natural treatments for diseases of the spleen disease

welcome tothe stanford health library. thank you forcoming here tonight. my name is michele jehensonand i work at the orofacial pain clinic at the stanfordpain center in redwood city. so today's topicis tmj disorders. tmd, i'm going to speak aboutthe nature of the disorder. what a tmj disorder really is. i'm going to also talk aboutwho is at risk for tmd. and finally, i will touch onthe common treatments that

are recognized asevidence-based treatment for tmj disorders. so, i guess it's customary to talk about disclosures asto if i'm affiliated with any kind of pharmaceuticalcompany or anything like that. i have no disclosuresto be done. so, i wanted to first showyou the anatomy of a tmj. it's a joint that isvery unique in the body. it's one of a kind.

there is a one disc, andyou can picture it as a donut. so, it's a circular,biconcave, just a donut, just doesn't have the actualhole in the middle. so it's kind of likea 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 seeto the right of the fossa. so the disc is flexible.

it's fiber cartilage, and it offers a perfect interfacebetween the skull and the jaw. it allows for smoother motion. the joint is also particularin a sense that not only it allows rotation ofthe joint, but it allows for forward motion of the jaw. so, if you put your handlike slightly over your, in front of your ear and youopen your jaw wide and slow, you can see that initially,it just starts rotating and

then you can feel itactually advance forward. and for some people, you canactually feel it coming out slightly, because even thoughthe jaw is seemingly fixed, the suture that is inthe front, it allows for certain flexibility in andout of the joint itself. so, what is a tmj disorder? so, a tmj disorderis defined by pain, either at rest orupon function. it is defined by somethingthat is a painful noise.

it can also be justa dysfunction, like a limited range ofmotion, or a jaw deviation such as this, like when youopen you go to one side or you are unable to go fromone side to the other. or a sudden unexplained bitechange, like you wake up and your jaw is to the front,or to the side. those are consideredtmj disorders. they can be associatedwith headaches, and ear aches, or ear pain.

so, the prevalenceis 5 to 12%. vast majority of them women. and the age group is betweenpuberty and menopause. and there's some researchsuggest that there's a link with hormones asthe cartilage and the tmj hasestrogen receptors. so that would make sense sincethe 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 ableto open your mouth wide, if you're able tochew 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 abnormalfindings in an mri or an x-ray withouthaving a tmj disorder.

there are a lot of people,and certainly, most of us over 40 will have some typeof changes on an x-ray, even though we are still completelyasymptomatic, and we can chew, and we can open our mouthwithout any restrictions. so, that's kind of somethingthat comes up a lot. i mean, i get patientswho come in because they have joint noises. because they have beentold by their dentist that they had a tmj disorder.

or because the dentistsaw 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'thave a tmj disorder. you don't have to worry, 'kay? 60% of people pop andclick, so it's a very common incidence. they don't really considerit a disorder because

it's a variation of normal,at this point. i will come back later aboutthe popping, the mechanism for popping and clicking. but i wanna touch onremodeling 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 bekind of rounded and

it should have a continuouswhite line around it. and you see here,it is a little bit flatter on the top but it hasa white line around it so. when it has a white linearound the perimeter of the condyle, it'sconsidered remodeling, and remodeling is a processof bone changes. and the bone isa dynamic structure, it's not like there to stay. like for example, if you'veever had braces, what

allows the teeth to move isactually the bone remodeling. on one part, you have some bone destructionthat allows it to move, and then the bone rebuilds onthe other side of the tooth, so it's a completelynormal and natural phenomenonto a certain extent. so, if it's a slow process, and if it's an adaptationprocess, it's normal and it doesn't give peopleany trouble whatsoever.

so this is considereda very normal cone beam ct scan of the jaw. which doesn't meanthe patient is asymptomatic, they can have painwith a normal x-ray. that's the thing. that's the other thing.you can have absolutely no pain with a terriblelooking x-ray, and we can have painwith a normal x-ray. so, what types of tmjdisorder are there?

well, we classify them as tmj disorders involvingthe muscles of mastication, involving the joint itself orpart of a systemic disease. so the muscle disordersare for the tmj, and the muscles of mastication arejust exactly the same as for any muscles in your body. there is muscle ache, restriction of range ofmotion, fibrosis, tendinitis. you know, you've had.

some people with tennis elbow, you can have tendonitisof the jaw as well. so, the muscles ofmastication, and you can feel those as well,are usually for the most part. the masseter andthe temporalis muscles. those are the ones that givepeople the most trouble. so if you feel here, and youput your teeth together, and then you clench really hard,you will actually feel a bulge, andthat is your masseter muscle.

if you put your hands uphere by your temples, and do the same motion. you can also feela muscle bulge, and that's the temporalis muscle. it's a fairly thin muscle,but very, very wide. both of these muscles helpto bring the jaw closed. so, a lot of patientswho come to our practice have myalgia or myofascialpain in the temporalis muscle, i mean temporalis muscle,sorry or the masseter muscle.

and that translatesinto very often, limitation of theirrange of motion. they cannot open theirmouth really wide or they develop pain. so that's a verycommon tmj disorder. medial pterygoid is the onethat is the mate, if you wish, of the masseter muscle, buton the inside of the jaw. and the lateral pterygoid isthe muscle that allows you to bring your jaw fromside-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 tojoint disorders. we can have a jointdisorder that is directly associated witha disc dysfunction. remember that little donutthat i was showing you? it's held by ligaments andit goes forward and backwards.

so there's a lot ofpossibilities for things to go wrong asfar as this little disc. there are, there's trauma ofcourse, i mean fractures and so on as well as systemicdiseases such as arthritis, rheumatoid arthritis,lupus, and the likes. as well as, of coursei didn't mention this, i have some slides ontumors of the jaw. so again this isthe same slide. i'm never really quite surehow you pronounce this.

i usually sayginglymoid-arthodial joint, which is the type ofjoint that the tmj is. so it just means itrotates and it slides. so the rotation, lower part of the joints or the disc withthe condyle, so the condylar rotates in relation tothe disc and the translation is the whole disc, andcondyle move forward. i tried to find a video, but icould only go through youtube and they were mostlydissection videos [laugh] so

i didn't think thatit was a good idea. this is an mripicture of the disk. if you see a little hourglass,darker. can you see a littledarker shadow in the shape of an hourglass? well, this is whata normal disk looks. and it is held by ligamentson this side, ligaments and muscles on this side. so, here, it is the same disc,

but in a more, in a mouth thatis wider open, and you can see that the disc is moved forwardin relation to this eminence. so again,this is a closed mouth, and this is an open mouth. and this is a normalposition of the disc and normal positionof the condyle. so, what kind ofdysfunctions are there? so we'll start with probablythe most common, and it is when the disc.

which you can see here in thepicture or here in the model is completely interiorto the condyle. if you look back at this one,the back of the disc is located as 12 'o' clock inrelationship to the condyle. on the anterior disc displace, it's actually way,way, way forward. and it's impossible for the condyle to get intothe middle of this disc. it's kinda stuck behind it.

and so, usually,it's something that happens very suddenly eitherwhile you're eating or sometimes when you're yawningor pretty abrupt motion. and, all of the sudden, you won't be ableto open your mouth. it's a very sudden event. and, sometimes it willlast for several hours. and, also,it will suddenly get better. or, you'll have togo to a dentist,

and help put it back in place. so this is isthe unfortunately, this is in an opening motion. so this is closed jaw and thisis 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'rehitting a brick wall. i mean, it, there's justno give whatsoever.

and, this is where i come backto the benign clicking that i was talking to you about. the benign clicking. oh, there's a spellingmistake 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 anyproblem with it, actually, one of our camera people showedthat to me earlier today. how many of you have clicking? do you have any symptomsassociated with it or do you just havebenign clicking? no pain. no dysfunction. like most peoplehave that situation.

so what it is, is in hereas you can see in figure a, the disc is alsoanteriorly displaced. but, during the opening motionthe condyle is actually able to go past the posterior partof the disc, which is slightly thicker to get and fall intothe middle of the disc. and this is the passingthrough and over the back of the discthat creates the noise. so it's justa functional noise, i consider it a nuisance.

there's nothing youwant to do about it, there's nothing youshould be doing about it, no surgeries,no treatment whatsoever. during the course of yourlifetime it might change, it might become a littlebit later in the motion. let's say when you're 18, itmight be really early because the disk is just a littlebit anteriorly displaced. and then as you getolder it might be, you only have a click when youopen your mouth really wide.

i only have a clicknow when i yawn, but i used to havea click all the time. and it was veryconvenient because i could demonstrate it tomy patients, you know. so, this is not necessarilygoing to evolve to a lock. for the vast majority ofpeople clicking will never evolve to a lock, but it's not,nobody's able to predict it. this is another one thatpeople have probably heard of.

it is an open lock, andit's actually a subluxation of the entire joint in frontof the articular eminence. and the joint is basicallynot able to come back over this bump here and it'sbeing stuck because the pull of the muscle's actuallymaintaining it in that fascia. so the more people tryto close their mouth, the least they're likely tobecause the pull of the muscle does not allowthe jaw to go back. so this is fairly rare but

it is an emergencybecause you cannot eat, you can hardly swallow,you cannot talk and it is something that necessitatesmedical attention to reduce. and usually i don't seethose patients because those patients go to an emergencyroom right away. i do see quite a bit of closelock, and unfortunately, i don't see them asearly as i should, and by the time i see them, thetreatments are more limited. but the open locks, they goto the emergency room, and

rightfully so. this is a posterior discdisplacement with the disc instead of going forward,goes backwards. this is very rare. i've actually neverseen a single one and i was unable to find a singlepicture online [laugh]. but it does happen andin those situations, extremely painful. it's a very,very painful condition.

also, rather suddenly, and ittranslate the symptoms is that you are no longer able tobite down completely and it's very, very painful to tryto put your teeth together. then we come to arthritis,a systemic disease, and all of them will kindalike this on an x-ray, a lot of degenerationof the bone. it's only further testingthat will show what kind of disorder it is. of course, osteoarthritisbeing the most common.

the great news in terms ofthe osteoarthritis of the tmj is that it is unlikeosteoarthritis of the knee, which is a situation whereyou have the knee that degrades to the pointwhere you're gonna have to have a jointreplacement. arthritis in the tmjis self limiting and will eventually burn out. and the reason for that, isthat, as opposed to the knee, that has high line cartilage,which is a type of cartilage,

where it doesn't have anykind of blood supply in it, the tmj is covered withfiber cartilage, and so the fiber cartilagewill regenerate. the joint will never looknormal because the bone is gone but the layer of cartilage willreform over the joint. and eventually peoplewith osteoarthritis of the joint will be able tofunction without pain and fully like before.

so that's a great thingto tell patients who are pretty scared whenthey see their x-ray. and believe it or not, a really terrible x-ray canbe seen in 16 year olds. and when you have a 16year 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 thateventually they'll be okay, it's a lot easier tohave a conversation.

so this is another oneof those x-rays, and the difference between thisone and the one that we saw before, where therewas just remodeling, is that if you look, insteadof 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'sa little bit of shadow. there's not quite a line here.

same thing here. we lose the line at thispoint in the image and that's the sign that there'san active process happening. that's the differencebetween the remodeling and the active joint degeneration. so this is a terrific image,it's totally underused. it's calleda cone beam ct scan. it's available in someof the dental offices, and ents use it as well,because you have a pretty good

view of the sinuses, andoral surgeons use it, but it's a lot less radiationthan a regular medical ct, and it gives us such a betterimage of the joints. this is another pictureof the degeneration. this is a 23 year old. i mean, this 23 year oldhas lost so much anatomy. you see it's really flat and it's really flathere as opposed to the rounded curves on boththe eminence and the condyle.

i mean, for a 23 year old,that's pretty dramatic. i have a coupleslides of tumors. this is an osteoblastomaof the jaw. it's pretty obviouson the x-ray as well. usually, very slow-growing. these are more,this is from the condyle, you see that bulge here andover here, you have a cyst. so, all these are benign, the first one was not butthese two are benign.

and usually, unless theyinterfere with function, if the patient can open andclose, we leave them alone and watch them. but that determinationhas to be done on a case-by-case basis. and the one thing you wanna dois eliminate the malignancy. you wanna make surethe tumor is not malignant, other than that, you know,you just watch it. so it comes to the really,really interesting and

controversial question ofwhat causes a tmj disorder. and there's a lot of debateabout 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 disorderwas due to a bad bite. and that the treatments fortmj disorder was to make the bite a perfectbite or improve the bite. i mean that was 30 years ago,you know. so it definitely haschanged since then.

and in the dental community,some people are still adhering to principles that are nolonger based on evidence. and certainly,that assumption that is not, i mean, the fact that it's notcaused by a malocclusion or bad bite has been studied. it has been studied andthe results are very clear and very consistent because theyhave studied people, a group of people, who had perfectbites and no tmj disorder. they created someinterference.

so they changed their bites so that they didn't havea bad bite anymore, and they left them like that forsix months. and they came back and theystill didn't have more tmj disorder thanthe general population. conversely, they took peoplewith tmj disorders and a bad bite, andthey corrected their bite, and they followed them up, and sothere's no relationship with. so people who say that youneed orthodontics to cure tmj,

it's just notbased on evidence. and unfortunately, that is done pretty commonlyin certain circles. and of course,in academics we don't do that. but that's something i wantmy patients to be aware of, because that's a very costlyproposition, of course, you know,if you have to have braces. or another thing thatwe know is that, of course blunttrauma fractures,

motor vehicle accidents, they can cause a tmj disorder,right? however, i have seen patientswith fractured condyles at a 90 degree angle whocame to my office, sent and referred by their dentist,who had seen the x-ray. and the same patients hadno dysfunction, no pain. so, it's very variable,as far as presentation, but definitely you can saymacrotrauma, blunt trauma, can cause a tmj disorder.

microtrauma or load is what wealways traditionally thought caused the tmj disorder. microtrauma orload would be grinding, clenching, going tothe dentist, having surgery, long openings, yawning,chewing hard foods. traditionally, especiallygrinding and clenching were associatedwith tmj disorders. and i'm going to come backto that particular item in a little while.

persistent pain isalso an etiology and persistent pain is more, thereis no finding on an x-ray, patients just have pain. and those types of patientsare more in the spectrum of fibromyalgia, ibs,chronic migraines, and tmj disorders fall inthat same spectrum. so there is a painissue that is central, that is brain-driven, that is definitelynot due to peripheral

components such as the bite oreven grinding or clenching. and disease process,that's pretty obvious. that's the arthritis andthe lupus and so on and so forth, andthat's pretty documented. now if you look atmicrotrauma or load, now the question now is,what kind of importance does a load have for patientswho have a tmj disorder, or have a propensity orare at risk for tmj disorder? is it more likean aggravating factor, for

some people who are justalready susceptible? is it a perpetuating factor,once you have it, you don't heal? it's, there's a lotof research, and there's a lot we don't knowabout the origins or why some people develop tmj disordersand why others don't. 60% of the people, or50% of people clench and grind in the populationat night. that's something we humans do.

it's controlled by our brain. it's no longer believed tobe brought about by stress. it can fluctuate. like daytime clenching andbruxing, and grinding, yes,stress may be involved in it. but night time bruxism andclenching are no longer believed to beassociated with stress. that's something 50% of peopledo and in the population, 50% of people don'tdevelop tmj disorders.

so there's not a directcorrelation with load and tmj disorder. and so, we're looking at otherthings that could potentially differentiate the people whodevelop tmj disorders and the people who don'tdevelop tmj disorders, given that both of themgrind and clench, okay? so, what are we looking for? okay? so we're looking atsymptomatic and asymptomatic

patients, patients with pain,patients without pain. and we look at patientswho have the same anatomy. maybe we look at a populationof people with a displaced disc and pain, orpeople with myalgia. and we look at their genetics,we look at the grinding and clenching they do,their anatomy. and we try to find somethingthat differentiate both groups of people, and it is very difficult, becausethere are so many variables.

but the one thing that hasbeen studied right now is adaptability and resilience. and so adaptability iskind of the ability, it's genetically determined,but it's the ability of ourbody 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 butno evidence of disease. well, for some people,

they will respond toload with adaptation. and other people willrespond to load with degenerative joint disease. okay?so there's somethingthat's genetic, and it's a risk factor thatwe can't really control. there is some evidence thatthere is a relationship between arthritis anddisplacement of the disc. now, is the person whohas arthritis at risk for

disc displacement oris the person that has disc displacement more at risk forarthritis? so, we haven't figuredthat one out yet. so, basically,when the patient comes in, we treat the symptoms. we can't reallytreat the cause. so, adaptability is a big one,and it's that we can observe. we can observe that somepeople, because of the x-ray, for example,

we can observe that somepeople do not degenerate. some people's jointdo not degenerate. but then, you know, we lookat, so this is what we're talking about, you havethe anatomy and the load. when it's not really great,you have pain. adaptability is the factorthat can be the difference between the people withsymptomatic, not symptomatic. but, then we also havesituation where we have seemingly the same adaptation.

there's nothing on the x-raythat's particular. nothing out of the ordinaryin terms of load, no seemingly trauma, nodysfunction, 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'scalled resilience. and resilience is an abilitythat is sometimes innate that we have to cope with certaindysfunctions and pain that makes it that we experienceless pain and dysfunction. so we started lookingat the resilience, and that's studies that are donemostly by pain psychologists on pain patients,on chronic pain patients. so usually people whohave good adaptation and resilience, when they havea certain amount of disease,

they seem to respondbetter to treatment. the treatment that we do,it works. and, then sometimes we do thesame treatment on seemingly the same type of patient,and it doesn't work. and, that's puzzling andfrustrating for us providers, of course. and, sowe wanna have more research. so, this research onreliance and adaptability. a resilience in adaptabilityhas led to this kind of

schematic. you know, where you haveyou know, the tmj pain or dysfunction, and you haveseveral areas that can influence, positively ornegatively, 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 lookat sometimes, this was the old way welooked at tmj disorders.

it had to be the load,it just had to be the load. they did not considerthese two factors. so once we started openingour mind, a little bit out of the box, then we bringin these two conditions, other pain conditions becauseit's well known that if you other pains in your body, youhave chronic pain in your leg, chronic pain in your back,chronic migraines and then you develop tmj disorder, youwill perceive that as worse. i mean that's justthe way the brain works.

once you have pain, the brainsignals can just free flow a lot more than if you don'thave any other pain condition. so we can think that thereare other pain conditions. we can think thatthe resilience is less. we can think that maybe it'sa combination of other pain conditions being interfering,and a lack of resilience. so there's a lot moretreatment options and treatment possibilitiesthat open up. this is how we all would liketo be able to treat, right?

you have the symptoms,you take a test. you figure out whatit is caused by and then you geta treatment that works. i mean that is the simpleequation that we sometimes can do with some disease butwith tmj disorders, it's just not like that andthat is the hard part for patients andproviders alike es that there are people who come in withexactly the same symptoms. you give them the sametreatment, and

they have different outcomes. so that is very difficult. so adaptability seems to havemore to do with the body's ability to cope, and the resilience withthe 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 onthe definition of pain.

if you go to the dictionaryand you look at pain, it's not only a body perception butit's also an emotional component and so the emotionalcomponent is just as big as the actual perceptionof the physical pain. so if you can reduce eitherthe emotional portion or the physical portionof the pain, you can actuallydecrease the overall experience of pain thatthe patient receives and that's a really big newapproach for chronic pain that

we've been practicing at thestanford pain clinic, is that we don't just think thatpain is a bodily perception. we also feel that theemotional distress associated with both the pain, thedisability, the dysfunction is just as important andit's the sum of these two that can make the patientmore or less miserable. so if you think about it thatway, you get better outcomes. unfortunately, dentistsjust 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 toneed to do something, they don't usually just thereare situation where it's better to do nothing,you know. so dentists are by training, they're used to actually doprocedures, make appliances. they have a drill,they want to use it. so it was an actual differentframe of mind that i had when

i went to my residency, it wastotally a different frame of mind to come back moreto a medical model. so this is the way we used to treat tmj disorders,okay? first line, we havethe first line treatments. anti-inflamatories,corticosteroids, physical therapy forthe muscles. you know, trigger pointinjection, if necessary. joint injections,if necessary.

joint manipulations you know,to reduce the joints. i mean not chiropracticmanipulation but if the joint was locked wemanipulated 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 havejoint replacement surgery that has really totally,totally been discredited.

joint replacement surgery isvery, very rarely indicated. maybe in case of trauma orcancer, yes. but the results were so disastrous that they're donereally, really, very rarely. open joint surgery, again, imean, some people had surgery for clicking, benign clicking,and ended up crippled. you know, not being able toopen their mouth, so its very, very sad, buti still see them. you know, so some reason somepeople still have surgery, and

never orthodontics biteadjustment, and opioids. we don't really use opioids. it's not a disorder thatnecessitates opioid treatment. the chronic disordersdon't really do anyway but even acutely,it's not usually the type of pain thatnecessitates opioids. so now that we know allthis about adaptability and resilience, we are moving this whole category intoa first line treatment.

so we have pain psychologiststhat will work on patients and give them better resilience. resilience is somethingthat some patients have on their own. they have thosecoping mechanisms. they were born with them or they acquired them along theway but you can teach them. you can teach them to people, and that's what the paidpsychologists do.

they teach patientscoping mechanisms, they increasetheir resilience, they decrease their focusing,their catastrophizing. catastrophizing isa feeling that you have that your disorder actuallyis very, very bad. it's not benign, it's goingto deteriorate, so it's like a doom and gloom approach todisorders and certainly, in the tmj world, there is reallyno need for doom and gloom. so they do lifestylemodification, relaxation,.

meditation also works quitewell even though you have to practice that and there ismore recently, there's more emphasis on sleep and sleepquality than there was before. there's some research thatshow that if you have poor sleep, you will tend tobrux grind your teeth more. because you never getto the very deep sleep. for some peoplewho wake up a lot, they never really go into thedeep sleep where the muscles are completely paralyzed.

and so, that might affecttheir adaptability or their resilience. so anyways, the resiliencedefinitely 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, thepain will appear more worse. so it's not that necessarilystress is inducing the pain. it's more that,when you have stress,

your pain highways or yourpain processes are different. and so that's where workingwith a pain psychologist is, for us, invaluable. and that's why going toa pain center, like stanford, that has the pain psychologistavailable is a real bonus. and i've worked both with and without a painpsychologists and i cannot tell you the difference thatit makes for the outcomes. so i will finish my talkhere to leave some room for

questions and answers. because it's such a difficultsubject in terms of, if you have been affectedby the disorder, you probably go to somephysician or a dentist and get five different options. or you look online andyou have these multiple opinions of what youshould be doing. the one thing that i have tosay and this is really pretty important, is that all of thetreatments that are done for

tmj disorder, allthe treatments are reversible. so things like fulltime wear of splints. it seems really benign, buta full time wearer of splints can change your bitein a permanent way. so if you wear a splint,day in and day out, for several months. your bite will mostlikely change. and what you do at thatpoint that you need braces. and some people actuallyhave a phase one,

phase two process. where they change the biteon purpose with the use of a full-time appliance. and then afterwards theyrestore the bite to a better position. so, stay away, if i can giveyou one recommendation, is stay away fromtreatments that cause, that are not reversible. so in the non reversibleone you have orthodontics,

full time wear splint,bio-adjustments, and everything else, you know, there are a lot ofthings that work. i mean, acupuncture might bea wonderful treatment for some people. other people will respondto muscle relaxants. other people don't wanna hear,i mean, there are a lot ofoptions of treatment. it's not like everybody thatgets a tmj disorder gets

exactly the same treatment. we discuss with patients whattheir preference is in terms of treatment philosophy. and if they want to seea pain psychologist and work on meditation relaxationfirst, it's fine with me. and depending onwhat they have, things like antidepressants,topical or oral, work really well forthings like inflammation, just like in otherjoints of the body.

but please, reversibleis what i would like you to bring homefrom this lecture. so i would welcome questionson any part of the speech or on other things youmay have read online. yes. >> i'm sorry, i came ina little bit late, but did i understand correctly, do youfeel that splint are overused? >> can you repeat that? >> yes.

the question, do you feel likesplint are overused, okay. [cough] [noise] in general,i really believe so. and the reason being thatthere is in dental school, we get no training. we have no trainingin tmj disorders. so most of what dentists pickup to treat patients is over the course of, you know,here and there continuing education, they learnhow to make a splint. so dentists basically, theonly thing that they know what

to do, is to make splints. so, that's usuallythe 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'llsend you somewhere else. so probably, 70% of peoplewho come to my practice have gotten the splintfrom their dentists. i would say that mostprobably, realistically, only 20% of people withtmj disorders would need

a splint orwould benefit from a splint. it's a very difficult questionbecause they have tried to do a lot of researchon splints. and there wasn't reallya particular type of patient that is ideal for splints. like some people respond allover the place, like 50% of people would respond 45 willnot, 5% will get worse, and we can not pinpoint which onesare the ones that get better. overall, forme an my practice,

if i have a patient whosepain is worse in the morning, when they get up,i will try a splint. if they are worse inthe afternoon and they have no painin the morning. i'm just assuming that they'renot doing anything at night that aggravate their disorder. so i don't really believe thatthe splint will do anything. i will use a splint if theygrind their teeth to protect their teeth.

cuz that we know the splintdoes but what the splint actually does forpatients in pain is unknown. and there certainly [cough]people out there [cough] and with good backgrounds, veryreputable people who believe that part of the benefitsof the splint is placebo. which you know placebois not all bad. placebo i mean 20% of anytreatment that i do patients including medications thathave research backing it is placebo.

>> can you explainwhat the splint does? >> a splint and, i should havetaken a picture of a splint. it's basically a night guard. do you know whata night guard is? a night guard is a piece ofplastic that is molded to your teeth and that isacting as an interface. it goes either onthe bottom teeth or the top teeth andit's basically a plastic interface between the topteeth 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 asyou don't use them full time. and certainly forsome people they do work. so in some patients ithink it's worth trying. i like them to be full arch.

i do not like the one thatonly are in the front teeth. they were marketing,they're called ntis, and they fit just inthe front teeth. and they were marketing. than for grinding, becausethey said that if you clench on your front teeth, you don'tclench as hard, which is kind of true, but you clenchenough to get bite changes. and so the research onthose has been pretty bad in terms of reversibility soi don't use those.

i use the full arch onewhich covers all the teeth, more like a retainer, like an invisalignretainer except thicker. and again,people do thick splints, thin splints, hard splints,soft splints, and a lot of people swear bythe splints they make but if you look at the research,there's really no type of splints that worksbetter than the next. so whatever your dentist wantsto make, if they are into hard

splints, by all meanshard splints is fine. if they want to do softsplint, it's fine too. it's just more like is itcomfortable for the patient. does the patientlike it better? yes?>> well, you said that really, no treatment is good foreverybody. >> 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 notreally so much as it, i put it there in the adjunct,okay? so adjunct is notreally a first line. i will try other things. but if the patient continuesto have morning pain, it's something that is nota medication, it's benign, and some people find benefits.

so it's still in the range of treatments thatare worth exploring. what else that you say. >> okay, is it the type ofthing that can get worse. >> mm-hm.>> it's reversible. >> yes, as long as youdon't use it full-time, and by worse, it's pain. just some people develop pain,and then you just haveto give it away.

yeah. >> by full time do you meannight and day, 24 hours? >> yeah. >> no. >> it won't change the bite orchange 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 iteveryday when you wake up.

make sure that yourbite hasn't changed, and it's usually fine. we have time fora couple more questions. yes? >> you mentioned in tmjthat you get ear pain. >> where the pain located,is it outside, or it's inside? >> well,what it is is if you look. >> question? i mentioned that the tmj painis also sometimes associated

or felt as an ear pain. it's more because ofthe proximity of the tmj with the ear. so if you look inan anatomy textbook, there's just the very thinpiece of bone that separates the tmj from the ear. and sobecause the pain sometimes, if it's reallyintense it expands, it kind of getsperceived in this area.

that's why a lot of peoplesee an emt doctor first before they see me becausethey perceive it as ear pain. but it's not because it isaffecting the ear directly. >> so would the pain aroundthe ear or inside it? >> well it's moreon the inside. i mean most people think itfeels 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 thataffect your bite? >> the bite changes, notbecause the teeth change, but because the positionof the condyle inside the fauca will change. so because of the,see when you look at the. let me put the pictureof the actual joint.

okay, almost there. okay sothis is the condyle and this is the fauca. okay, when you have a nightguard in your mouth, you are going to havea different position of this disk and this condylebecause the jaw will be slightly more open, so thedisk will be a little bit more anterior and the condyle willbe a little bit more anterior because of the positionof the jaw.

and if you keep it there 24/7,the soft tissue within the capsule willadapt to that position, and it will be difficult to goback to the old position. >> but if it's justused as a night guard? >> yes if it's just usedas a night guard at night, in the morning whenyou take it out. i wear one because iwear one as a retainer basically becausei had braces, so for me a night guardis the right thing.

i don't wear it for pain or a tmj disorder, but when itake it out in the morning, even though it's very thin,my bite is a little bit different because ofthe muscle position. but that's okaybecause within five minutes it's back to normal. >> yeah,never noticed anything. >> i used to wear one andit 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 comfortand it's symmetrical and it's the sameamount of force and you feel like you're biting onboth sides in the same way, it shouldn't need toget any adjustments. i mean you will continueto wear it down, but you wear it downbecause of function.

and so you continue wearing itdown until there's a hole in it and you need to haveit replaced, that's all. >> huh. >> and what is the biteadjustment aside from braces? >> oh that's when theyactually grind your teeth. you know, when you don'thave a perfect bite, you may have a tooth that'sa little crooked, right? or that is a littlebit tilted and when you go side to sideyou hit that tooth first.

and so they shave thatpart of the tooth away, so that you can translatefrom side to side. and i'd say, if a perfect bitewas the solution, putting a night guard on everyoneshould heal everyone because once you have a night guardyou have no interferences. you actually havea pretty perfect bite, because the night guardis adjusted perfectly. so the theory that a biteis a determining factor, is pretty muchobviously not right.

and during the day you'renever touching your teeth together anyways. so you function, except forwhen you swallow, that you briefly put yourteeth together even when you bite on food,because food is the interface. your teeth are not actuallycontacting that much. and i have seen people withincredibly horrible bites and no symptoms. the only time that i wouldsay bite has an issue,

is of importance is you havepeople who lose all posterior support. like they lose their premolarsand their molars and they don't have a stable bite. so whenever they bite,their jaw does this. cuz they have nothingto bite on one side. in that instance, i understandthat the bite should be restored toa stable occlusion. but as long as you have astable occlusion, which means

you bite on both sides on yourback teeth, it should be fine. >> well, i never heard ofthat kind of bite change. that's interesting. that when you go toan orthodontist- >> yes.>> and specifically by chance to have your teeth fixed. then it would- >> sure. >> that would neither hurt norhelp the tmj.

is that [inaudible]. [crosstalk].>> that is correct. >> okay. >> that is correct. and, actually, orthodontistsget a really bad reputation because very often,tmj disorders start, at the same time asorthodontic treatment. but it's mostly becausethe onset is usually around puberty which is also the sametime as people get braces.

but some treatments doneby the orthodontist can aggravate the tmjdisorders like elastics that bring the jaw back. if you already havea 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 forsleep apnea they will prescribe a dental procedure. >> a dental procedure oran appliance? >> or an appliance.>> yes.

>> and i'm just wondering ifyou see that [inaudible]. yeah, i am very familiarwith the appliance, cuz i make them formy patients with sleep apnea. an appliance for sleep apneais basically an appliance, if you're familiar with cpr. are you familiar with cpr? well, you know how youdo a jaw thrust for unconscious patientsto open their airway? well, basically an appliancebrings the jaw forward

into a thrusted positionto open the airway. and have patientsbreath better at night. so, it's an appliancewith which the jaw is maintained in a forwardposition through the night, which is pretty dramatic,you know? and it's done in a veryprogressive way, you know, one-tenth ofa millimeter time, maybe over several months. and certainly,in those situation,

you get more chances ofhaving bite changes than with a regular night guard. but, even in those patients, you don't find a lotof bite changes. you see some bite change but usually they don't notice it,in terms of tmj disorder, bringing the jawforward slightly. if they have a joint disease,might not be a bad thing for their symptoms becausethere will be more space in

the joint when the jawis brought forward. but if they havea myofascial issue, it will be very difficult totolerate, because the muscles are trying all night longto bring the jaw backwards. and so even patients who don'thave tmj disorders or myalgia, sometimes get myofascial pain,and pain in the muscle, initially, when theystart the appliance. but it's a very, verywell-tolerated appliance, and it's an alternativeto see path for

patients with mild andmoderate sleep apnea. well, your second question, the load is consideredany kind of movement that puts undo forces inloading on the joint. so, grinding, bruxing, crunching part foods,chewy foods. incidentally, salad,it's very difficult to chew. people think oh, no problem, idon't have to eat hard foods, i'll eat salads, well salads,i have bad news, salads with

tmj disorder patients are justthe hardest thing to chew. >> [inaudible] thank you somuch. >> you're welcome.[applause]. >> i hope this was useful. i hope that you learnedsomething and that you are now more able to look atthe literature online and see the good from the bad, and the evidence based fromthe coocoo out there. [laugh].

>> just one moreabout the department. this is a new department? >> well it's not a newdepartment per se. it's part of the stanfordpain clinic and so it's in the same building. and it was the same facultyof the pain clinic, but it's an orofacial pain focus. so, we have a groupof neurologists, anesthesiologist, dentists,physical therapists,

psychologists thatspecifically tend to orofacial pain problems. but, if you call- >> it's more gentle. >> no dental work, no. no. i haven't toucheda drill in 20 years. [laugh] except toadjust the appliances. >> one thing is medicaredoesn't pay for any tmj.

>> that's not true. that's not correct. i do take medicare inmy private practice. it will not pay forthe appliance, for the night guard. but it sometimes does. i mean if you appeal,it might. but they certainly pay forthe appointments, because i bill medical codes.

so i bill a regularmedical visit. this is not considered dental. because that's the thing, insurance wise, that's reallydifficult because they kinda throw the ball at each other. the dental insurance saysit's a medical issue, the medical insurancesays it's a dental issue. but it's actuallya medical issue. it's a joint,it's not a dental pathology.

>> well, thank you very much. >> you're welcome.