TMJ disorders have been long misunderstood by dentistry, because the way the teeth fit together in the bite controls the way the jaws grow; but dentists have never understood how bites work or how they affect the way the jaws grow. Dentistry doesn't even understand the natural function of the bite, so their clinical advice to dentists is to simply avoid making any changes to it. This surprising deficiency in the core principle of dentistry is explained in detail in hundreds of pages on this website.
The website provides a kind of unified field theory to explain how bites function and dysfunction; and also how they are involved in the cause and treatment of TMJ disorders, sleep apnea, and postural problems as products of a strained facial and jawbone growth pattern. Under TMJ DISORDERS, it describes clinically relevant aspects of the underlying pathophysiology and the causal factors behind the symptom generating process. Under TREATMENTS, it describes orthopedic treatments and contrasts them with other types of treatment. Under FOR DOCTORS, it describes the underlying cause of TMJ disorders and the ineffectiveness of many current treatments, as well as three long files explaining how bites should work, how they don't work correctly, and the sources of confusion associated with them. Under MANAGEMENT, it describes simple ways to cope with the symptoms. 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, and how this change is involved in the backward jaw postures and forward head postures along with the associated craniofacial and postural asymmetries that have become endemic in modern populations.
ORTHOPEDIC TMJ TREATMENT - For decades, dentists have not tried to prevent or cure TMJ disorders, but just to "manage" them using physical therapy, exercises, stretches (myofascial release), medications, corticosteroid or trigger point injections, Botox, and simple oral appliances or splints to protect the teeth or treat the tight jaw muscles that produce most of the pain. Treating tight jaw and neck muscles usually provides enough short-term relief to stop the patients from complaining or seeking additional treatment; but it doesn't address the source of the muscle tightness or the strained facial growth patterns at the root of the problem. Muscles are responding organs. They rarely start problems; but, when they don't have a healthy platform to rest on and exercise against, they become hypervigilant. They cannot relax enough to allow good resting circulation throughout their capillary beds, and waste products build up in certain areas. Treatments that weaken the muscles (such as Botox, trigger point injections, and esthetic orthodontics) can sometimes provide short-term relief of the resulting 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 power natural mandibular advancement that creates adequate space for airway passage and maintains it during aging. Also, the same relief mechanism (weakening the forces used in noctural bruxism) can be accomplished by wearing the right type of oral orthopedic appliance during sleep without damaging the muscles or requiring repeated treatments.
Most dentists who offer TMJ treatment include an oral appliance to "relax" the jaw muscles or protect the teeth or TMJs as part of their management plan. Any oral appliance that interposes a layer of plastic between the teeth protects them from wear, and wear is rarely the problem. Teeth are made for wear, and it is only a problem if your teeth will not last as long as you do. Appliances with tall stable bite surfaces can treat tight muscles, but these appliances also do not address the root problem. Some TMJ dentists advertise their oral appliances as orthopedic devices, but orthopedically they are just being used as a crutch.
Despite all the overtreatment commonly provided in this field, the vast majority of TMJ disorders can be permanently cured and the symptoms eliminated on both a short-term and long-term basis by simply wearing the right kind of oral orthopedic appliance at night to restore health in the jaw system and to ensure that the symptoms never return by controlling the slow jawbone growth of adulthood by redirecting forces of nocturnal bruxism (clenching and grinding during sleep) to optimize healthy function and airway preservation. The goal of the oral orthopedic appliance is to rehabilitate your jaw system and gradually accomplish the orthodontics that you need for an optimal bite table. Different types of 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 elongating, unstable bites need stabilizing, and strained bites need adjusting.
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 and is not the cause of your symptoms. MRI is the only way to image the disk and the presence of inflammation, the clinically significant features. Dr. Summer has extensive experience with reading MRIs of the TMJs. Airways are too dynamic for current imaging techniques that claim to measure the size of the pharyneal airway.
TMJ INFLAMMATION - Most TMJ disorders undergo an inflammation phase, usually within months or years after the disk first became dislocated. When inflamation is present, it must be addressed before treating the muscles; because the inflammation could be the source of the jaw muscle tension. 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 immediate pain during clenching and a sustained increase in jaw muscle tonus due to reflex protective guarding (hypervigilance). Effective treatment requires wearing a TMJ protective oral appliance during sleep to stop the bruising for long enough to allow the damaged TMJ to fully heal, usually about two months. Then, your appliance can be modified orthopedically to rehabilitate your muscles and improve your facial growth pattern so the problem never returns.
TIGHT JAW MUSCLES - are always involved, along with neck muscle tightness, because the jaw is part of the neck. Therefore the jaw muscle tightness can be caused by tight neck muscles; but more frequently the jaw muscles have become tight due to strained bite. If the bite does not provide a comfortable platform for the mandible to rest on and work against, the jaw muscles cannot fully relax. A displaced biting position automatically displaces the postural position for the mandible, because protective reflexes 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 bite controls jaw posture.
BODY POSTURE - is always affected, because your jaw is part of your neck, and your mandible is part of your head posture mechanism. If a displaced bite platform prevents your mandible from resting under the middle of your face, your head cannot rest straight on the top of your spine. Backwardly displaced bites cause backward jaw posture and forward head posture. Laterally displaced bites cause head posture tipped toward the side of the displacement, as explained in THE ROLE OF POSTURE, and in detail in BITES AND BODY POSTURE under FOR DOCTORS. The posture of the head determines how the body aligns beneath it to provide physical support in a resting postural stance.
TMJ ARTHRITIS - is a diagnosis based solely on X-ray; and it 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 misshapen and therefore create a diagnosis of arthritis. 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 smooth rounded shapes. Most older people have TMJs that show flattening, erosions or ledges which meet the definition of arthritis; but that does not mean they are symptomatic or needing treatment. If a TMJ is no longer inflamed (effusion on MRI), it has healed; and any remaining 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, nutrition, counseling, biofeedback, exercise, assisted whole muscle stretching, muscle fiber stretching (myofascial release), trigger point injections, and techniques such as hypnosis to relax muscles 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 the 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 we believe is most likely to help them. We rarely prescribe medications, because they make it difficult to monitor the effects of orthopedic treatment, and we find we don't need them.
OBSTRUCTIVE SLEEP APNEA - is caused by choking on the tongue base and the distal end of the soft palate. Many dentists now treat the problem with mandibular advancement appliances, but their success rate is only about 50%, as shown in hundreds of studies; because the mandible is only loosely attached to the tongue base and not at all to the soft palate. Also mandibular advancement appliances cannot be used in people without natural teeth to support them. For denture patients and people whose mandibular advancement appliances cannot successfully treat their apnea, Dr. Summer has developed new devices that can be added to their 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. They will all be marketed together in a kit of components that can be used by labs to build the oral appliances or add them to previously made dual arch oral appliances to carry out the new functions. 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. Once we understand the root of the problem, we can treat it societally. Only by understanding how we have 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 even be purchased online. Also, a genuine story from a real patient does not mean the treatment worked, because of a statistical factor called "regression to the mean." In conditions that fluctuate over time, the symptoms are likely to diminish shortly after patients begin 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 $75 - $400 depending on the amount of time required and whether or not the visit included a temporary oral orthotic device. Fees for consultations just depend on the time required. Fees for oral appliances range from $300 for rubber bite cushion appliances to $4000 for comprehensive multilevel sleep apnea treatment. In people with dental problems that complicate appliance fabrication, such as multiple missing or crooked teeth or implants, the fee may be increased for the extra doctor time required to fabricate the appliance.
For health insurance, 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