Treatments

Self-Care

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:

  • Training in diet and nutrition
  • Home exercise and jaw stretching program,
  • Postural training, ergonomics
  • Heat and ice
  • Relaxation training
  • Habit reversal training

Remember your teeth should never touch unless you are swallowing or chewing.  All other times there should be space between your teeth.

Medication and Referral Management

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.

Physical Medicine and Jaw Manipulation

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.

  • Myofascial release which treats the tight painful trigger points in the jaw muscles using manual pressure.
  • Vapo-coolant Spray and Stretch is a technique that uses vapo-coolant ethyl chloride topically on your skin while we stretch your jaw and head in order to establish normal movements and reduce muscle tightness.
  • Orthopedic jaw mobilizations are a special technique which Dr. Pehling has specifically developed using chiropractic and osteopathic techniques specific to jaw manipulations to improve the gliding motion of the jaw joint and to improve condyle and disk position.  Often we are able to unlock stuck jaws in one or two appointments using this technique.  On occasion this technique is also used with IV sedation.
  • Ultrasound is used to increase blood flow to an area to speed healing and collagen growth in the joint.
  • TENS/MENS are electrical nerve stimulators, which helps the muscles relax and decreases pain.
  • Iontophoresis uses electrical stimulation to drive medications through the skin into the TMJ without the use of needles.
  • Hot and cold therapy to relax the muscles and decrease inflammation.

Therapeutic Injections

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.

  • Trigger Point Injections involve injecting a numbing solution into the tight knots in your muscles in order to break the knots up and increase blood supply to the dysfunctional area.  Dr. Pehling was trained by a student of Dr. Simons (Travell and Simons).
  • 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.  This allows Dr. Pehling to go into multiple trigger points at the same  time with very minimal injection pain (similar to acupuncture needles).
  • 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. Steroid Injections are given into the muscle tendons or joints to decrease pain and inflammation.
  • Prolotherapy Injections are given using strong sugar water into the tendon and ligaments in order to stimulant  collagen repair.

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 :

  • Increase synovial fluid levels of  hyaluronic acid improving its viscosity.
  • Decrease levels of prostaglandins, improving pain.
  • Increase the cartilage thickness on load bearing surfaces

Botox Therapy

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.

Oral Appliance Therapy

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:

  • Decrease compression on the pain sensitive tissues within the posterior retro-discal tissue area. When the disk slips forward, then clenching, swallowing and biting forces are placed onto the primary area of nerve and blood supply. This causes pain and inflammation within the joint. An inflammatory cascade can then start cartilage and bone degeneration. Secondarily, the jaw (and neck) muscles will tighten-up in order to protect the TM joint. By decompressing the joint, it allows for decreased pain, improved circulation and muscle relaxation.
  • Re-establish a better condyle-disk relationship. As the disk slips 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.
  • 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.
  • 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 300 pounds per square inch of pressure onto their teeth and jaws. Studies have shown that up to 95% of the population clenches or grinds their teeth. Oral appliances cannot only act as a behavioral reminder they can also be designed to take advantage of the body’s natural ability to inhibit jaw muscle contraction.
  • Open the airway space thereby decreasing sympathetic arousal at night and decreasing Bruxism.
  • 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 necessitate 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 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.

Minimally Invasive Surgery

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

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.

Ultrathin TMJ Arthroscopy

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:

  • Osteoarthritis
  • Defects in joint lubrication
  • Small adhesions in the joint space
  • Dislocated disc
  • Perforation (or puncture) of the disc

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.

Snoring Treatment

Self Care
  • Weight gain is a significant cause of snoring and sleep apnea as fat tissue are deposited into the tissue of the throat. Therefore a weight reduction program can lessen or eliminate Snoring and OSA.
  • When you sleep on your back the tongue and soft palate due to gravity will sag into the back of the throat. Snoring and OSA is usually improved by sleeping on your side.
  • Many medications, especially relaxants can decrease muscle tone within the tongue and pharyngeal muscles which leads to increased apnea. Alcohol in the evenings also causes decreased muscle tone within the tongue, soft palate, and pharynx.
  • Maxillary dental nightguards have been shown to increase OSA by as much as 50 %.   Since patients with apnea also have increased Bruxism or teeth grinding episodes the nightguard may be contributing to the cause of the problem. Special nightguards can be made that do not increase the apnea. This can be verified with a home sleep study such as we use at our office.
CPAP

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 Appliance Therapy

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.

Oral Sleep Appliance treatment program
  • A thorough clinical evaluation is done which includes a review of your PSG (Please bring a copy of your PSG to your appointment).
  • A Craniofacial cone beam CT will be done which allows us to visualize your teeth, your jaw joints and jaw position, and a 3-dimensional view of your airway. Typically a second CT is done at a bite position which approximates the position of the oral sleep appliance. We then measure for improvement in airway volume as that can be a sign that treatment with an oral sleep appliance will be effective. Our CT machine is the only lay-down cone beam CT machine in the northwest. Only a lay-down CT machine can visualize your airway in the sleep position. Our NewTom CT machine was also designed to minimize radiation exposure so that it uses about 10% of the radiation of a typical hospital head CT.
  • Models of your teeth and bite records of the jaw position are taken.
  • Insertion of your new appliance is done approximately 3 weeks later. In addition, jaw exercises and often a bite-repositioning appliance is given to decrease potential side effects of bite change and jaw discomfort.
  • Titration of the appliance for comfort and effectiveness is done.
  • A Home sleep study is done to verify effectiveness.
  • Once effectiveness has been verified you will be referred back to your sleep physician for a follow-up.
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.
OSA Surgery
  • Tracheotomy During a tracheotomy, a surgeon cuts an opening into the windpipe and then inserts a tube into the opening to be used for breathing only during the sleeping hours. Patients will be able to breathe and speak normally during the daytime. A tracheotomy is reserved for severe cases of sleep apnea that cannot be adequately treated with other modalities.
  • Uvulopalatopharyngoplasty (UPPP) During the UPPP procedure, a surgeon cuts away the soft tissue at the back of the throat and palate in order to minimize the risk of the airway collapsing during sleep. The tonsils and part of the uvula will be extracted also. UPPP is done rarely today because of the significant risks and side effects from the procedure.
  • Laser Assisted Uvuloplasty – LAUP The laser assisted UP procedure, or LAUP, uses the same principles as the UPPP, but uses a laser to remove uvula, throat and palate tissue. Unfortunately, the LAUP has not been shown to be very effective for treating OSA.
  • Somnoplasty Somnoplasty can be used to tighten and reduce soft palate tissue, turbinates and the base of tongue. The advantage to this procedure is that it has much fewer side effects than other surgical procedures. Dr. Pehling has found that this procedure in combination with oral sleep appliance therapy can be effective in severe or refractive OSA patients.
  • Tonsillectomy and adenoidectomy During a tonsillectomy and adenoidectomy, a surgeon will remove the tonsils and adenoids, creating more space for airflow and reducing the opportunity for tissue collapse. This procedure is often recommended for children with sleep apnea or heavy snoring problems. Orthodontic widening of the maxilla in young children not only increases the oral airway but can significantly enlarge the nasal airway. This procedure can also be used in conjunction with oral sleep appliance therapy.
  • Bimaxillary Advancement During a bimaxillary advancement an oral surgeon will surgically move the maxilla and mandible forward (much like an oral appliance) decreasing the possibility of a collapsed airway. The enlarged mouth also reduces the chance that the tongue will interfere with correct breathing. This is the most useful surgical procedure and can give 100% relief. Successful oral appliance therapy can predict success of bimaxillary advancement. This procedure is often combined with GGA procedure.
  • Genioglossus and Hyoid advancement (GGA) A surgeon uses GGA procedure to pull the tongue muscles forward and prevent the collapse of the airway. By tightening the front tendon in the tongue, the procedure decreases the chance that the tongue will collapse and inhibit breathing. GGA involves an incision inside the mouth, and the creation of an avenue in the bone that is used to pull the front tendons forward. The result is an enlarged space between the rear of the tongue and the patient’s airway. GGA is often recommended as a supplemental procedure used in addition to another procedure or oral appliance.

 

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.