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Our treatment uses a rehabilitative protocol in order to eliminate pain and increase jaw function. Our clinic sees daily the debilitating effects of persistent and severe pain in the head. Unfortunately, many treatment approaches do not address the full scope of problems and only try to “help you live with your problems” instead of treating them. Pain and dysfunction can be the result of a single traumatic event or a series of microtraumas. They may represent a compensation response to behavioral, functional and emotional factors. Dr. 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, Dr. Pehling has specifically adapted many of these treatment approaches for use within the delicate orofacial region. Dr. Pehling has been able to do this through his multidisciplinary training in TMJ and Orofacial Disorders during his residency and then during his post-doctoral pain fellowship. He has also had the opportunity to work with several well-known TMJ experts from across the country. This has resulted in a unique set of skills that blends the field of medicine, dentistry, and psychology.
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.
Utilizing the latest research and our experience we will use when necessary various medications including muscle relaxers, nerve stabilizing medications, anti-inflammatory, pain medications and headache medications. We also encourage appropriate supplements and the reduction of stimulants such as caffeine and nicotine.
Depending upon your diagnosis one or more of these therapies may be prescribed:
1. Myofascial release is a manual therapy technique developed by Dr. Janet Travell that treats the tight painful trigger points in the jaw muscles.
2. Orthopedic jaw mobilization is a special technique developed by Dr. Pehling and Dr. Gordon which improves 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 jaw movements and reduce muscle tightness.
4. Trigger point injections involve injecting a numbing solution into the tight muscle 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 TMJ, muscle tendons and ligaments to decrease pain and inflammation.
8. TMJ injections typically use anesthetic and sometimes a steroid or collagen replacement to decrease inflammation and lubricate the joint
9. Ultrasound is used to increase blood flow to an area to speed healing and collagen growth in the joint.
10. TENS/MENS are electrical nerve stimulators, which helps the muscles relax and decreases pain.
11. Hot and cold therapy to relax the muscles and clam the nerves
12. 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.
13. 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.
14. 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.
These are used typically for TMJ disorders, Bruxism and Sleep Apnea:
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 which appliance design is the best for your problem. This may necessitate one or more appliances.
Properly designed oral appliances can:
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. 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.
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. 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. Oral appliances are tools to be used to achieve the desired outcome. Similarly anyone can use a scalpel, but it is the surgeon’s skill in using the scalpel that counts.
Results is why our clinic has received thousands of referrals form healthcare providers around the state and beyond. 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.
Most patients do not need permanent bite changes. However when the bite is causing a significant problem it can necessitate changes which may include:
1. Bite adjustments
2. Orthodontics
3. Dentures
4. Composites
5. Crowns
As patients often have more than one problem that needs to be addressed we work with a wide variety medical, dental and alternative medicine practitioners around the state
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