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Hamidreza Nassery , DMD, FICOI, FAGD, FICCMO  
Male, 51
Miami Beach, FL

Interests: My family, Dentistry, all sports, Travel
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Hamid Nassery, DMD, FICOI, FAGD, FICCMO
Miami Beach,
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TMJ Pain Relief :  TMJ and TMD Prototypical Patient

Dec 06, 2016 - 45 comments

While at work the other day, I received an email notification from my oldest and most popular blog on TMJ/TMD Pain Relief matters. While reading it and in my mind formulating my answer to a TMJ and TMD Prototypical Patient, I realized that the post really deserved its own thread. I am including the post here.


Dear Dr. Nassery-


You have heard this before but thank you and Dr Chan for continuing this blog, it is very important to the TMD community.


My story begins in 2000, when I received a whiplash injury to my jaw.  Forward to November 2003 and I developed serious TMD, with the right masseter in spasm as well as headaches and facial pain.  I saw a local (Portland Oregon) neuromuscular dentist who set me up with a really good TMJ massage therapist  to help my jaw movement. Then he put me in a flat plane splint that he would periodically adjust a little bit and in a few months I was pain free.  I went to yoga class for a few years and wore my splint at night off and on for several years,  but eventually I stopped each.   He did mention that I would have a risk of developing osteoarthritis later in life in my right jaw. Forward on to 2016 and I started to notice my neck and shoulders tightening.  I do not know if there is an association but last summer I did fall off a boat and hit my head on a wood dock .....I ended up cracking the 2x4 where my head landed....I noticed my upper body tightening up more after that but again it may be just a coincidence.  Well in late September I could hardly turn my head left or right and after a round of golf I went into severe upper body spasms.  I went into emergency.  After 3-4 days of pain my appointments with my massage therapist started.  Basically I had cervical nerve pain down my left arm and shoulder  originating in C5-C6.  My SCM.'s , levators, left and right were all very tight as were other upper back and neck muscles.  After a few days I noticed my bite was going bad as my right masseter was spasming and unstable.  I was in a lot of  pain with headaches, right ear pain and all of the muscular dysfunction.  I was using a lot of Advil. I thought I was done with TMD as of 2004!  As time has gone on with physical therapy in addition to massage therapy my symptoms have settled down to the following-
1).  Variable tension in my right masseter with a constantly changing bite.
2).  Constant low grade ear ache in my right ear.
3)  A sore area in my throat  upper back right side
4).  Sometimes low grade pain behind my left eye.
5).  Variable nerve pain down my left arm and sometimes in my right shoulder.
6).  Variable muscle tension in my neck.


I should add that I now do 30 minutes of yoga daily in addition to the PT and various stretches and exercises he has me doing.  I have improved a lot since early October,  but each day (minute?) is different with the symptomatology and the intensity of the symptoms.  I should add that I went back to wearing my old flat plane splint from13 years ago .  I wear it only at night .  I do notice my overbite has increased since October.  I can open my mouth about 35 mm with no pain, but I cannot capture the disc, my right jaw clunks and deviates only when I open wide and as I start to close.  


Historically I have many of the usuals mentioned as perhaps part of the etiology of TMD.....anxiety, forward posture, clenching etc.  I am diligently correcting my posture with yoga while paying attention to ergonomics at all times.  I try not to clench and am controlling my anxiety with antidepressants. I have made gains, but I would like to go further.From your perspective is there anything I should be doing differently or is there something I am missing? I am prepared to accept that my TMD may be chronic, but I would love to mitigate the current symptomatology and/or prevent further degradation.  Guess I am regretting dropping yoga 7 years ago, then again maybe it would have made no difference.  Oh yes I am currently 60 years old, but I have to keep going as I have a couple of teenagers at home.  Any help or advice you can give I will appreciate. I tried to be as concise and detailed as possible in my report.  I will add that I had orthodontia as a teenager with 4 wisdom teeth and 4 additional teeth pulled.  I have a smaller mandible so maybe this has an effect on my muscular symptoms.....I think a previous dentist mentioned there is a pretty small space to accommodate the musculature....then again the left side of my face is not spasming.


Dear Mark,


The last part of your letter was the beginning of your story not 2000, I beg to differ.  Yes, as you may have guessed from my previous answers I am strongly opposed to 4 bicuspids extraction orthodontics. That’s where your issues were made more complex. I say that because you must have had a particular set of issues that made them recommend 4 bi extraction. So I am going to go on a limb and say you had lots of allergies or breathing issues as a child. This I suspect resulted in your facial growth pattern to change from a horizontal pattern to a longer form vertical growth pattern, which would have resulted in narrow arches and crowded teeth. Gummy smile?? Perhaps?
Long face people have a short distance from their hyoid (adam's apple) to the tip of their chin.  This means your airway is smaller than it should be. Let’s keep that little fact in the back of our mind.
Then you were taken to an orthodontist, and he/she did what they were taught in school. 4 on the floor. Well, let’s think about the circumstances that changed your dental profile. So when we can not breath through our nose, we naturally breathe through our mouth. Including when we are asleep.  This little fact is perhaps the mother of all malocclusion. When our mouth is open the tongue is unable to do its job. Which is to develop the dental arch in the correct position. Remember bone goes where the muscle directs it. So the outer limit of our dental arch, namely maxilla,  is set by our muscles of facial expression, and the inner limit is set by the tongue..following me Mark?  But we already established that your tongue was out of commission. So now your upper arch which has to grow, will only be directed by your facial musculature.. This direction is down and back.. So if you have been following this you can start to see the picture. Then of course you saw the orthodontist and he/she took 4 more teeth and pulled your teeth, you guessed it, further back. The last direction we want to go..
Your masticatory muscles didn’t know all this was going to happen. They are genetically designed to work in a preset trajectory. However, since the body works as a unit, we are able to make accommodation to still bring our teeth together and eat. These accommodations will take their toll over time. A large part of these accommodations are made in our neck, so yes all of those cervical issues are very typical of our patients, and yes the degenerative pattern in the lower cervical vertebrae is very common.
Going back to the “posteriorized” dental arches, will cause the jaw joint positioning to also be distalized, hence creating the issues in the jaw joint such as displacing the disc and pressurizing the condyle which causes bending and arthritic changes within the joint. Of course when you are in a less than ideal postural and spinal position you will be more predisposed to injury in case of accident.
Based on your list of symptoms, I know that your right side dentition are lower than the left side, this means your lower jaw would have a larger torque or rotation to the right. Therefore, you are more symptomatic on that side. As a matter fact I am willing to bet that if we took and x-ray of your cervical spine, your C2 would be turned to that side. Which means the rest of the vertebrae would follow that que and very good chance you have scoliosis in mid thoracic. So going down the list of your symptoms,
1).  Variable tension in my right masseter with a constantly changing bite.  
Lower plane of occlusion means your masseter has to work harder to bring that side together
2).  Constant low grade ear ache in my right ear.
Again, another reason why I know your right side  is more distalized and C2 is rotated. That joint is both more loaded and the nerve root between C1 and C2 is more pinched.
3)  A sore area in my throat  upper back right side
Various muscle spasm, very typical of a patient whose body has been making long term accommodation for parts not doing their parts.More than likely Superior pharyngeal constrictor muscle.. Again, I am only speculating here..
4).  Sometimes low grade pain behind my left eye.
Spasmodic Pterygoid muscles, indication of joint derangement
5).  Variable nerve pain down my left arm and sometimes in my right shoulder.
This is due to the degenerative disc issues in your lower cervical spine and loosing space between them, hence pressurizing the nerves going to your hands and shoulders.
6).  Variable muscle tension in my neck.
CranioCervical symptoms are the number one reason for patients coming to us. Perhaps 1 out of 10 of my patients really suffer from joint pain. That is not to say that they do not have joint pathology, but many of us can live a long life without any real life altering symptoms from our deranged joints.


Now I want to talk about the things that you are doing right and what you need to do to complement those to a greater extent. You are actually the most ideal type of patient as you have educated yourself and are doing a lot of good things to help yourself and to work towards a more  natural TMJ Relief.
First, understand that at this stage of your development there are skeletal issues that we can not undo, unless you don’t mind having double jaw surgery.  However, you can make things better quite a bit.  Most of your complaints are muscular in nature. That means that if we bring your daily function into a more physiologic position you should get a lot of relief. When I look at all the things you have done and are doing, I get jealous. I wish some of my patients would listen to me more in those respects. You are like my dream patient. You see my approach is three pronged. I diagnose, then work with a PT specializing first and foremost in the treatment of Cervical Spine, and finally try and get my patients into Yoga and exercise.  That latter part, is like pulling teeth, pun intended.


You have done great, also with natural TMJ Pain Relief Exercises, the only missing part is for a good Neuromuscular doc to put you into a physiologic orthotic. I am sorry to tell you but a flat splint is not Neuromuscular. The very definition of Neuromuscular means that you provide specific detailed Gnathologic anatomy on your splint to maintain the physiologic trajectory of function. I know a mouthful. Flat splints don’t do anything aside from taking the load from your jaw joint for a little time. Then you wake up and go about your day eating and functioning in that same pathologic position all day.
I am sure you have heard the expression “Form follows function”, well if you accept that and agree with it, then you must also agree that based on the same principle “Deformity follows dysfunction”. You are expecting that you would go to yoga and exercise to correct your body, but meantime keep functioning in a totally wrong form. Well It's not going to happen.


Find yourself a practitioner that understands this concept and can help you achieve better health. In closing, I want to go back to one little fact I asked you to keep in your mind. Your airway. It is my strong belief that while we can help make you better quite a bit, that our results will be limited by how we can improve your airway. So while I think you should move forward with getting an orthosis and correcting your function, this can only untap some of what is possible to achieve for you. Granted you have never experienced a life without these limitations, even when you were asymptomatic, so it will seem like wonders.


I could go on...but I am afraid it has become a very long answer already. I hope I have been able to give you some beneficial information and that this would help you navigate through the rest of your journey to optimal health. Free of TMJ Pain. All the best and Godspeed.


H.Nassery, DMD FICOI FAGD FICCMO
www.MiamiBeachDentistry.com




Comments
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Avatar universal
by Sparty80, Dec 07, 2016
Dear Dr. Nassery-

Thank you for your reply!

Yes, I did have the 4 bicuspids taken out.  I did have seasonal allergies as a child....can't remember if I had a gummy smile but I know I had a mouthful of crooked teeth.  I have a pending appointment with a well -regarded osteopath who I am sure will interpret an X-ray of my upper spine that was taken when I was in serious pain in early October.  That appointment will occur later this month.  When my MT worked on me today again it seemed all my other symptoms, well certainly the throat pain and the eye pain, abated and the ear pain went down a level or two to a 1 or 2......the neck muscles were looser but still somewhat tight but in particular the masseter got noticeably tighter as did the digastric. The symptoms really seemed to concentrate and intensify there.  Those muscles were not happy!

Thank you for your opinion on the orthotic.  I assume, contrary to the opinion of my MT, That I should concentrate my efforts firstly there as opposed to muscle-skeletal issues in the neck via the osteopath?  I guess this osteopath has had many TMD patients also.......

I have talked with employees of 2 neuromuscular dentists in Portland who do orthotics. Do you know Drs. Parker or Summer?

Pyschologically I try to put my TMD in a little box or just roll with it during my day, it certainly is not easy and I empathize with those worse off than I.

I will continue forth on my journey and will give you an update(s) in the future.  

Perhaps at some point we can discuss your statement on the airway issue

Avatar universal
by Sparty80, Dec 07, 2016
Thank you sir,
Mark

Dear Mark,

The work of the PT or DO and your NM Dentist has to be congruent. Meaning they need to have communication , you need alignment first and then your physiologic bite has to be taken,. Literally walking out of the PT or DO and going to the NM Dentist for your bite.

Then and only then you could expect the best result. Since they probably don't know this themselves, you may have to introduce the idea to them yourself and become the quarterback sorta speak here.

In portland the only people I know are Drs Kwon and Chung. you can see them on our map here;

https://batchgeo.com/map/ab93500357547df41bb5e83c52ed3c8e

All the best, you can ask them to contact me if they have any questions about my approach. They know me..

All the best and keep us informed.

h.Nassery, DMD
www.miamibeachdentistry.com
www.iccmo.org

Avatar universal
by StaciWalk, Dec 08, 2016
WOW!!!! Dr. Nassery, do you know of any good doctors in Savannah Georgia?

I have seen 2 Maxillofacial doctors here and have had 4 surgeries total and still suffer from pain, muscle spasms and being looked at as I am a pill seeker. Nobody believes me when I tell them that I still hurt after 4 surgeries but I clearly have a very crooked smile.

July of last year I had a bigger surgery where they took fat from my hip, opened me up along my ear and reconstructed my jaw. They said they found several bone spurs and "chizzled" them back to normal as well as my condyle had great damage from rubbing bone to bone for so long and removed the meniscus that was shattered and created a new one. I am not a medical person so the terms I am not aware of. Hope that makes sense.

Then, I never see this doctor for any of my follow up appointments as I only dealt with the nurse and saw him three times during a year and a half of treatment with them (consult, 1st surgery and 2nd surgery). I was then suggested at my 6 month follow up that I needed to have Orthoganathic surgery and I would need to give them 5k per jaw and get braces and "not to depend on my insurance to cover it". I then needed a new splint and started having severe pain, headaches, neck pain and back pain (I have scoliosis which is pretty severe to the point that I had to wear a brace as a child for about 3 years, my mom has had spinal fusion surgery for hers and my aunt actually has the same jaw issues as me). Not once was I ever mentioned doing PT or anything of that nature as I would have been happy to do before having these surgeries.

Now, just because I don't have 10k to give this doctor (which ive hardly seen, again! a girl I met there that has same issues as me call him the Wizard) he (or his nurse, i'm not sure if he even knows anything about me since surgery) refuses to see me and says that's my only option.

My left condyle is a lot shorter than my right, although I've had surgery on both sides of my jaw. First surgery was in 2008, 2nd in 2009, 3rd in May 2015 and 4th in July of 2015. I actually called my insurance and gave them the medical codes that I would need to be approved for this surgery and they clearly stated that it would be covered by them and that they would actually cover it at 100% because I had met my out of pocket max and deductible (its been a crazy year for me medically (emergency hernia surgery, tonsillectomy and thyroid disease diagnosis). The insurance company actually called the nurse on 3 way with  me and told her and they still refused to do anything to help me.

I think it comes from trauma as a child as my brothers ran me over with a bike and knocked out my teeth when I was 5. What I've been told is that that probably stunted the growth of my left condyle. Its very frustrating to deal with. Nobody understands the headaches or how I can have a headache every day.....

Any and all suggestions would be great and highly appreciated. As well as doctors in savannah Georgia area plus I am willing to travel as long as it isn't to far away from home.

317787 tn?1473362051
by Dee1956, Dec 13, 2016
Hello, I am trying to find the best night guard I can. Do you have a brand that you could recommend?  I have one from my dentist but it is so hard that I still bite my cheek. I have a Dentek boil type guard that has been discontinued and am now on a search for another.  I have TMJ with ear pain and headaches if I don't wear a bite guard as well as my teeth are suffering due to the wear and tear of clenching/grinding. I appreciate any help you can provide. Dee

Avatar universal
by Sparty80, Dec 15, 2016
Dear Dr. Nassery-

Well I saw a NM for an initial evaluation yesterday.  He is going to do some CT imaging, some scans and use a TENS device to fit me with an orthotic.  One I wear at night and another during the day.  He is more than willing to connect and work with my team of LMT, PT and my DO....(as you suggested) Yeah!  He seems to think it will take 4-7 months for resolution or the full effect.  Meanwhile I continue with the daily yoga, stretches and exercise. My symptoms are the same, maybe even have eased off a bit more.....not bad compared to full upper body lock-up in early October.

I think the physical work is as important for stress and anxiety release  as it is for the musculature.  It helps with sleeping which is huge too.  ( I suspect the majority of the TMD community suffers from a lack of quality sleep).  Anything to stay away from the prescriptive anti anxiety drugs......!  More on this later and if you pardon me my opinion on a pharmacological anti-anxiety option w/o the potential side effects of benzodiazepines and the others!!!  Not THC

Avatar universal
by Sparty80, Dec 15, 2016
My dentist shares similar concerns on the airway issue you commented on, we discussed the airway a bit but first things first.

Thank you and Sincerely,
Mark

Dear Mark,

Please keep us informed of your progress.

H.Nassery, DMD
www.miamibeachdentistry.com

Avatar universal
by Sparty80, Jan 15, 2017
Dear Dr. Nassery-

Well I received my lower orthotic Thursday the 5th and my upper orthotic on the 12th.  I am to wear the lower at night and the upper during the day for 24/7 splint coverage.  I have continued with my exercise regime as well as the yoga, unfortunately not as intensively over the past few days as I have been sick with a nasty cold.  I did have a visit w/ an osteopath who after telling me I was a mess

Avatar universal
by Sparty80, Jan 15, 2017
Shoot, looks like I didn't wait long enough for the full message to post......

Proceeded to do a lot of wonderful work on my neck, back, ribs and hips.  My range of motion increased after seeing him and I had lees of the grating noises emanating from my neck.  I will see him again in late January as he said every 4-6 weeks suffices.  My current symptomology is....few days with ear or throat pain, my eye pain seems to flair with the days (every other) of more intense muscle spasms....my arm pain has lessened and I continue to do my nerve glides and weight work......as well as take a real good multivitamin package and Alpha Lipoic acid/ Acetyl L-CarnitineHCL.  My SCM (both sides) and disgastric (more right side) get tighter when my masseter tightens.  My bite is more centered and less variable then prior to the orthotics.  Good news!!!!!!my tomography showed 2 nice condyles w/ good corticular surfaces....so my dentist says I must have had some level of reduction which he aims to increase via moving the condyles to a more advantageous position.  I also TENS daily as my nm says that, in conjunction w/the splints, can decrease the time for  therapy/resolution.  So the good days are a lot better than October....it has taken a lot of work and is a team effort.  Think at this point my bad days and good days alternate. I am more pessimistic on the bad days... how do you counsel your patients and their emotions through this (generally) long process of therapy?  Are there any considerations I am not tending to at this time? My dentist is quite confident that we will have many more gains.  Guess maybe I am a little impatient...thank you for the suggestion of the repositioning orthotic....I really can't say how much ......

Avatar universal
by Sparty80, Jan 15, 2017
Sincerely,
Mark

Avatar universal
by Sparty80, Jan 15, 2017
Sorry, they are both lower orthotics.

MArk

Dear Mark,

I am very happy to learn that the process is helping you. Just a couple of notes.
Continue your work with the Osteo.
Make sure your next orthotic, or when he is planning to refine your bite is done in conjunction with your Osteo. Meaning
You would have to see the Osteo first for alignment, then you do not wear the orthotic, but rather you keep couple of pieces of cotton rolls between your teeth until the new bite is taken.

As far as your exercise, do not rush into more strenuous work outs yet. Work your way up.
As for emotions, yes, we know that there is a large effect with TMD patients on the limbic system which controls emotions.  I know that I need to be patient and re-assuring....the cause of many white hairs on my head..:)

All the best ,
Keep us informed of your progress.

H.Nassery, DMD
www.miamibeachdentistry.com


Avatar universal
by Sparty80, Jan 16, 2017
Dear Dr Nassery-

I did forget to ask you your opinion to some thoughts I had. How long  will it take in splint therapy until the condyles are optimally postioned to capture the greatest portion of the disc (or maybe the most effective translation of the disc's movement)?  Is it a week's, months' or years(s) thing?  I suspect the answer is that it depends....:) .Yesterday for a one time experiment I opened my mouth wide without my daytime splint and after 2 or 3 times opening and closing my mouth the old thunk and deviation reappeared in my right jaw joint.....maybe not as dramatic as before but if not darn close.  The facial muscle (primarily the masseter I surmise) tightened in response.  So.......I suspect the answer is don't do that again.....but  it caused me to reflect.  If the joint is unstable can I achieve some measure of stability in my bite and have minimal to no muscular symtomomolgy if I wear a splint (s) ad infinitum?  Is that even an option?  I have not had an MRI.....maybe I should or maybe my dentist has decided it really wouldn't change what he is doing so why bother...could it be that I am reduced initially and as my jaw opens my disc slides off the condyle?  As I close it comes back on?  Would a ligament laxity be involved?  I don't have any pain in the joint and my condyles are in good condition so I am pressing for an answer(s).......I am a scientist by trade :). Weird random thought but why don't oral surgeons use cadaver jaw discs when warranted instead of fat grafts et al?  As always I  thank you and I of course will ask my dentist his thoughts on all too.  I realize it is is somewhat unfair for me to to ask you these specific questions as you have not examined me first hand, I will ask him of course:)  and understand if you defer.  Sincerely, Mark

Avatar universal
by Sparty80, Jan 16, 2017
Think my limbic system got worked up :)

Dear Sparty,

From the depth of your questions I should have guessed that you are a scientist.
Many of your questions are legitimate and more thoughtful than many dentists would ask. So to answer your question, I would give you my own example. I have been wearing my orthosis ( not the same one of course) for the past 13 years. Without it I would have retired from dentistry due to the sever neck issues and headaches. I have been fine, and even better, I am more active and stronger today than I was at 30 or 40. In the absence of my neck and head pain, I was able to work on my posture and get stronger and healthier. Highly recommend that to all my patients.

As for your very good questions about the joint. Yes, please stop over opening. I tell my patients "No more double whoppers".. Normal opening range is between 35-45 mm, please measure and see how much is that ..most TMD patients have joint hypermobility, and that is part of the problem. You can study more about our high sugar and Carb diet and its effect on our connective tissue on your own. If you bend any of your joints beyond their normal range, you will have uncomfortable feelings and hear unpleasant sounds.

However, to your concern about surgically repairing the disc. I have not found it to be a necessity. As my good friend and colleague Dr. Vasquez has shown, occlusion is about function. Dr. Chan calls it Optimized bite. I think they are the same. If you bring the function along the right or physiologic path, and then create an occlusion that is clean and without  interference, you will have happy patients.
I hope this answers some of your questions.

H.Nassery, DMD
www.miamibeachdentistry.ccom

Avatar universal
by TascosaRex, Mar 11, 2017
Hi Dr. Nassery,
I have TMJ. 15 years ago, dentist wanted to do surgery. I declined. Jaw is out of alignment and pops. Over last several years, front uppers have become more crowded. Never knew, til reading your blog, that lifelong allergies may be part of cause.
Would like to see you but you are pretty far from Okla City. The O.C. map shows nearest specialist to be near Dallas.
Suggestions appreciated.
Many thanks,
Rex

Dear Rex,

Unfortunately I don't have any other esource other than that map, or the ICCMO website. Try the ICCMO library of doctors.There could be someone closer.

Keep us posted.

H.Nassery, DMD
www.miamibeachdentistry.com

Avatar universal
by GreenCoral, Mar 20, 2017
Dear Dr Nassery,

my 15-year old daughter presents several symptoms of TMJ issues.
I have only been able recently to put all the puzzle pieces together and understand the root of her problems:
- bad posture (Kyphosis) with a forward neck (and a leg longer than the other)
- continuous headaches
- crooked teeth (before her orthodontics)
- sleep apnea/fatigue
all caused by her mouthbreathing.

She has been having Damon braces for the last 18 months, but still seems to have a cross bite.
We have seen an ALF appliance specialist in the UK who says that she would need to have her braces removed and 3 years of treatment with an ALF appliance to expand her palate and realign her jaw.  With an appointment every month (1 and 1/2 hour drive).
He also recommends we see a podiatrist (to have orthotics in her shoes to improve her posture by compensating for the longer leg) and a chiropractor to align the spine and neck vertebra.

I feel quite overwhemed by the orthodontic treatment (a commitment over 3 years and a heafty financial budget, over £10 000) so I seek to have a second opinion. It is very difficult to find anyone knowledgeable enough on these issues to help in making a decision.

My questions are
- do you think this is the right approach?
- Should I wait for the ALF appliance to be put on to start the chiropractor sessions or is it the other way around?
- same question for starting the shoe orthotics before or after starting the orthodontic treatment ? Willl the shoe orthotics become obsolete when the jaw is better aligned?

Finally we have visited a scoliosis clinic that promises to fix her kyphosis with physical exercises (6 hours of physical exercises per day during 4 weeks). Here again this is quite a commitment in terms of time and money. What would be your thoughts about it?

Thank you very much in advance for your advice!


Dear Coral.

I love how you have put the puzzle together. Your daughter definitely needs ortho , but done the right way. Personally, I like alf appliance, but I am not sure if it is the proper application for this case. There are many other tools that do the job of expansion more effectively and faster.

Why don't you look up Dr. John Mew in London. His clinic should be able to help you with proper development of your daughter's jaw.
I love the idea of the scoliosis clinic and physio approach to correcting it. I am doing the same for my daughter. She has the uneven growth pattern in her vertebra and will never be all ok, but physical therapy is important to maintain better structural integrity.
Chiro can be started at anytime, but the results will not last until her bite is in a better place. With respect to the shoe orthotic, I would want to know if the problem is an uneven leg? if not the physio, chiro, and jaw work should take care of it. So hold off.
I hope this helps in making your decision.
Warm regards,

H.Nassery, DMD

Avatar universal
by GreenCoral, Mar 21, 2017
Dear Dr Nasseri,

thank you so much for replying that quickly!!!!
I have taken an appointment with Mike Mew, who is the son of John Mew (this Thursday) as well as with an osteopath tonight. And I will let you know how it goes.
I forgot to mention that we have also started myofunctional therapy to teach my daughter how to position her tongue properly.

As regards to the podiatrist. In addition to her kyphosis which is surely related to her misaligned jaw, my daughter also have inward knees and hips that are not at the same height which could be due to flat feet. Hence shoe orthotics done by a podiatrist. But I am going to wait for the appointment with Mike Mew to take a decision on the shoe orthotics.

Thank you and have a lovely day!



Avatar universal
by GreenCoral, Mar 26, 2017
Dear Dr Nasseri,

as mentioned, we had an appointment with Mike Mew last Thursday.
Considering that my daughter is already 15 years old, that the treatment requires a lot of work every day at home (in terms of chewing, swallowing exercises etc) and a huge commitment in terms of time and money (appointments every 2 or 4 weeks during 3 years), he was not entirely sure whether he would do it if he were in my shoes.
He said the decision should come from my daughter not from me as she would be the one to put the effort.I think that was a very honest statement
He however mentioned that the jaws were really misaligned despite the Damon braces with a cross bite and the jaws clicking. He also recommended that she improves her posture asap.

In all fairness, I do not know what to do. I know that my daughter is not that motivated by this treatment so i cannot drag her there every 2 weeks during 3 years and force her to do the exercises at home.
At the same time, something has to be done:
- to stop her mouthbreathing
- to realign her jaws and treat the TMJ issues
- to treat her kyphosis
What can we do?
You mentioned that there are many other tools that do the job of expansion more effectively and faster than ALF. Which other tools?
Would you recommend anyone else in London or in Paris who could do something (with a lower commitment in time and money)?
Do you know the Harmony labial treatment (by Patrick Curiel -Paris)?
We are also hesitant about the scoliosis clinic as we were told that there could be a relapse if physical exercises were not continued every day at home.
Finally do you knwo the Starecta approach and would you recommend it?
Apologies for so many questions
Have a good evening


Dear Green,


I am glad you saw him. As you can understand, no one in any branch of medicine can give any guarantees. However, we know that if don't do anything things will only get worse.
These treatments are expensive. I know out that way people talk about Damon brackets like those are some incredible thing, but on their own, they are not any more effective than ordinary brackets in opening cross bite. They are faster, but not more effective. There is a difference. In my experience most people need in excess of 6-7 mm off expansion, that is even more so for patients with cross bite.. just opening that will help your daughter quite a bit..Unfortunately at 15 she may already be at the end of her growth cycles, and many of the issues with the asymmetrical bone growth may not be able to be remedied. However, muscular strengthening of her postural system will be of great importance to her well being long term.
My wife and I have the same exact thing with our 15 yr old.. its hard but we are hoping that she will see the importance in the exercises soon and help more with her part.
I am not familiar with the other systems you mentioned.

H.Nassery, DMD

Avatar universal
by gaea, Mar 31, 2017
hi I am suffering tremendously from suspected TMJ disorder that has resulted in swelling on left side of face that travels over to left side of my chin. I figured that is probably the trimen. nerve involvement. This has happened several other times following a dental procedure where the dentist hit my jawbone and probably harmed the nerve at that time.
A week later came the first painful episode and I went back to them for answers. They offered antibiotics but the episode disappeared on its on by the next day.
It resurfaced much worse the next time and was 5 days of horrible pain that I was fearful of returning to them and since then the painful episodes return quarterly. I am unable to find information on how to avoid triggering these episodes. The one before this was last fall, so they seemed to be coming further apart but more painful. Oddly enough that last time the pain was too intense so I took a mirror to see could I pinpoint what was happening and stuck a sterilized needle in and red blood poured out. The pain left and did not return until almost a week ago, and with a vengeance. My jaw on right side is swollen badly, feels hard and lumpy and is above and below the jaw, and the lip swelled and is numb.. this may be from taking Aleve gel cap and opening it over the tooth which had provided immediate relief at another episode. The next day was when my lip swelled and has stayed swollen/numb for 4 days. I have -0- insurance  and little money, but will find the money for procedure which will take care of this. Recommendations - advice - suspicions would be so appreciated and if you know of a practice in North Alabama.   Also have the pain that feels like ear ache and that is probably in the joint. The pain takes a traveling route, beginning at the point where the needle was inserted to numb the area for the work to be done but then moves to other teeth from back to front and then poof, it is gone. This is the first time the TMjoint has been involved and has lasted longer with no feeling of an end in sight.
Thank you for your time.

Avatar universal
by Sparty80, Apr 02, 2017
Dear Dr. Nassery-

Well I wanted to give you an update.  I have been wearing each of my my lower orthotics for about 11 weeks now.  The orthotic I wear at night is offset a bit in that the left side is angled higher than the right, it is also much thicker than the orthotic I wear during the day.  The daytime orthotic is easier to talk with as it is an invisalign.  This orthotic has an additional built up surface over each side of the molar areas.

I can openand close my jaw generally without any clicking or clunking.if i open say 30-35 mm......with my splint in or without.  My dentist said that is an indicator that I am recapturing the disc!  The thing is that without my splints my lower teeth hit the back of my upper teeth ( those darn bicuspids that were pulled when i was 12?) and my molars don't touch at all.

My right masseter varies in how tight it is during the day or from day to day, sometimes it is in a very distracting spasm, other days or times it is not very noticeable.  I however feel that I have progressed from where i was prior to this treatment.  I do not have ear/eye pain or headaches anymore.  My neck muscles (SCM etc.)  are not as tight as they were, the same w/ the trapezius, infraspinatus or deltoid etc.  I did develop some tendinitis in my left shoulder from probably a combination of computer work, driving and a heating pad.  Once I iced it  and started doing some chicken wing stretches, along with some ibuprofen it has settled down quite a bit.  That said according to my PT my  back and neck muscles are still quite a bit tighter than normal...........

Now that spring is here I get a fair amount of exercise at work.  I am not sure how much stretching or yoga i should do at this point as I am still in treatment  and not stable.  I am thinking maybe 20-30 minutes a day?  (I had backed off from this a bit as my face/body muscles were adapting to the splints).  I try to not clench.

So I have good days and not as good days.  But I am progressing. I am generally in good spirits and have positive thoughts. My NM dentist said that I will be in therapy for an estimation of 4-7 months........... Any comments or thoughts you have would be appreciated.  Sincerely,  Mark

Dear Gaea,

Unfortunately your symptoms and description are not really consistent with solid diagnostic reasoning. This is a case that in my view needs thorough diagnostic work up, first to rule out infections and then , once all regular dental issues are ruled out, to look into possible TMJ issues.

Regards,


H.Nassery, DMD

Hello Mark,

I am glad to hear of your positive progress.It seems like you are on the right path. You are now beginning to understand that the discrepancy in your bite was dictating your neck to make accommodations for you to bring them together, and now those parts( namely your neck and jaw joint) are finally able to start healing and going back to their normal states.
Be patient, follow with your exercise and PT.
Don't be surprised if your bite still wants to improve and come more forward. Listen to your body. Keep us posted.

H.Nassery, DMD
www.miamibeachdentistry.com

Avatar universal
by Sparty80, Apr 03, 2017
Thank you for all Dr. Nassery.  Dr. Chan posed the simple question on a TMJ group site "Slow or Quick"?  I am in for slow, since it took a while for my body to get to the point of dysfunction where it could not adapt, it is going too take a while for the body to re-adapt to a new paradigm.  By the way, thank you for the prior reference of GNM dentists in my area, my current NM dentist was a lot closer to me.  Yes, patience..............MHG

Avatar universal
by ChrisinColumbusOH, Apr 05, 2017
I have severe TMD.  I clench my jaw so tight that every morning I wake up with daily migraines that progress to severe migraines where I am sensitive to light and sound.  I am nauseous and am currently taking up to 3 shots per day along with daily nausea medications.  I have tried Botox in my jaw, neck, temples, forehead and back of my neck without success.  I have tried myobloc injections which have lasted up to 3 months which reduced the migraines from daily to 1-2 per week for 6-8 weeks and then returned to 4-5 around 10-13 weeks when the shots were restarted.  As of December 2016 my insurance will no longer pay for the myobloc injections which works somewhat like Botox in paralyzing the muscles.  

I have tried a rubber mouthpiece to protect my teeth from being chipped, a harder mouthpiece which keeps my mouth open but is supposed to keep pressure of the joints but doesn't work at all.  I have a mouthpiece that goes on just a few front teeth but when I wear it at night my jaw moves to far forward causing even worse headaches.

I had braces when I was 14 and then again in my 20's to realign my teeth for tmj.  I think both times cause more problems with my jaw.  I have severe jaw pain and popping that just about everyone can hear.

I am currently 52 and on permanent disability due to the chronic migraines and chronic pain and fatigue.

I live in Columbus, Ohio and am wondering if you have any suggestions?  I am living on less than $1000 income so I can't afford some of the $3000-4000 mouthpieces that some dentists I have called have offered.  With the daily migraines and nausea I often am unable to eat and have lost over 35 lbs in the last year.  I am currently 6'1" and weigh 139 lbs.  Without any solutions I'm not sure how much longer I can go on living this way.

Thanks for any suggestions or help you may be able to provide.  Chris

Avatar universal
by zubair_fayyaz, Apr 06, 2017
I have a problem if enlarge c7 transverse processes .while I am suffering pain in my neck dezziness and high bp . plz reply what should I do

Dear Chris,

I am sorry to hear about your difficulties. In Columbus, I have my dear  friend and colleague Dr. Mike Firouzian. He is great.
However, I really can not tell you what  he charges or how to afford the treatment you need on the income you have. I really think this should be something that the med insurance covers.
I wish I could be of more help.
Try and see if you can get coverage through your medical plan. Its worth a shot.

Warm regards,

H.Nassery, DMD
www.miamibeachdentistry.com

Zubair,

that sounds like something that should be checked by an orthopedic surgeon, or Neurologist. If medical issues are ruled out then you could seek other routes for treatment.

All the best.

H.Nassery, DMD

Avatar universal
by Sparty80, Apr 16, 2017
Dear Dr. Nassery-

Well I continue to progress w/ my TMD therapy.  Very slow, but the long term continuum is positive.  I can open w/out the disc slipping and the facial musculature continues to adapt with greater facial symmetry and less symtomology!  I will be interested what y no says when I see him this Tuesday!

Unfortunately my "tendinitis" ( my diagnosis) is becoming a bigger deal.  I have been doing light stretches somewhat inconsistently since I stopped PT in early February ( actually I didn't stop it, my insurance deemed that is all the visits they would fund). I will admit that my arm, back nerve pain had settled down, still some pain but definitely manageable.   I do have a visit scheduled this Tuesday with a PT who specializes in orthopedics.  I have had increasing left shoulder pain, (muscles behind the shoulder, in front of the shoulder and to the side of the shoulder). The pain does not extend down my arm or into my fingers (yet?). The muscles along  the left side of the spinal column are tight.  The pain has been pretty tough for the last few days...7.5-8.5!  I am taking 3200 mg of inbuprofen daily and am icing the shoulder periodically through the day. I fear this is cervical radiculopathy (what my original PT diagnosed me with) and/or it may relate to some nerve compression and damage when I went into spasm on 10/1.  Or it may be a combo of the two.  The intensity of this has taken me by surprise.  Not sure if it is rotator cuff too?.  Regardless I see now where you refer to TMD as a cevical disease too.  My MD sent me to PT as a precursor to insurance covering an MRI.....So I am depressed and fearful of the unknown and potential impact on my work and family.  It has been a long haul.  TMD is tough, particularly when folks just don't understand why you hurt.... you look normal!  I will continue to keep you informed of my journey .  Sincerely, Mark


Avatar universal
by Sparty80, Apr 16, 2017
"What my NM says" ( 4th sentence 1st paragraph)..... Mark

Avatar universal
by Sparty80, Apr 20, 2017
Dr Nassery-

I might add that I have an appointment with an orthopedist who specializes in neck pain on 5/1.  Evaluation by a PT and my my family physician has led them to conclude the dysfunction in the left trap, and other left shoulder muscles Is not a rotator cuff or tendinitis issue, it likely relates to a cervical spine issue.  It particularly hurts  when I bend my neck backwards.  Likely a CAT scan or MRI in my future.  My C 5/C6 area a little to the left of the spine is hot and feels as though there is an ice pick in it.  Muscle tightness is referring up the levator and even over to my right masseter.  So I think the culprit is finallly starting to reveal itself...... my cervical spine.....we'll see.  Interesting it is influencing my TMJ....My guess.... issues with my facet joints (s).  I will keep you informed.  I am still working but it can be a struggle, UGH!

Mark

Dear Mark,

Thank you for your updates. They are very helpful. This is exactly what we are seeing in our population of patients too. That is why we have incorporated a dynamic and full body approach. The whole body needs to be addressed simultaneously.
Work on your postural system. Exercising, full body strengthening is critical to moving forward in TMD.

Thanks for sharing.

H.Nassery, DMD FICOI FAGD FICCMO
www.miamibeachdentistry.com  

Avatar universal
by Sparty80, May 04, 2017
Dear Dr. Nassery-

Well Dr. Nassery I had a MRI done and it showed disc degeneration and bulging, particularly in C4/5 and C5/6.  The spinal cord at those sites is being pressured also, it is deformed, (fortunately I do not have any symtomology in my extremities from  such). So surgery is scheduled for 6/12.  ACDF C4/5 and C5/6.  I am hopeful this will address the issues with the cervical nerves at those sites and the associated pain and muscle issues. If all goes well I will be cleared to drive a bit in 6 weeks and commence PT in 3 months. I hope at that time I can really address my muscle dysfunction as it relates to my upper body and "TMJ" in a sustainable methodology.  All those following my story should read our posts above....It has been a bit of a convoluted trail.  I thought my issue was primarily "TMJ"........My TMJ dentist looked at me last time and said Mark, you need to fix your neck.  I think if I do that, wholly or in part, it will help w/ my TMJ.....any thoughts or observations Dr Nassery?  It has been a long road and will continue to be so but I remain hopeful.  By the way I am glad it is only a two level fusion, as their is a much better chance of success with the joints fusing at two levels than three.  C6/C7 has some DDD and a bit of spinal narrowing, but very very modest symtomology arising from that.  His recommendation is to not fuse there.  My surgeon said that there is a 25-50% chance I will need a fusion at that site in 20 years, by then I will be 80......C3/4 looks great.  So I am mentally preparing myself for the surgery to come.  Regards, Mark

Dear Mark,

Thank you for updating this blog. Your condition is actually very understandable to me. Once, I discovered the correlation between the bite and the cervical spine, I reviewed all the x-rays of my patients over a period of 8-9 years. This condition is actually present in all TMD patients. To varying degrees of course.
So, I would go on a limb and tell you that I believe, the issue in your neck are a direct result of your bite. Basically it is the result off many years of accommodating the wrong bite.
I prefer to have my patients go the PT route if possible. However, I agree that after certain amount of degeneration in the neck we do need surgical intervention. I am glad that you have gotten your orthosis, and that you would do PT afterwards.
Don't be surprised that after the surgery you may need a new orthotic made to the new spacing of your neck.
The current orthosis, re-emphasizes the old neck spacing, do not try and do with that one.
Hope this helps. Keep us updated.

H.Nassery, DMD
www.miamibeachdentistry.com

Avatar universal
by oogieboogie777, May 05, 2017
My brother had TMJ as a teen and subsequent orthodontic work with a lower mandibular saggittal split surgery done back in 2009. It was to correct an overbite as well. The surgery, cosmetically, was successful but did not alleviate much pain or headaches.

About five yrs later his dentist convinced him to go to his friend, a neuromuscular dentist and get an orthotic device for $3000. He wore that for a few years but it was cumbersome and still had the tense neck muscles and clenching as well as some headaches.  What could be the reason this didn't work?

Avatar universal
by oogieboogie777, May 05, 2017
My brother had TMJ as a teen and subsequent orthodontic work with a lower mandibular saggittal split surgery done back in 2009. It was to correct an overbite as well. The surgery, cosmetically, was successful but did not alleviate much pain or headaches.

About five yrs later his dentist convinced him to go to his friend, a neuromuscular dentist and get an orthotic device for $3000. He wore that for a few years but it was cumbersome and still had the tense neck muscles and clenching as well as some headaches.  What could be the reason this didn't work?

Dear Oogieboogie,

There are many reasons that this may have not worked. As with any other sciences, there is a great variability in the application of the principles, as well as the level of the knowledge. The degree of difficulty from case to case is also very much different. I can tell you that surgical cases are always more challenging.

Saying one is a Nueromuscular doctor, is like saying some one is a martial arts practitioner. That encompases from a white belt all the way to a black belt. The ability of that practitioner to execute the knowledge does not reflect on the science but rather the level of expertise and practice of the that individual.

With out knowing the details and diagnostic information about his case, it is very hard to comment.

I hope this makes sense.

H.Nassery, DMD
www.miamibeachdentistry.com
www.TMJresearchfoundation.com

Avatar universal
by ShyPatty, May 06, 2017
To all who do not have the money for those darn splints, I have a bit of good news for you.

What I had to do is finally open one of those 12/18/ or possibly 24-month free credit cards, with 0% interest-free, upon paying your monthly bill of a minimum of what you think you can afford to pay for that year to get it paid off.

I had TMJ due to braces as well.

The surgeon (Maxillofacial Surgeons). told me (after all the tests/x-rays) that he took on me, that I definitely needed the surgery.

I was told I would be needing yet another set of braces put on before the surgery, then the explanation of the surgery came next.

The reason I got the TMJ--was due to how orthodontists were trained back in the 80's.

You lied flat as the patient while being adjusted by the orthodontist.

What happens when one lies flat for getting braces adjusted?  The jaw moves back.

NOW, a proper ortho sits one upright to adjust.

My upper jaw, having a bad overbite, got pushed TOO far back.

I was restrained all of those years and in pain.

Without realizing it; I would move my head forward to relieve my jaw pain.  

After years of this, my head in a side view look looks as if I'm some sort of chicken sticking his neck forward, but STAYING in the forward position.

I saw the only dentist in Ohio who does the correction of TMJ in Ohio w/o surgery.

She said to me that the patients who choose the surgery are doing an injustice, for it will not last, being pain-free.  

THOSE patients eventually come to HER, once they hear of her work.

So, for 6 years, I wore a new splint molded for my mouth, and the cost was all MINE.

NEVER have I had an insurance that covered anything if due to with TMJ.

What I had to do to pay for these splints, was put the first of 5 (yearly splints) onto one of those credit cards that we all are receiving in the mail.

You know the type I am speaking of:  WITHOUT ANY INTEREST.

Once you start those, your name is put on some list, and you get more....(ENDLESSLY).

When, the second year came, I would close out the first card, and put my second splint on a new card without interest, and so one, until all treatment was over and paid for.

Unfortunately, I had to wear my splints 24/7. and I did it religiously, some looking ridiculous as hell.

The other unfortunate thing that happened is that due to the splint moving my BONE, my migraine meds didn't even TOUCH 'that' pain.

So, my neurologist had to put me on Oxycodone for the pain, and Klonapin for relaxing the muscle.

My girlfriend feels I should ask SOMEONE if I have TMD, instead of TMJ, and to find out, all you need is an MRI.

If the splints did not build a new soft tissue as the dentist claims the body does, then she took me for my money.

Her son takes Pamelor for the pain, and had surgery to remove any little fragments of bone, for he was a deep grinder of teeth at night while sleeping, and the surgeon put in a mad made soft tissue.

He is no longer needing the Pamelor, and without pain.

I am soooooooo confused.

Nothing medically ever works out for me.

While going through all of THIS, I developed a fast-growing breast cancer.  I decided on Double Mastectomies, and my surgeon was REFERRED, but not once did he tell me to exercise these things daily.

I think one is like a bocce ball, but yet I started massaging it, and am due to see my PCP in 6 months.

Even my oncologist never told me.  She hardly did a breast exam so did not realize that they were becoming hard to me, and hurtful.

Anyhow, back to my story:

My dentist was worried that since I had NO tissue at all left, and I had NO relief at all, year after year, she was so fearful that I would get my jaw in place, with no more restrictions, but the PAIN would still be there.

SADLY, I ONLY REPLACED ONE PAIN FOR A DEEPER PAIN; FOR I TRY NOT TO SPEAK AT ALL.

She was correct, sadly.

My profile looks great now, and the restriction of not being able to move my lower jaw is wonderful, but, my chicken neck is still there, and I am still on the Oxy.  I wear a set of what look like false teeth over my bottom molars, for without this final splint, my jaws REALLY ache.

I know one can get rid of the chicken neck by slowly laying on your bed with your head slightly tilted down. Stay in that position for about 30 seconds.  The next day, do the same hang over technique, but up the amount of your time, just slightly.  Do this until your head no longer hurts doing the new position.

The next step is to angle your head, even MORE, doing this routine all over again, until NO PAIN is in the neck.

In a short time frame, with you doing this daily morning exercise, you will eventually keep moving it downward, and soon the back of your head is EVEN and TOUCHING THE MATTRESS.

You basically are retraining those neck muscles to be straight again. )No, I have yet to do those.  I am fearful of a migraine with the blood going to my head, but I will...............).  lol

And NO SURGERY.

So I hope with my story I have helped a lot of people.

Yes, eventually, 30 years later, pain developed in my jaws after daily genetic migraines.

The surgeon said my insurance would not cover it..  So then he lied to me, and said:  "Oh I was in the wrong anyway: You don't need the surgery, it is in your MUSCLES, that is why you are having pain".

I have hypothyroidism.  Had to add that, for before I wrote on this blog, I got out my drivers license to see when it was due to be renewed.  My throat actually has the outline of a small goiter, it looks.  But, yet, my Endocrinolgist never TOLD me that.  I bet I will have to have it removed one of these days.   For the past week, I've been getting 'CHARLY HORSES' under my TONGUE of all places.  WEIRD.

61, feel 30 in my brain, but my body tells me I'm 81.

Nursing home life for me EARLY, I am predicting.
Wishing Blessings on all who read this post.

Patty



Thank you Patty, for sharing your story.

H.Nassery, DMD
www.miamibeachdentistry.com
www.tmjresearchfoundation.com

Avatar universal
by Sparty80, May 20, 2017
Thank you Dr Nassery.  I will update my status sometime after my surgery on 6/12.  My NM told me to see him after I get my neck "fixed".  It will be at least 6 weeks after surgery as I will not be able to drive or ride in a car until then.  I think after my surgery I will go back to my old upper flat plane splint that was made for me in 2003......it still fits fine.......until I see him.  
I never did feel comfortable after my orthodontic treatment as a teenager.  My bite felt so very constrained.
Thank you sir,
Mark

Avatar universal
by akail, Oct 02, 2017
Hi Dr, Nassery,

I  had orthodontics when I was 35 years old and wore them for about  4 years. I had an impacted canine on the left side, which the orthodontist tried to pull but it had ankylosed, so I have an implant there now. I had a cross bite in the front and underbite on the right. She also pulled one of my front lower teeth to bring my bite together.
My braces came off mar 2016 and I was on a retainer for my upper teeth with a permanent retainer only for my lower front teeth (the back teeth were free to move).
I had been having some problems after a day of chewing or talking with my pressure in my ears over the last year. Never connected to TMJ, when about 8 weeks back after a routine dentist cleaning, my left TMJ clicked. What followed was 2 weeks of muscle pain that my dentist refused to do anything about. He also didnt send me to any specialist. What made my condition worse was going to a chiropractor who over adjusted me. My left cartilage seems to slipped enough that there is no muscle issue. I also dont open wide enough to make it click. My right however seems to be stuck and there is a lot of muscle pain, sometimes with active trigger points that don't let me sleep.
About 3 weeks back, my dental surgeon (referred by my dentist for TMJ) sent me to a TMJ specialist called Dr. Polson in the DFW area who put me in a splint about 2.5mm height.

I still however wear my retainer in the night over my upper teeth. The fit seems to tighter than before I started wearing the splint. My question though is,  should I continue to wear the retainer in the night ?

Thanks,
Aparna

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