TMD - More

By Joseph Gronka posted 09-30-2013 10:05 PM

I learn from extreme cases. So I am going to relate some of the most extreme in hopes that you learn the same way.
Most heartbreaking: I was treating this woman's daughter for a class i crowded condition with a deep bite. This is not the case. Her mother, early thirties school teacher scheduled an appointment for exam and prophy. This family of two were new to my practice. My only prior contact was during evaluation of her daughter's orth problem. One of my first questions to young females is "Do you get headaches"? Her response was completely unexpected. She sat up and asked "Why did you ask me that"? "you are here for an exam, right"? was my response. "Yes, but no dentist has ever asked me that before". she said. "Too bad, do you get headaches"? I persisted. Then I got the "story". In her late teens she began having incapacitating headaches. These persisted until the exam. Many years of going to bed and waking up with head pain. "Presently on tegretol" was her response to my questioning her present course of treatment. I completed my exam. and  asked her to go home and write a complete history for me and bring it in for the next appointment. It turned out to be completely medical oriented, mostly medications. At one point, they, MDs, told her that her problem was hormonal and she needed a hysterectomy. After that failed to relieve the pain, they gave up and recommended psychiatric therapy. So after 13 or so years, here she was talking with a dentist about her headaches. omg, right?? It must have been a case of "what the hell does this guy want? At the time of my exam, I told her she had beautiful teeth. all 32, Not one restoration, miraculous. BUT they were not functioning in a harmonious fashion. "What"? Yes there is definitely a problem or you would not have all that pain in your head.:))) I laugh at everything. She said to me "do you mean all of these years of treatment and pain, that my teeth are the cause"? "uh huh". She looked at me like I was insane. I told her I needed to make some impressions of her jaws and that we would have all of her pain gone in less than 2 weeks. Forever. She was in a state that might be termed shock and awe. She was willing to go along with whatever I said. 
Examination of her study casts showed heavy faceting on the DBu cusp of #17. all the rest of her teeth were almost pristine. #16 and 17 were the source of her discomfort, I was convinced. To be sure, I fabricated a MORA and an anterior jig. I gave her the MORA along with instructions to wear all the time except to eat. The following week, I told her I knew what her problem was and I "am going to correct it today". I used my anterior jig to guide her into a "first touch" position. It showed me that the third molars were premature in contact as I expected. I kept adjusting the jig and the molars until the jig fell apart. By that time I had her in a very nice Man/max relationship. I confirmed this with a tap test. Her muscles remained in a relaxed state. DONE!. When she was getting ready to leave, she asked for her MORA. I told her that she did not need it anymore. She insisted and I insisted. Finally, I promised that I would give it back at the very first sign of any pain. She reluctantly agreed. She never asked for it again. At the very beginning, especially in cases like this (medical), I exact a promise from these pts that they will return to their MDs and tell them what I found and did. So I asked her on one seperate occasion if she did that. She said "yes" I asked "What did he say"? She told me that he said I got lucky and that his mother has the very same problem and has had it for years. I told her "go back and tell him to send his mother to me". :)) I love when stuff like this happens,
So, two opposing teeth created a problem via poor muscle tone that led this woman on a horrific path. I believe that she found me through Divine intervention. Why? because it happens.
Next case: I was at home one evening and I had a visitor. My nephew was home from college in mid week and in a panic. He was not able to close his mouth. His jaws would not come together and he experienced terrific pain in making at attempt. I positioned him in front of me and noticed that he had no neck, a bodybuilder, I knew,.. but no neck? I asked him how long he  has been in this condition. He said it happened this afternoon and he left school to come to see me. He was at Penn State, I lived in Nanticoke, so that was quite a drive, especially in that condition. I knew it did not have anything to do with teeth and judging by his "no neck" appearance, I also knew that he ignored my advice about body building. The "no neck" meant that both upper traps were in spasm and most likely, their antagonists as well. These muscles were creating such cranial pressure that they were squeezing the skull so as to dislocate the condyles. Yes, I know, I'm a dentist. But we studied anatomy right? I told him to lay on the floor on his belly. He did. I began a very deep massage on his back beginning at the origin of the traps in the vertebral column all the way up to the nuchal line. Also the SCMs. After about 20 minutes of agony and much crying, He stood up and his jaws came together. He smiled,
 thanked me and left.

These are the extreme cases that were presented to me early in my treatment of TMD. They served to show me that not all Jaw/Jaw joint problems are related to malocclusion. :))

Statistically 80 - 85% of all of our patients are suffering from varying degrees of malocclusion. I can walk into any dentist office and demonstrate this simply by applying the tap test. Try it yourself. Do not take my word for it.

Treatment. This must be decided on a case by case basis. In a previous blog I discussed briefly, the case of the speech therapist who followed my advice and treated herself to a successful outcome. As good as any of us could have done, maybe even better. Most of my treatment is occlusal equilibration. Finish always with the tap test. If you are not able to achieve complete relaxation of the muscles, you are not finished. Dr. Niles Guichet likens it to having a patient with grit in his/her eye. The eye cannot open fully, comfortably until that last grain is out. Very true in TMD as well. Some cases are treated by orthodontics and finished by equilibration.
As I wrote previously. Would it not be wonderful if we treated our young patients in such a way, that this TMD stuff would become rare maybe even non existent. It is possible, I believe. Think now of how much work you have in your own office, waiting to be recognized, explained and treated. Learn AK, applied kinesiology, muscle testing. Impress your pts. I would gladly teach you to perform in a more proficient manner. I never had a "slow" time in practice. Just the opposite. I was so happy to have a cancellation. I used to post notes on my door, very early in practice. "Please change all appointments today, gone fishin" Just to get a break. True. You don't understand how much work in your office, is waiting to be recognized.

I look forward to answering specific questions.