMJ disorder?
And it's pretty obvious.
If there's no pain,
no dysfunction.
Dysfunction is if you're able
to open your mouth wide,
if you're able to
chew without pain,
you don't have a TMJ disorder.
You may have noises,
you may have joint noises, but
you do not have,
by definition, a TMJ disorder.
You can have abnormal
findings in an MRI or
an X-ray without
having a TMJ disorder.
There are a lot of people,
and certainly, most of us
over 40 will have some type
of changes on an X-ray, even
though we are still completely
asymptomatic, and we can chew,
and we can open our mouth
without any restrictions.
So, that's kind of something
that comes up a lot.
I mean, I get patients
who come in because
they have joint noises.
Because they have been
told by their dentist that
they had a TMJ disorder.
Or because the dentist
saw on the X-ray that
there was something abnormal.
So, of course,
we can determine it.
But by, as a rule of thumb,
if you don't have any pain or
dysfunction, you don't
have a TMJ disorder.
You don't have to worry, 'kay?
60% of people pop and
click, so
it's a very common incidence.
They don't really consider
it a disorder because
it's a variation of normal,
at this point.
I will come back later about
the popping, the mechanism for
popping and clicking.
But I wanna touch on
remodeling of the TMJ,
which sometimes occurs in,
you see on an X-ray.
So if you look at this X-ray,
the TMJ's right,
this is one TMJ,
this is the other TMJ, right?
Right and left.
So it should be
kind of rounded and
it should have a continuous
white line around it.
And you see here,
it is a little bit flatter
on the top but it has
a white line around it so.
When it has a white line
around the perimeter
of the condyle, it's
considered remodeling, and
remodeling is a process
of bone changes.
And the bone is
a dynamic structure,
it's not like there to stay.
Like for example, if you've
ever had braces, what
allows the teeth to move is
actually the bone remodeling.
On one part,
you have some bone destruction
that allows it to move,
and then the bone rebuilds on
the other side of the tooth,
so it's a completely
normal and
natural phenomenon
to a certain extent.
So, if it's a slow process,
and if it's an adaptation
process, it's normal and
it doesn't give people
any trouble whatsoever.
So this is considered
a very normal cone beam CT
scan of the jaw.
Which doesn't mean
the patient is asymptomatic,
they can have pain
with a normal X-ray.
That's the thing.
That's the other thing.
You can have absolutely no
pain with a terrible
looking X-ray, and
we can have pain
with a normal X-ray.
So, what types of TMJ
disorder are there?
Well, we classify them as
TMJ disorders involving
the muscles of mastication,
involving the joint itself or
part of a systemic disease.
So the muscle disorders
are for the TMJ, and
the muscles of mastication are
just exactly the same as for
any muscles in your body.
There is muscle ache,
restriction of range of
motion, fibrosis, tendinitis.
You know, you've had.
Some people with tennis elbow,
you can have tendonitis
of the jaw as well.
So, the muscles of
mastication, and
you can feel those as well,
are usually for the most part.
The masseter and
the temporalis muscles.
Those are the ones that give
people the most trouble.
So if you feel here, and you
put your teeth together, and
then you clench really hard,
you will actually
feel a bulge, and
that is your masseter muscle.
If you put your hands up
here by your temples, and
do the same motion.
You can also feel
a muscle bulge, and
that's the temporalis muscle.
It's a fairly thin muscle,
but very, very wide.
Both of these muscles help
to bring the jaw closed.
So, a lot of patients
who come to our practice
have myalgia or myofascial
pain in the temporalis muscle,
I mean temporalis muscle,
sorry or the masseter muscle.
And that translates
into very often,
limitation of their
range of motion.
They cannot open their
mouth really wide or
they develop pain.
So that's a very
common TMJ disorder.
Medial pterygoid is the one
that is the mate, if you wish,
of the masseter muscle, but
on the inside of the jaw.
And the lateral pterygoid is
the muscle that allows you
to bring your jaw from
side-to-side, and
bring your jaw forward.
So, it's a tiny little muscle.
We can't palpate it,
but occasionally,
it causes problem,
even though it's pretty rare.
Then moving on to
joint disorders.
We can have a joint
disorder that is
directly associated with
a disc dysfunction.
Remember that little donut
that I was showing you?
It's held by ligaments and
it goes forward and backwards.
So there's a lot of
possibilities for
things to go wrong as
far as this little disc.
There are, there's trauma of
course, I mean fractures and
so on as well as systemic
diseases such as arthritis,
rheumatoid arthritis,
lupus, and the likes.
As well as, of course
I didn't mention this,
I have some slides on
tumors of the jaw.
So again this is
the same slide.
I'm never really quite sure
how you pronounce this.
I usually say
ginglymoid-arthodial joint,
which is the type of
joint that the TMJ is.
So it just means it
rotates and it slides.
So the rotation, lower part
of the joints or the disc with
the condyle, so the condylar
rotates in relation to
the disc and the translation
is the whole disc, and
condyle move forward.
I tried to find a video, but I
could only go through YouTube
and they were mostly
dissection videos [LAUGH] so
I didn't think that
it was a good idea.
This is an MRI
picture of the disk.
If you see a little hourglass,
darker.
Can you see a little
darker shadow
in the shape of an hourglass?
Well, this is what
a normal disk looks.
And it is held by ligaments
on this side, ligaments and
muscles on this side.
So, here, it is the same disc,
but in a more, in a mouth that
is wider open, and you can see
that the disc is moved forward
in relation to this eminence.
So again,
this is a closed mouth,
and this is an open mouth.
And this is a normal
position of the disc and
normal position
of the condyle.
So, what kind of
dysfunctions are there?
So we'll start with probably
the most common, and
it is when the disc.
Which you can see here in the
picture or here in the model
is completely interior
to the condyle.
If you look back at this one,
the back of the disc is
located as 12 'o' clock in
relationship to the condyle.
On the anterior disc displace,
it's actually way,
way, way forward.
And it's impossible for
the condyle to get into
the middle of this disc.
It's kinda stuck behind it.
And so, usually,
it's something that
happens very suddenly either
while you're eating or
sometimes when you're yawning
or pretty abrupt motion.
And, all of the sudden,
you won't be able
to open your mouth.
It's a very sudden event.
And, sometimes it will
last for several hours.
And, also,
it will suddenly get better.
Or, you'll have to
go to a dentist,
and help put it back in place.
So this is is
the unfortunately,
this is in an opening motion.
So this is closed jaw and this
is a little bit further open.
But you get the idea.
It usually is painful,
but not necessarily.
But, if you try to open,
it will be like you're
hitting a brick wall.
I mean, it, there's just
no give whatsoever.
And, this is where I come back
to the benign clicking that I
was talking to you about.
The benign clicking.
Oh, there's a spelling
mistake there.
Sorry about that.
No?
>> No.
>> No, no.
There is no scent, oh, good,
good.
Okay, good.
So, the benign clicking,
the clicking that 60% of
people have and don't have any
problem with it, actually, one
of our camera people showed
that to me earlier today.
How many of you have clicking?
Do you have any symptoms
associated with it or
do you just have
benign clicking?
No pain.
No dysfunction.
Like most people
have that situation.
So what it is, is in here
as you can see in figure a,
the disc is also
anteriorly displaced.
But, during the opening motion
the condyle is actually able
to go past the posterior part
of the disc, which is slightly
thicker to get and fall into
the middle of the disc.
And this is the passing
through and
over the back of the disc
that creates the noise.
So it's just
a functional noise,
I consider it a nuisance.
There's nothing you
want to do about it,
there's nothing you
should be doing about it,
no surgeries,
no treatment whatsoever.
During the course of your
lifetime it might change,
it might become a little
bit later in the motion.
Let's say when you're 18, it
might be really early because
the disk is just a little
bit anteriorly displaced.
And then as you get
older it might be,
you only have a click when you
open your mouth really wide.
I only have a click
now when I yawn, but
I used to have
a click all the time.
And it was very
convenient because
I could demonstrate it to
my patients, you know.
So, this is not necessarily
going to evolve to a lock.
For the vast majority of
people clicking will never
evolve to a lock, but
it's not,
nobody's able to predict it.
This is another one that
people have probably heard of.
It is an open lock, and
it's actually a subluxation of
the entire joint in front
of the articular eminence.
And the joint is basically
not able to come back
over this bump here and it's
being stuck because the pull
of the muscle's actually
maintaining it in that fascia.
So the more people try
to close their mouth,
the least they're likely to
because the pull of the muscle
does not allow
the jaw to go back.
So this is fairly rare but
it is an emergency
because you cannot eat,
you can hardly swallow,
you cannot talk and it is
something that necessitates
medical attention to reduce.
And usually I don't see
those patients because those
patients go to an emergency
room right away.
I do see quite a bit of close
lock, and unfortunately,
I don't see them as
early as I should, and
by the time I see them, the
treatments are more limited.
But the open locks, they go
to the emergency room, and
rightfully so.
This is a posterior disc
displacement with the disc
instead of going forward,
goes backwards.
This is very rare.
I've actually never
seen a single one and
I was unable to find a single
picture online [LAUGH].
But it does happen and
in those situations,
extremely painful.
It's a very,
very painful condition.
Also, rather suddenly, and it
translate the symptoms is that
you are no longer able to
bite down completely and
it's very, very painful to try
to put your teeth together.
Then we come to arthritis,
a systemic disease, and
all of them will kinda
like this on an X-ray,
a lot of degeneration
of the bone.
It's only further testing
that will show what kind of
disorder it is.
Of course, osteoarthritis
being the most common.
The great news in terms of
the osteoarthritis of the TMJ
is that it is unlike
osteoarthritis of the knee,
which is a situation where
you have the knee that
degrades to the point
where you're gonna
have to have a joint
replacement.
Arthritis in the TMJ
is self limiting and
will eventually burn out.
And the reason for that, is
that, as opposed to the knee,
that has high line cartilage,
which is a type of cartilage,
where it doesn't have any
kind of blood supply in it,
the TMJ is covered with
fiber cartilage, and
so the fiber cartilage
will regenerate.
The joint will never look
normal because the bone is
gone but
the layer of cartilage will
reform over the joint.
And eventually people
with osteoarthritis of
the joint will be able to
function without pain and
fully like before.
So that's a great thing
to tell patients who
are pretty scared when
they see their X-ray.
And believe it or not,
a really terrible X-ray can
be seen in 16 year olds.
And when you have a 16
year old that come in and
with their parents, usually,
and they're told that they had
arthritis, it's kind of a,
it's not a good thing.
But if you tell them that
eventually they'll be okay,
it's a lot easier to
have a conversation.
So this is another one
of those X-rays, and
the difference between this
one and the one that we saw
before, where there
was just remodeling,
is that if you look, instead
of having the line that
goes all the way around,
just like on this view.
For example, on this view,
it's the way we want it.
But on some of the views,
you could see there's
a little bit of shadow.
There's not quite a line here.
Same thing here.
We lose the line at this
point in the image and
that's the sign that there's
an active process happening.
That's the difference
between the remodeling and
the active joint degeneration.
So this is a terrific image,
it's totally underused.
It's called
a Cone Beam CT Scan.
It's available in some
of the dental offices,
and ENTs use it as well,
because you have a pretty good
view of the sinuses, and
oral surgeons use it, but
it's a lot less radiation
than a regular medical CT,
and it gives us such a better
image of the joints.
This is another picture
of the degeneration.
This is a 23 year old.
I mean, this 23 year old
has lost so much anatomy.
You see it's really flat and
it's really flat
here as opposed to
the rounded curves on both
the eminence and the condyle.
I mean, for a 23 year old,
that's pretty dramatic.
I have a couple
slides of tumors.
This is an osteoblastoma
of the jaw.
It's pretty obvious
on the X-ray as well.
Usually, very slow-growing.
These are more,
this is from the condyle,
you see that bulge here and
over here, you have a cyst.
So, all these are benign,
the first one was not but
these two are benign.
And usually, unless they
interfere with function,
if the patient can open and
close, we leave them alone and
watch them.
But that determination
has to be done on
a case-by-case basis.
And the one thing you wanna do
is eliminate the malignancy.
You wanna make sure
the tumor is not malignant,
other than that, you know,
you just watch it.
So it comes to the really,
really interesting and
controversial question of
what causes a TMJ disorder.
And there's a lot of debate
about it, because in the, even
within dental professionals,
I mean, when I was in school,
I graduated in 1988, they were
teaching us that TMJ disorder
was due to a bad bite.
And that the treatments for
TMJ disorder was
to make the bite a perfect
bite or improve the bite.
I mean that was 30 years ago,
you know.
So it definitely has
changed since then.
And in the dental community,
some people are still adhering
to principles that are no
longer based on evidence.
And certainly,
that assumption that is not,
I mean, the fact that it's not
caused by a malocclusion or
bad bite has been studied.
It has been studied and
the results are very clear and
very consistent because they
have studied people, a group
of people, who had perfect
bites and no TMJ disorder.
They created some
interference.
So they changed their bites so
that they didn't have
a bad bite anymore, and
they left them like that for
six months.
And they came back and they
still didn't have more TMJ
disorder than
the general population.
Conversely, they took people
with TMJ disorders and
a bad bite, and
they corrected their bite, and
they followed them up, and so
there's no relationship with.
So people who say that you
need orthodontics to cure TMJ,
it's just not
based on evidence.
And unfortunately,
that is done pretty commonly
in certain circles.
And of course,
in academics we don't do that.
But that's something I want
my patients to be aware of,
because that's a very costly
proposition, of course,
you know,
if you have to have braces.
Or another thing that
we know is that,
of course blunt
trauma fractures,
motor vehicle accidents,
they can cause a TMJ disorder,
right?
However, I have seen patients
with fractured condyles
at a 90 degree angle who
came to my office, sent and
referred by their dentist,
who had seen the x-ray.
And the same patients had
no dysfunction, no pain.
So, it's very variable,
as far as presentation,
but definitely you can say
macrotrauma, blunt trauma,
can cause a TMJ disorder.
Microtrauma or load is what we
always traditionally thought
caused the TMJ disorder.
Microtrauma or
load would be grinding,
clenching, going to
the dentist, having surgery,
long openings, yawning,
chewing hard foods.
Traditionally, especially
grinding and
clenching were associated
with TMJ disorders.
And I'm going to come back
to that particular item
in a little while.
Persistent pain is
also an etiology and
persistent pain is more, there
is no finding on an x-ray,
patients just have pain.
And those types of patients
are more in the spectrum of
fibromyalgia, IBS,
chronic migraines, and
TMJ disorders fall in
that same spectrum.
So there is a pain
issue that is central,
that is brain-driven,
that is definitely
not due to peripheral
components such as the bite or
even grinding or clenching.
And disease process,
that's pretty obvious.
That's the arthritis and
the lupus and so
on and so forth, and
that's pretty documented.
Now if you look at
microtrauma or load,
now the question now is,
what kind of importance does
a load have for patients
who have a TMJ disorder,
or have a propensity or
are at risk for TMJ disorder?
Is it more like
an aggravating factor, for
some people who are just
already susceptible?
Is it a perpetuating factor,
once you have it,
you don't heal?
It's, there's a lot
of research, and
there's a lot we don't know
about the origins or why some
people develop TMJ disorders
and why others don't.
60% of the people, or
50% of people clench and
grind in the population
at night.
That's something we humans do.
It's controlled by our brain.
It's no longer believed to
be brought about by stress.
It can fluctuate.
Like daytime clenching and
bruxing, and
grinding, yes,
stress may be involved in it.
But night time bruxism and
clenching are no longer
believed to be
associated with stress.
That's something 50% of people
do and in the population,
50% of people don't
develop TMJ disorders.
So there's not a direct
correlation with load and
TMJ disorder.
And so, we're looking at other
things that could potentially
differentiate the people who
develop TMJ disorders and
the people who don't
develop TMJ disorders,
given that both of them
grind and clench, okay?
So, what are we looking for?
Okay?
So we're looking at
symptomatic and asymptomatic
patients, patients with pain,
patients without pain.
And we look at patients
who have the same anatomy.
Maybe we look at a population
of people with a displaced
disc and pain, or
people with myalgia.
And we look at their genetics,
we look at the grinding and
clenching they do,
their anatomy.
And we try to find something
that differentiate
both groups of people, and
it is very difficult, because
there are so many variables.
But the one thing that has
been studied right now is
adaptability and resilience.
And so adaptability is
kind of the ability,
it's genetically determined,
but
it's the ability of our
body to heal themselves.
So you can have, for example,
somebody that will lean more
towards what we saw there as,
you know where the x-ray
was remodeling but
no evidence of disease.
Well, for some people,
they will respond to
load with adaptation.
And other people will
respond to load with
degenerative joint disease.
Okay?
So
there's something
that's genetic, and
it's a risk factor that
we can't really control.
There is some evidence that
there is a relationship
between arthritis and
displacement of the disc.
Now, is the person who
has arthritis at risk for
disc displacement or
is the person that has disc
displacement more at risk for
arthritis?
So, we haven't figured
that one out yet.
So, basically,
when the patient comes in,
we treat the symptoms.
We can't really
treat the cause.
So, adaptability is a big one,
and it's that we can observe.
We can observe that some
people, because of the x-ray,
for example,
we can observe that some
people do not degenerate.
Some people's joint
do not degenerate.
But then, you know, we look
at, so this is what we're
talking about, you have
the anatomy and the load.
When it's not really great,
you have pain.
Adaptability is the factor
that can be the difference
between the people with
symptomatic, not symptomatic.
But, then we also have
situation where we have
seemingly the same adaptation.
There's nothing on the x-ray
that's particular.
Nothing out of the ordinary
in terms of load,
no seemingly trauma, no
dysfunction, particularly, and
the patient is in pain.
So, we thought, okay,
maybe their load is bigger.
You know,
that's a possibility.
Maybe they grind more,
maybe they clench more.
Who knows, right?
But we also looked
at something that's
called resilience.
And resilience is an ability
that is sometimes innate that
we have to cope with certain
dysfunctions and pain that
makes it that we experience
less pain and dysfunction.
So we started looking
at the resilience, and
that's studies that are done
mostly by pain psychologists
on pain patients,
on chronic pain patients.
So usually people who
have good adaptation and
resilience, when they have
a certain amount of disease,
they seem to respond
better to treatment.
The treatment that we do,
it works.
And, then sometimes we do the
same treatment on seemingly
the same type of patient,
and it doesn't work.
And, that's puzzling and
frustrating for
us providers, of course.
And, so
we wanna have more research.
So, this research on
reliance and adaptability.
A resilience in adaptability
has led to this kind of
schematic.
You know, where you have
you know, the TMJ pain or
dysfunction, and you have
several areas that can
influence, positively or
negatively, on the outcomes.
So the load is obvious.
The anatomy is obvious.
Genetics and adaptability,
we can't do anything about,
so we have to look
at sometimes,
this was the old way we
looked at TMJ disorders.
It had to be the load,
it just had to be the load.
They did not consider
these two factors.
So once we started opening
our mind, a little bit
out of the box, then we bring
in these two conditions,
other pain conditions because
it's well known that if you
other pains in your body, you
have chronic pain in your leg,
chronic pain in your back,
chronic migraines and then you
develop TMJ disorder, you
will perceive that as worse.
I mean that's just
the way the brain works.
Once you have pain, the brain
signals can just free flow
a lot more than if you don't
have any other pain condition.
So we can think that there
are other pain conditions.
We can think that
the resilience is less.
We can think that maybe it's
a combination of other pain
conditions being interfering,
and a lack of resilience.
So there's a lot more
treatment options and
treatment possibilities
that open up.
This is how we all would like
to be able to treat, right?
You have the symptoms,
you take a test.
You figure out what
it is caused by and
then you get
a treatment that works.
I mean that is the simple
equation that we sometimes
can do with some disease but
with TMJ disorders,
it's just not like that and
that is the hard part for
patients and
providers alike es that there
are people who come in with
exactly the same symptoms.
You give them the same
treatment, and
they have different outcomes.
So that is very difficult.
So adaptability seems to have
more to do with the body's
ability to cope, and
the resilience with
the mind's ability to cope.
A friend of mine,
psychologist,
had a very simple equation.
She would say, pain is,
and it's actually based on
the definition of pain.
If you go to the dictionary
and you look at pain, it's
not only a body perception but
it's also an emotional
component and so the emotional
component is just as big
as the actual perception
of the physical pain.
So if you can reduce either
the emotional portion or
the physical portion
of the pain,
you can actually
decrease the overall
experience of pain that
the patient receives and
that's a really big new
approach for chronic pain that
we've been practicing at the
Stanford Pain Clinic, is that
we don't just think that
pain is a bodily perception.
We also feel that the
emotional distress associated
with both the pain, the
disability, the dysfunction
is just as important and
it's the sum of these two
that can make the patient
more or less miserable.
So if you think about it that
way, you get better outcomes.
Unfortunately, dentists
just by our training,
we are used to doing things,
right.
You see a cavity,
you drill a hole,
you fill it, problem solved.
So dentists tend to
need to do something,
they don't usually just there
are situation where it's
better to do nothing,
you know.
So dentists are by training,
they're used to actually do
procedures, make appliances.
They have a drill,
they want to use it.
So it was an actual different
frame of mind that I had when
I went to my residency, it was
totally a different frame of
mind to come back more
to a medical model.
So this is the way we
used to treat TMJ disorders,
okay?
First line, we have
the first line treatments.
Anti-inflamatories,
corticosteroids,
physical therapy for
the muscles.
You know, trigger point
injection, if necessary.
Joint injections,
if necessary.
Joint manipulations you know,
to reduce the joints.
I mean not chiropractic
manipulation but
if the joint was locked we
manipulated them open and
as an adjunct,
we used to have moist heat,
meditation, muscle relaxant,
pain psychology.
Rarely, surgery.
Even though, 20 years ago,
it was very very in vogue and
a lot of people used to have
joint replacement surgery that
has really totally,
totally been discredited.
Joint replacement surgery is
very, very rarely indicated.
Maybe in case of trauma or
cancer, yes.
But the results were so
disastrous that they're done
really, really, very rarely.
Open joint surgery, again, I
mean, some people had surgery
for clicking, benign clicking,
and ended up crippled.
You know, not being able to
open their mouth, so its very,
very sad, but
I still see them.
You know, so some reason some
people still have surgery, and
never orthodontics bite
adjustment, and opioids.
We don't really use opioids.
It's not a disorder that
necessitates opioid treatment.
The chronic disorders
don't really do anyway but
even acutely,
it's not usually the type of
pain that
necessitates opioids.
So now that we know all
this about adaptability and
resilience, we are moving
this whole category into
a first line treatment.
So we have pain psychologists
that will work on patients and
give them better resilience.
Resilience is something
that some patients have
on their own.
They have those
coping mechanisms.
They were born with them or
they acquired them along the
way but you can teach them.
You can teach them to people,
and that's what the paid
psychologists do.
They teach patients
coping mechanisms,
they increase
their resilience,
they decrease their focusing,
their catastrophizing.
Catastrophizing is
a feeling that you have
that your disorder actually
is very, very bad.
It's not benign, it's going
to deteriorate, so it's like
a doom and gloom approach to
disorders and certainly, in
the TMJ world, there is really
no need for doom and gloom.
So they do lifestyle
modification, relaxation,.
Meditation also works quite
well even though you have to
practice that and there is
more recently, there's more
emphasis on sleep and sleep
quality than there was before.
There's some research that
show that if you have poor
sleep, you will tend to
brux grind your teeth more.
Because you never get
to the very deep sleep.
For some people
who wake up a lot,
they never really go into the
deep sleep where the muscles
are completely paralyzed.
And so, that might affect
their adaptability or
their resilience.
So anyways, the resilience
definitely because people who
don't sleep well.
You can ask universally,
if a patient has chronic pain,
if they're more stressed,
the pain will feel more.
If they don't sleep well, the
pain will appear more worse.
So it's not that necessarily
stress is inducing the pain.
It's more that,
when you have stress,
your pain highways or your
pain processes are different.
And so that's where working
with a pain psychologist is,
for us, invaluable.
And that's why going to
a pain center, like Stanford,
that has the pain psychologist
available is a real bonus.
And I've worked both with and
without a pain
psychologists and I cannot
tell you the difference that
it makes for the outcomes.
So I will finish my talk
here to leave some room for
questions and answers.
Because it's such a difficult
subject in terms of,
if you have been affected
by the disorder,
you probably go to some
physician or a dentist and
get five different options.
Or you look online and
you have these multiple
opinions of what you
should be doing.
The one thing that I have to
say and this is really pretty
important, is that all of the
treatments that are done for
TMJ disorder, all
the treatments are reversible.
So things like full
time wear of splints.
It seems really benign, but
a full time wearer of splints
can change your bite
in a permanent way.
So if you wear a splint,
day in and day out, for
several months.
Your bite will most
likely change.
And what you do at that
point that you need braces.
And some people actually
have a phase one,
phase two process.
Where they change the bite
on purpose with the use of
a full-time appliance.
And then afterwards they
restore the bite to a better
position.
So, stay away, if I can give
you one recommendation,
is stay away from
treatments that cause,
that are not reversible.
So in the non reversible
one you have orthodontics,
full time wear splint,
bio-adjustments, and
everything else, you know,
there are a lot of
things that work.
I mean, acupuncture might be
a wonderful treatment for
some people.
Other people will respond
to muscle relaxants.
Other people don't wanna hear,
I mean,
there are a lot of
options of treatment.
It's not like everybody that
gets a TMJ disorder gets
exactly the same treatment.
We discuss with patients what
their preference is in terms
of treatment philosophy.
And if they want to see
a pain psychologist and
work on meditation relaxation
first, it's fine with me.
And depending on
what they have,
things like antidepressants,
topical or
oral, work really well for
things like inflammation,
just like in other
joints of the body.
But please, reversible
is what I would like
you to bring home
from this lecture.
So I would welcome questions
on any part of the speech or
on other things you
may have read online.
Yes.
>> I'm sorry, I came in
a little bit late, but did I
understand correctly, do you
feel that splint are overused?
>> Can you repeat that?
>> Yes.
The question, do you feel like
splint are overused, okay.
[COUGH] [NOISE] In general,
I really believe so.
And the reason being that
there is in dental school,
we get no training.
We have no training
in TMJ disorders.
So most of what dentists pick
up to treat patients is over
the course of, you know,
here and there continuing
education, they learn
how to make a splint.
So dentists basically, the
only thing that they know what
to do, is to make splints.
So, that's usually
the first thing they try.
They say okay,
we'll make you a splint and
If it works, great.
If it doesn't work, well I'll
send you somewhere else.
So probably, 70% of people
who come to my practice
have gotten the splint
from their dentists.
I would say that most
probably, realistically,
only 20% of people with
TMJ disorders would need
a splint or
would benefit from a splint.
It's a very difficult question
because they have tried to
do a lot of research
on splints.
And there wasn't really
a particular type of patient
that is ideal for splints.
Like some people respond all
over the place, like 50% of
people would respond 45 will
not, 5% will get worse, and
we can not pinpoint which ones
are the ones that get better.
Overall, for
me an my practice,
if I have a patient whose
pain is worse in the morning,
when they get up,
I will try a splint.
If they are worse in
the afternoon and
they have no pain
in the morning.
I'm just assuming that they're
not doing anything at night
that aggravate their disorder.
So I don't really believe that
the splint will do anything.
I will use a splint if they
grind their teeth to protect
their teeth.
Cuz that we know the splint
does but what the splint
actually does for
patients in pain is unknown.
And there certainly [COUGH]
people out there [COUGH] and
with good backgrounds, very
reputable people who believe
that part of the benefits
of the splint is placebo.
Which you know placebo
is not all bad.
Placebo I mean 20% of any
treatment that I do patients
including medications that
have research backing it is
placebo.
Yes.
>> Can you explain
what the splint does?
>> A splint and, I should have
taken a picture of a splint.
It's basically a night guard.
Do you know what
a night guard is?
A night guard is a piece of
plastic that is molded to your
teeth and that is
acting as an interface.
It goes either on
the bottom teeth or
the top teeth and
it's basically a plastic
interface between the top
teeth and the bottom teeth.
>> And it's called a splint?
>> It's called a splint,
it's called a night guard.
It's called an orthotic.
It's got various names.
Splints, you know,
to me it's in a category of,
it's pretty benign as long as
you don't use them full time.
And certainly for
some people they do work.
So in some patients I
think it's worth trying.
I like them to be full arch.
I do not like the one that
only are in the front teeth.
They were marketing,
they're called NTIs, and
they fit just in
the front teeth.
And they were marketing.
Than for grinding, because
they said that if you clench
on your front teeth, you don't
clench as hard, which is kind
of true, but you clench
enough to get bite changes.
And so the research on
those has been pretty bad
in terms of reversibility so
I don't use those.
I use the full arch one
which covers all the teeth,
more like a retainer,
like an invisalign
retainer except thicker.
And again,
people do thick splints,
thin splints, hard splints,
soft splints, and
a lot of people swear by
the splints they make but
if you look at the research,
there's really no type of
splints that works
better than the next.
So whatever your dentist wants
to make, if they are into hard
splints, by all means
hard splints is fine.
If they want to do soft
splint, it's fine too.
It's just more like is it
comfortable for the patient.
Does the patient
like it better?
Yes?
>> Well, you said that really,
no treatment is good for
everybody.
>> Yes.
>> Why would you even bother
with a splint?
It costs money.
>> Right.
>> You have to live with it.
Why would you even do it?
>> Well, yeah it's not
really so much as it,
I put it there in the adjunct,
okay?
So adjunct is not
really a first line.
I will try other things.
But if the patient continues
to have morning pain,
it's something that is not
a medication, it's benign,
and some people find benefits.
So it's still in the range of
treatments that
are worth exploring.
What else that you say.
>> Okay, is it the type of
thing that can get worse.
>> Mm-hm.
>> It's reversible.
>> Yes, as long as you
don't use it full-time,
and by worse, it's pain.
Just some people develop pain,
and
then you just have
to give it away.
Yeah.
>> By full time do you mean
night and day, 24 hours?
>> Yeah.
>> No.
>> It won't change the bite or
change the jaw line?
>> If you wear them full time,
yes.
>> How about just nights?
>> Nighttime it can,
but it usually doesn't.
And as long as you check it
everyday when you wake up.
Make sure that your
bite hasn't changed,
and it's usually fine.
We have time for
a couple more questions.
Yeah.
Yes?
>> You mentioned in TMJ
that you get ear pain.
>> Yes.
>> Where the pain located,
is it outside, or it's inside?
>> Well,
what it is is if you look.
>> Question?
>> Yes.
I mentioned that the TMJ pain
is also sometimes associated
or felt as an ear pain.
It's more because of
the proximity of the TMJ
with the ear.
So if you look in
an anatomy textbook,
there's just the very thin
piece of bone that separates
the TMJ from the ear.
And so
because the pain sometimes,
if it's really
intense it expands,
it kind of gets
perceived in this area.
That's why a lot of people
see an EMT doctor first
before they see me because
they perceive it as ear pain.
But it's not because it is
affecting the ear directly.
>> So would the pain around
the ear or inside it?
>> Well it's more
on the inside.
I mean most people think it
feels like an ear infection.
>> So if a night.
>> Yeah.
>> Sorry.
>> Go ahead.
>> If a night guard
is prescribed.
>> Mm-hm.
>> And it fits your mouth.
How does that
affect your bite?
>> The bite changes, not
because the teeth change, but
because the position
of the condyle inside
the fauca will change.
So because of the,
see when you look at the.
Let me put the picture
of the actual joint.
Okay, almost there.
Okay so
this is the condyle and
this is the fauca.
Okay, when you have a night
guard in your mouth,
you are going to have
a different position
of this disk and this condyle
because the jaw will be
slightly more open, so the
disk will be a little bit more
anterior and the condyle will
be a little bit more anterior
because of the position
of the jaw.
And if you keep it there 24/7,
the soft
tissue within the capsule will
adapt to that position, and
it will be difficult to go
back to the old position.
>> But if it's just
used as a night guard?
>> Yes if it's just used
as a night guard at night,
in the morning when
you take it out.
I wear one because I
wear one as a retainer
basically because
I had braces, so
for me a night guard
is the right thing.
I don't wear it for pain or
a TMJ disorder, but when I
take it out in the morning,
even though it's very thin,
my bite is a little bit
different because of
the muscle position.
But that's okay
because within five
minutes it's back to normal.
>> Yeah,
never noticed anything.
>> Yeah.
Yes?
>> I used to wear one and
it was a hard one.
I have to go every month,
or every three months,
to be adjusted.
So they have to grind.
>> It shouldn't need to.
Once it's adjusted to comfort
and it's symmetrical and
it's the same
amount of force and
you feel like you're biting on
both sides in the same way,
it shouldn't need to
get any adjustments.
I mean you will continue
to wear it down, but
you wear it down
because of function.
And so you continue wearing it
down until there's a hole in
it and you need to have
it replaced, that's all.
>> Huh.
>> Yeah.
>> And what is the bite
adjustment aside from braces?
>> Oh that's when they
actually grind your teeth.
You know, when you don't
have a perfect bite,
you may have a tooth that's
a little crooked, right?
Or that is a little
bit tilted and
when you go side to side
you hit that tooth first.
And so they shave that
part of the tooth away, so
that you can translate
from side to side.
And I'd say, if a perfect bite
was the solution, putting
a night guard on everyone
should heal everyone because
once you have a night guard
you have no interferences.
You actually have
a pretty perfect bite,
because the night guard
is adjusted perfectly.
So the theory that a bite
is a determining factor,
is pretty much
obviously not right.
And during the day you're
never touching your teeth
together anyways.
So you function, except for
when you swallow,
that you briefly put your
teeth together even when you
bite on food,
because food is the interface.
Your teeth are not actually
contacting that much.
And I have seen people with
incredibly horrible bites and
no symptoms.
The only time that I would
say bite has an issue,
is of importance is you have
people who lose all posterior
support.
Like they lose their premolars
and their molars and
they don't have a stable bite.
So whenever they bite,
their jaw does this.
Cuz they have nothing
to bite on one side.
In that instance, I understand
that the bite should be
restored to
a stable occlusion.
But as long as you have a
stable occlusion, which means
you bite on both sides on your
back teeth, it should be fine.
Yes?
>> Well, I never heard of
that kind of bite change.
That's interesting.
That when you go to
an orthodontist-
>> Yes.
>> And specifically by chance
to have your teeth fixed.
Then it would-
>> Sure.
>> That would neither hurt nor
help the TMJ.
Is that [INAUDIBLE].
[CROSSTALK].
>> That is correct.
>> Okay.
>> That is correct.
And, actually, orthodontists
get a really bad reputation
because very often,
TMJ disorders start,
at the same time as
orthodontic treatment.
But it's mostly because
the onset is usually around
puberty which is also the same
time as people get braces.
But some treatments done
by the orthodontist can
aggravate the TMJ
disorders like elastics
that bring the jaw back.
If you already have
a TMJ disorder,
it's probably not recommended.
But the bite thing,
not so much.
One more?
>> Yes.
>> One more.
One more question.
Who hasn't?
No, you haven't said anything
yet, so?
>> I have two questions
if I can sneak them in.
One is, can you explain what
bode means?
And then the second one is,
sometimes for
sleep apnea they will
prescribe a dental procedure.
>> A dental procedure or
an appliance?
>> Or an appliance.
>> Yes.
>> And I'm just wondering if
you see that [INAUDIBLE].
>> Okay.
Yeah, I am very familiar
with the appliance,
cuz I make them for
my patients with sleep apnea.
An appliance for sleep apnea
is basically an appliance,
if you're familiar with CPR.
Are you familiar with CPR?
Well, you know how you
do a jaw thrust for
unconscious patients
to open their airway?
Well, basically an appliance
brings the jaw forward
into a thrusted position
to open the airway.
And have patients
breath better at night.
So, it's an appliance
with which the jaw is
maintained in a forward
position through the night,
which is pretty dramatic,
you know?
And it's done in a very
progressive way, you know,
one-tenth of
a millimeter time,
maybe over several months.
And certainly,
in those situation,
you get more chances of
having bite changes than with
a regular night guard.
But, even in those patients,
you don't find a lot
of bite changes.
You see some bite change but
usually they don't notice it,
in terms of TMJ disorder,
bringing the jaw
forward slightly.
If they have a joint disease,
might not be a bad thing for
their symptoms because
there will be more space in
the joint when the jaw
is brought forward.
But if they have
a myofascial issue,
it will be very difficult to
tolerate, because the muscles
are trying all night long
to bring the jaw backwards.
And so even patients who don't
have TMJ disorders or myalgia,
sometimes get myofascial pain,
and pain in the muscle,
initially, when they
start the appliance.
But it's a very, very
well-tolerated appliance, and
it's an alternative
to see path for
patients with mild and
moderate sleep apnea.
Well, your second question,
the load is considered
any kind of movement
that puts undo forces in
loading on the joint.
So, grinding,
bruxing, crunching part foods,
chewy foods.
Incidentally, salad,
it's very difficult to chew.
People think oh, no problem, I
don't have to eat hard foods,
I'll eat salads, well salads,
I have bad news, salads with
TMJ disorder patients are just
the hardest thing to chew.
>> [INAUDIBLE] Thank you so
much.
>> You're welcome.
[APPLAUSE].
>> I hope this was useful.
I hope that you learned
something and that you
are now more able to look at
the literature online and
see the good from the bad, and
the evidence based from
the coocoo out there.
[LAUGH].
>> Just one more
about the department.
This is a new department?
>> Well it's not a new
department per se.
It's part of the Stanford
Pain Clinic and so
it's in the same building.
And it was the same faculty
of the pain clinic, but
it's an orofacial pain focus.
So, we have a group
of neurologists,
anesthesiologist, dentists,
physical therapists,
psychologists that
specifically tend to orofacial
pain problems.
But, if you call-
>> It's more gentle.
>> No dental work, no.
No.
I haven't touched
a drill in 20 years.
[LAUGH] Except to
adjust the appliances.
>> One thing is Medicare
doesn't pay for any TMJ.
>> That's not true.
That's not correct.
I do take Medicare in
my private practice.
It will not pay for
the appliance,
for the night guard.
But it sometimes does.
I mean if you appeal,
it might.
But they certainly pay for
the appointments,
because I bill medical codes.
So I bill a regular
medical visit.
This is not considered dental.
Because that's the thing,
insurance wise, that's really
difficult because they kinda
throw the ball at each other.
The dental insurance says
it's a medical issue,
the medical insurance
says it's a dental issue.
But it's actually
a medical issue.
It's a joint,
it's not a dental pathology.
>> Well, thank you very much.
>> You're welcome.
