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 2×4 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.

Hamid Nassery, DMD

Reprinted from medhelp.org

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