We believe it is very important for the individual to thoroughly understand their condition and to develop skills for decreasing the pain and dysfunction. These include:
Remember your teeth should never touch unless you are swallowing or chewing. All other times there should be space between your teeth.
Dr. Pehling has been trained and is experienced in safely Utilizing a variety of medications including Muscle Relaxers, Nerve stabilizers, headache abortive and preventive medications, anti-inflammatory medications and anti-spasmodic medications. Dr. Pehling also will utilize herbal and Ayurvedic supplements
Dr. Pehling works with a network of high-quality health care professionals in the medical, dental and alternative medicine fields. As TMJ and Orofacial disorders often fall into the “crack” between medicine and dentistry Dr. Pehling is respected amongst his peers in both communities and is a valuable bridge between them.
Dr. Pehling has adapted a variety of physical medicine approaches that are commonly used to treat other orthopedic problems such as knees or neck dysfunction. Dr. Pehling will often combine several of these therapies in a single visit to maximize treatment.
Dr. Pehling, using his extensive training and experience, has provided thousands of patients with safe and effective injection therapy. The type of injection will depend upon the diagnosis.
Hyaluronic Acid Injections are given into the TMJ just like they are given into the knees. Hyaluronic acid naturally occurs within the cartilage and joint fluid of the TMJ. When the joints suffer damage due to excessive load or trauma the cartilage and synovial fluid are often first structures to be compromised. Research studies and Dr. Pehling’s clinical experience have shown that Hyaluronic Acid (HA) injections can help restore this damage and aid in joint lubrication and movement. Typically, it requires a course of 3-4 injections spaced out over 6-8 weeks.
HA injections have been shown to :
Dr. Pehling has been successfully using Botox therapy for over 8 years for treatment of jaw pain, teeth clenching and grinding, Oromandibular Dystonia and head and face pain. The effects of Botox generally last 3-6 months but can have cumulative effects after 2-3 treatments.
They are also effective at reducing the Masseter muscle bulk along the sides of the face. The injections are given with a tiny needle into the face and jaw muscles thereby thinning the face. They decrease muscle contraction by blocking the nerve that attaches to the muscle. They also block the activity of the pain nerves which can be helpful in the treatment of head pain.
A thorough knowledge of both Botox and the orofacial anatomy is imperative to decrease unwanted consequences of altering facial expression and swallowing. The potential benefit is that Dr. Pehling has had patients with severe jaw and head pain that went away within 1 week of treatment. Botox therapy is the only effective treatment for focal dystonias.
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 dilating 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 treat your condition. Appliances can be used to:
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 and are not designed to change mandibular load dynamics.
Research and experience has also shown that nightguards can sometimes increase teeth clenching and can worsen TMJ disk displacements by causing jaw clicking to progress to jaw locking. Additionally, nightguards have also been shown to make snoring and sleep apnea significantly worse.
Dr. Pehling’s appliances are not designed in most cases to permanently change your bite and their use can usually be weaned down over time as healing occurs. There is the possibility of changes in your bite as the TMJ adapts. However, there are instances when due to structural and functional factors you can experience some bite change but the majority of these can be remedied through minor bite adjustments.
There are instances where it is clear that someone’s bite is contributing to their pain and dysfunction and bite correction is necessary. This will usually be done in conjunction with your dentist or an Orthodontist or Prosthodontist.
Both research and Dr. Pehling’s experience have shown that approximately 5-10% of the time non-surgical care does not adequately treat the TMJ pain and dysfunction and therefore a surgical procedure is considered. Due to the challenges associated with open joint procedures (TMJ disk plication, arthroplasty, and replacements) in the past, we typically recommend a minimally invasive procedure which has a very low chance of creating unwanted side effects of degenerative joint changes, bite shifting and scar tissue formation.
The Minimally-Invasive TMJ lysis and lavage procedure has had well documented success in both research studies and in our clinical practice. Clinical research has shown that the lysis and lavage procedure has a success rate of approximately 80%. This is better than or equal to the reported success rate for open joint procedures with much less risk. These procedures are typically done in our office under sedation by a licensed anesthesiologist. It is very important that these procedures be followed by physical medicine treatments in order to maintain the surgical gains.
Dr. Pehling was residency trained in the lysis and lavage procedure and has found it to be very effective for patients refractive to non-surgical care.
TMJ Arthrocentesis is done using one or two needles that are inserted into the TMJ and than saline is pumped through the TM joints. Typically once finished a jaw mobilization is done to increase the mouth opening. This can be an effective treatment to flush out the inflammation within the TMJ and to lubricate the structures within the TMJ.
This can be an effective treatment for “frozen disk syndrome” as well. With this procedure there is no visualization within the TMJ, therefore there are certain limitations to this procedure compared to an arthroscopic procedure.
Dr. Pehling is the first doctor in the Northwest to be trained to employ an ultrathin arthroscope for TMJ lysis and lavage procedures. The Ultrathin arthroscope is about the size of a needle, therefore no incisions are necessary. This results in much less trauma to the joint than in traditional arthroscopy. Traditional arthroscopy requires the use of two probes about the size of a pencil to be placed into the TMJ. Arthroscopy is a procedure where a small endoscope (a high-powered fiber optic camera) is placed inside the joint for diagnostic and therapeutic purposes.
This allows Dr. Pehling to treat specific areas of joint inflammation and to target articular disks that have adhesions or are “stuck” in place or displaced. Due to the fact that the scope is so small complications are rare and patients can typically return to work and daily activities within 24-48 hours.
Ultrathin Arthroscopy is used after non-surgical treatments have not been successful in conditions such as:
A 2008 study of 344 patients suffering from their jaws being locked underwent either TMJ arthroscopy or an open joint procedure found “No statistical differences were observed between arthroscopic lysis and lavage and more invasive operative treatment in relation to postoperative pain or jaw opening at any stage of the follow-up period. It was concluded that ultra-thin TMJ arthroscopy should be considered as a first-line treatment for jaw locking of the TMJ.”
Open joint TMJ procedures: Dr. Pehling works closely with several TMJ surgeons for TM joint replacement and Arthroplasty procedures when these are indicated.
This has been the gold standard for the treatment of OSA. It utilizes a mask that fits over the face and is connected to a machine by a long tube which then blows air through the nose into the throat. The influx of air keeps the throat from collapsing during sleep and allows the patient to breathe freely without worry of episodes of non-breathing. This is an extremely effective treatment but while CPAP is highly successful when used properly, many patients have trouble complying with its use.
Some studies have shown that only 23% – 45% of patients are successful with the CPAP method. Unfortunately, CPAP is difficult because the device requires the use of a mask over the nose and mouth, and must be worn each night and can be a cause of claustrophobia, face breakouts from the straps, eye, sinus and nasal irritation, mouth dryness, runny nose, sore throat and gastric bloating. Additionally, many people find the aesthetics of being a “jet-pilot” less than desirable and can also find being tethered by the hose to the machine impedes their sleep comfort. This results in many people who use CPAP and wear it for 4 hours or less per night.
Oral appliances that treat snoring and obstructive sleep apnea are small devices that are worn in the mouth, similar to orthodontic retainers or sports mouth guards. These appliances help prevent the collapse of the tongue and soft tissues in the back of the throat; keeping the airway open during sleep and promoting adequate air intake.
Currently, there are approximately 70 different oral appliances available, so it important that your dental sleep specialist be familiar with the pros and cons of different appliances. Oral appliances may be used alone or in combination with other means of treating OSA, including general health and weight management, surgery or CPAP. Studies have shown that oral sleep appliances can be as effective as CPAP at reducing cardiac risk factors associated with OSA.
Potential drawbacks of oral sleep appliances are that they can increase headaches, neck pain, TMJ pain and dysfunction and cause tooth and bite shifting. When the lower jaw sits in a different position during sleep, there is a risk of creating discomfort in the Temporomandibular joint or “T.M.J.” and can lead to irreversible bite changes. Jaw exercises and bite repositioning therapy can help to minimize these changes. Our clinic which specializes in the treatment of disorders within the jaw and bite is ideally suited for providing oral sleep appliance and expertly managing their potential side effects.
Dr. Pehling is an expert in the treatment of jaw disorders, therefore unlike many other providers of oral sleep appliances, Dr. Pehling is able to address any problems with your jaw and bite should they come up.
Dr. Pehling works closely with several ENT physicians and oral maxillofacial surgeons. We also find that a combination of surgery and oral appliances can be effective treatment for OSA.