Treatment Philosophy

Pain and dysfunction can be the result of a single traumatic event or a series of microtraumas. As the orofacial region is responsible for the life sustaining functions of breathing, eating, drinking and speaking the body has set-up an exquisite feedback system in order to regulate these functions. Any treatment needs to address the interactions between the jaw muscles, TMJ, teeth, cranial bones, cervical vertebra, neck muscles, tongue, teeth, dental occlusion, trigeminal nerve and cortical processing areas in order to adequately treat pain and dysfunction within the area so that any treatment to one component of the system does not adversely affect another component. Utilizing their years of post-doctoral education and experience Dr. Pehling and Dr. Gordon have established a protocol treatment of these disorders. Drs. Gordon and Pehling believe in the use of a non-surgical multidisciplinary treatment approach customized to meet the individual needs of the patients. After extensive research and application, Drs. Pehling and Gordon have specifically adapted many of these treatment approaches for use within the delicate orofacial region.

I. Self Care and Patient Education
We believe it is very important for the individual to thoroughly understand their condition and to develop methods for decreasing the pain and dysfunction.  These include training in diet and nutrition, home exercise and stretching program, postural training, ergonomics, heat and ice and relaxation training.

II. Medications and Nutritional Supplements
Utilizing the latest research and our experience we will use when necessary various medications including muscle relaxers, nerve stabilizing medication, anti-inflammatory, pain medications and headache medications.  We also encourage appropriate supplements and the reduction of stimulants such as caffeine and nicotine.

III. Physical Medicine

1. Myofascial release which treats the tight painful trigger points in the jaw muscles.

2. Orthopedic jaw mobilizations are a special technique which we have developed to improve the gliding motion of the jaw joint and to improve condyle and disk position.

3. Spray and Stretch is a technique that uses vapocoolant ethyl chloride topically on your skin while we stretch you jaw and head in order to establish normal movements and reduce muscle tightness.

4. Trigger point injections involve injecting a numbing solution into the tight knots in your muscles in order to break the knots up.

5. Intramuscular Stimulation involves the placement of multiple very fine needles into the muscles in order to increase blood flow and also to release the knots in the muscles

6. Trigeminal nerve injections are to given to reduce pain and to allow the nerve to re-stabilize. Sometimes they are needed to allow us to do joint mobilizations as well.

7. Steroid injections are given into the muscle tendons or joints to decrease pain and inflammation.

8. Ultrasound is used to increase blood flow to an area to speed healing and collagen growth in the joint.

9. TENS/MENS are electrical nerve stimulators, which helps the muscles relax and decreases pain.

10. Hot and cold therapy to relax the muscles and clam the nerves.

11. BOTOX injections are given into the jaw muscles as they decrease muscle contraction by blocking the nerve that attaches to the muscle.  They also selectively block the activity of the pain nerves.

12. TMJ Arthrocentesis is done to flush out the inflammation in the TMJ and break up adhesions within the joint which are limiting the movement of the jaw.

13. Jaw mobilizations under general anesthesia are done so that we can control your pain and also completely relax your jaw muscles while we perform the mobilizations.

IV. Oral Appliances
There are several factors which influence the design and fabrication of your oral orthopedic appliances (orthotics).  We use several designs including increased vertical dimension appliances, anterior repositioning splints, 3-way expansion appliances, Herbst appliances, airway dialating appliances, anterior deprogramming and NTI-type appliances.  Based upon our clinical examination, radiographic interpretation, and analysis of your dental models we determine how to best:

1. Decrease compression on the pain sensitive tissues within the posterior joint area.  When the disk slips forward then clenching, swallowing and biting forces are placed onto the primary nerve and blood supply to the area.   This causes pain and inflammation within the joint.  Secondarily, the jaw muscles will tighten-up in order to protect the joint.  By decompressing the joint it allows for decreased pain, improved circulation and muscle relaxation.

2. Re-establish a better condyle-disk relationship.  As the disk slip forward and to the side it interferes with the movement of the condyle within the joint fossa.  This causes limitations and/or deviations when opening and closing the mouth.  By altering this adverse anatomic relationship it decreases the chances of a permanent or repeated dislocation of the disk.

3. Realign the mandible into a physiologic maxillo-mandibular relationship.  The dental bite, the jaw muscles, head posture and the TMJ all determine the relative jaw position.  When one or more of these factors is dysfunctional secondary to genetic, developmental, traumatic factors it can alter the relationship between the upper and lower jaw causing further pain and dysfunction in the other areas.  By reestablishing proper physiologic positioning it allows the body to heal and decreases the chances of further pain and dysfunction.

4. Decrease adverse behaviors such as clenching and grinding.  When a joint or muscles are injured they need to be able to rest in order to heal.  When a person is clenching or grinding their teeth they can exert up to 3000 pounds per square inch of pressure.  Studies have shown that up to 95% of the population clenches or grinds their teeth.  Orthotics can not only act as a behavioral reminder they can also be designed to take advantage of the bodies natural ability to inhibit jaw muscle contraction.

5. Open the airway space thereby decreasing sympathetic arousal at night and decreasing Bruxism.

6. Protect the teeth, supporting bone and periodontal structures.  The adverse load on the teeth is one of the major causes of tooth pain, tooth fracture and tooth loss.  Additionally it can increase bone loss and periodontal recession.  This can necessitates crowns, root canals, periodontal surgery, tooth extractions and resulting in replacement with bridges, dentures and implants.

Frequently Asked  Questions

What is the difference between a nightguard and an oral orthotic?

Many of our patients have either been previously given a nightguard appliance and found it ineffective or initially found it helpful but due to a change of factors no longer find it beneficial.  Nightguards are typically designed to only provide a thin layer of protection over the teeth in order to prevent tooth wear.  Additionally, for many people they also decrease jaw clenching and grinding.  However, at times some people will clench and grind their teeth more with a nightguard.  Research and experience has also shown that nightguards can sometimes worsen TMJ disk displacements causing increased clicking and locking and have also been shown to make snoring and sleep apnea worse.  We design our appliances to decrease load onto the TMJ and we evaluate for any changes in your breathing.

 

Are there any risks associated with treatment?

There is the possibility of changes in your bite as the TMJ adapts.  This chance is low with proper follow-up appointments and even if it does occur it can usually be remedied with small dental adjustments.  However there are instances when due to anatomic and functional factors you can experience some bite change.

What are my chances for success?

Fortunately, they are very high.  This is why our clinic has received thousands of referrals form healthcare providers around the state and country.  Despite the fact that we are often referred the most difficult cases, our oral orthopedic appliance therapy program in addition to any necessary physical medicine procedures has a very low incidence (About 1-2%) of failure resulting in the need for surgery.  Depending upon the chronicity and level of dysfunction, the TMJ may never return it’s “normal” state but a successful outcome would be diminished pain and the ability to talk eat and chew relatively normal.  As in other rehabilitated joints in the body there are certain things that should be avoided like gum chewing or eating excessively hard or chewy foods.

The jaw joint has a tremendous capacity to heal when given the opportunity.  This is why many people have relatively asymptomatic TMJ disorders.  However when the adverse factors overwhelm the body’s innate ability to heal we get pain and dysfunction.  Correctly designed oral orthopedic appliances can help to ameliorate the adverse factors thereby allowing the body to adapt and heal.