This website contains a surprising amount of actual content, including a complete description of the cause and treatment of TMJ disorders as well as the forward head posture and airway problems (mouth breathing, snoring, and obstructive sleep apnea) which are commonly associated with them as products of a strained facial growth pattern maintained by an unstable or displaced bite table. Under TMJ DISORDERS, we explain the clinically relevant aspects of the underlying pathophysiology as well as some of the irrelevant ones that frequently confuse treatment, the causal factors behind the symptom generating process, and the ways symptoms are commonly managed. Under TREATMENTS we describe orthopedic treatments we offer, along with their costs and rationales; as well as other aspects of treatment, including the role of glymphatic circulation. Under FOR DOCTORS are more detailed descriptions of the cause and treatment of TMJ disorders, three long files explaining the clinical aspects of bites, and a frequently updated and detailed explanation of our new oral appliance treatments for treatment of snoring and obstructive sleep apnea. Under ETIOLOGY is a thorough explanation in 5 chapters of how bites work with the rest of the body in mammals and humans, how bites have recently changed in humans due to the softening of our diet, and how this change has produced the backward jaw postures, forward head postures and craniofacial asymmetries along with a multitude of common symptoms that have become endemic in modern populations.
MANAGEMENT - For decades, dentists have not tried to prevent or cure TMJ disorders, but to "manage" them using physical therapy, exercises, stretches (myofascial release), medications, corticosteroid or trigger point injections, Botox, and simple oral appliances that provide a raised bite table.
MUSCLES - produce most of the symptoms, but muscles are responding organs. They rarely start problems. When a TMJ is inflamed, the jaw muscles hold increased tonus at rest and fire weakly to automatically protect that joint, like your leg muscles would make you limp if you tried to walk on a swollen ankle. When the bite is unstable, the jaw muscles brace, like your leg muscles would automatically tighten up if you tried to walk barefoot on gravel. The compression from the increased resting tonus in the muscles can prevent adequate resting circulation, causing waste products to accumulate in their capillary beds. Treatments that weaken the jaw muscles (such as Botox, trigger point injections, and esthetic orthodontics) can sometimes provide short-term relief of the muscle symptoms by breaking up a symptom generating cycle in which one of the components is the forces used in nocturnal bruxism, but these treatments can also exacerbate the long-term problem by depriving the jaw muscles of the strength they need to regulate facial growth and power natural mandibular advancement that is needed to maintain an adequate airway passage with age.
COMMON TMJ APPLIANCES - can provide symptoms relief but lack the orthopedics necessary to address the root problem. Any oral appliance that interposes a layer of plastic between the teeth protects them from wear, but tooth wear is rarely the problem. An oral appliance with a tall stable bite surface can stretch tight jaw muscles and thereby provide short-term relief without addressing the cause of the tightness. Oral appliances that reposition the mandible can provide a crutch in the form of an improved platform for the mandible to rest on and exercise against; but, unless they also improve the facial growth pattern ultimately responsible for the strained platform, they can leave you dependent on the crutch.
ORAL ORTHOPEDIC APPLIANCES - can eliminate the symptoms on both a short-term and long-term basis by protecting the joints, rehabilitating the muscles, and redirecting forces of nocturnal bruxism to gradually accomplish the orthodontics that you need for an improved bite table. Different types of oral orthopedic appliances are needed for different types of TMJ disorders. For example, an inflamed TMJ needs protection (the crutch), weak jaw muscles need a good exercise platform, tight jaw muscles need stretching, unstable bites need stabilizing, and strained bites need adjusting or repositioning.
AT YOUR FIRST APPOINTMENT - Dr. Summer will determine the root cause of your condition and explain your short-term and long-term treatment options. Imaging is useful but rarely necessary. X-rays can show that TMJ damage has occurred in the past, but they cannot tell when it occurred or if it has already fully healed. MRI is the only way to image the disk shape and location or the presence of inflammation. Dr. Summer has extensive experience with reading MRIs of the TMJs.
THE BITE - affects the core pathophysiology and the facial growth pattern behind it, because the bite functions orthopedically as a joint between the upper and lower jawbones. However, dentistry has never understood the central role that bites play in TMJ disorders and sleep apnea, because dental researchers have never seen the bite table as a joint between the jawbones, a postural component or a regulator of facial growth. Without understanding the bite, most dental authorities simply warn dentists against any treatment of the bite. A goal of this website is to explain the bite and its role in these conditions for both patients and dentists so we can finally treat them effectively.
TMJ INFLAMMATION - Most TMJ disorders undergo an inflammation phase, usually shortly after the disk dislocation. The inflammation must be treated before the muscles; because the resting tonus in muscles depends on the health of the joints they surround, and the TMJs (temporomandibular joints) are surrounded by the jaw muscles. TMJ disorders generally start with a dislocation of the articular disk from a TMJ, which leaves that TMJ without a cushion and therefore vulnerable to bruising by the condyle during the forceful clenching or grinding that affects everybody during sleep. The bruising produces inflammation, which triggers pain during clenching and a sustained increase in jaw muscle tonus due to reflex protective guarding (hypervigilance). Effective treatment at this "intracapsular" stage of a TMJ disorder requires wearing a TMJ protective oral appliance during sleep to stop the bruising for long enough to allow the damaged TMJ to fully heal, about two months. Then your appliance can be converted orthopedically into a long-term use appliance that rehabilitates your muscles and improves your facial growth pattern so your problem never returns.
TIGHT JAW MUSCLES - are commonly caused by unstable or displaced bite platforms. If the bite platform does not provide a comfortable platform for the mandible to rest on and work against, the jaw muscles remain on guard and can never fully relax. If the bite platform is displaced, it also displaces the postural position for the mandible, because protective reflexes automatically program the jaw muscles to always hold the mandible in a resting posture just beneath its most stable bite platform, even if the jaw muscles have to strain to hold it there. In this manner, the displaced bite produces a strained jaw posture.
In some people, the tongue reflexively attempts to relieve the strain by resting between the teeth to provide a cushion for the mandible that is more comfortable than rows of jagged rocks that don't fit comfortably or force the mandible backward and/or to one side. When the bite forces the mandible backward, the front of the mandible runs into the pharyngeal airway space, often triggering a shifting of the tongue to find an adaptive position that maintains an adequate resting airway passage; which leaves scalloped shapes in the sides of the tongue from the indents produced by the tooth surfaces that you can see by looking in a mirror.
BODY POSTURE - is always affected by jaw posture, because the jaw is part of the neck. The mandible is an integral component of the head posture mechanism, and the posture of the head determines how the body aligns beneath it to provide physical support in a resting postural stance. If a displaced bite table prevents your mandible from resting under the middle of your head, your head cannot rest straight on the top of your spine. Backwardly displaced bite tables cause backward jaw posture and forward head posture. Laterally displaced bite tables tip head posture toward the side of the displacement, as explained in THE ROLE OF POSTURE under the TMJ DISORDERS tab, and in detail in BITES AND BODY POSTURE under the FOR DOCTORS tab.
TMJ ARTHRITIS - is a diagnosis which is based solely on X-ray and therefore does not reveal any need for treatment, because damaged TMJs heal with time and especially with age - even when the bones above and below them remain extremely misshapen. There are some systemic arthritic conditions, like rheumatoid arthritis; which can attack a TMJ. However, the vast majority of TMJ arthritis is osteoarthritis, which is just wear-and-tear arthritis. It means that the bones at the TMJs no longer have the smooth rounded shapes of young joints. Many older people have TMJs that show flattening, erosions, ledges, or other irregular shapes that resulted from adaptive remodeling some time in the past, which makes those TMJs fit the definition of arthritis; but that does not mean they need treatment. If a TMJ is no longer inflamed (effusion on MRI), it has healed; and the symptoms are myogenic, not arthrogenic. They are coming from the muscles, not the joints (the TMJs). Treatment aimed at the TMJs, (surgery or injections) is misdirected and inappropriate.
SUPPORTIVE TREATMENTS - such as physical therapy, myofunctional therapy, massage, accupuncture, chiropractic, improved nutrition, psychological counseling, biofeedback, exercise, muscle stretching (myofascial release), trigger point injections, and relaxation are often helpful in the treatment of TMJ disorders for the same reasons they are often helpful in the treatment of other musculoskeletal disorders. Some of them treat your muscles, and others increase your ability to adapt to the strain. We encourage patients who want to pursue these additional treatments to see the local practitioners with expertise in the treatment that is most likely to help them. We don't prescribe medications, because they make it difficult to monitor the effects of orthopedic treatment and get to the root of the problem.
OBSTRUCTIVE SLEEP APNEA - is caused by choking on the tongue base and the distal end of the soft palate. Many dentists treat the problem with mandibular advancement appliances, but those appliances only solve the problem in 1/2 to 2/3 of the patients treated; because the mandible is only loosely attached to the tongue base and not at all attached to the soft palate. Also mandibular advancement appliances cannot be used in full denture patients. To solve these problems, Dr. Summer has developed three new devices that can be added to ineffective mandibular advancement appliances or denture base plates to also control the positions of the tongue base and soft palate. Two of the new devices have already been FDA cleared, and the third is undergoing its final clinical trial in full denture patients with untreated obstructive sleep apnea. At this point, the devices are only available locally. Next year they will all be marketed together in a kit of components that can be used by dental labs to add them to oral appliances as needed. The devices are described in detail in MULTILEVEL ORAL APPLIANCE TREATMENT OF SLEEP APNEA under the tab FOR DOCTORS.
THE BIG PICTURE (SOCIETAL CAUSE) - If you are interested in why TMJ disorders, sleep apnea, and forward head posture have become such significant and endemic health problems in modern societies, under the ETIOLOGY tab you will find a long story which details in 5 chapters how the softening of our diet in the last couple of centuries has changed how our jaws and faces grow in a way that has made us susceptible to these problems. Only by understanding how we developed these problems can we learn how to solve, treat, and prevent them.
TESTIMONIALS - are not included, because I consider them to be just advertising. They can be made up or purchased online. Also, even a genuine story from a real patient does not mean the treatment worked, because of a statistical factor called "regression to the mean." In medical conditions that fluctuate, the symptoms are likely to diminish shortly after beginning any kind of treatment; because patients usually seek treatment at the time when their symptoms are relatively severe and therefore likely to get better soon anyway just by returning to their average state. In addition, because TMJ disorders eventually resolve on their own, the relief caused by regression to the mean may become a permanent cure and therefore a resounding treatment success, even if the treatment never addressed the condition.
FEES - Fees for exams are $100 - $300 depending on the amount of time required and whether or not the visit included a temporary oral orthotic device. Fees for consultations depend on the time required. Fees for oral appliances are included in the descriptions of various appliances. The fees have a range, because they require more time and effort in some cases.
Our evaluation and treatment for TMJ disorders and sleep apnea is considered medical rather than dental, because we treat the joints and muscles rather than the teeth. We are in network with Regence Blue Cross, but we can't guarantee coverage. Healthshare Care Oregon (OHP) covers the initial evaluation, but not treatment. We are out of network with most other insurance companies, but some of them cover benefits for out of network providers. We encourage our patients to contact their insurance company to inquire about benefits for non-surgical TMJ treatment, oral appliances, CPT code 21089. In some cases, we will provide a completed claim form for patients to submit to their insurance company.
CONTACT INFO
PHONE: (503) 241-7353 FAX: (503) 525-2966
EMAIL: theThis email address is being protected from spambots. You need JavaScript enabled to view it. PHYSICAL ADDRESS: 833 SW 11th Ave. Suite 810 Portland OR 97205