This website contains an extensive 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 strained facial and jawbone growth patterns maintained by an unstable or displaced bite. Under TMJ DISORDERS are clinically relevant aspects of the underlying pathophysiology and the causal factors behind the symptom generating process. Under TREATMENTS are the orthopedic treatments we offer along with costs and rationales. Under FOR DOCTORS are more specific descriptions of treatments along with three long files explaining how bites function and dysfunction clinically. 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 has produced the backward jaw postures, forward head postures and craniofacial asymmetries that have become endemic in modern populations.
MANAGEMENT - 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. Under the tab TMJ DISORDERS are two MANAGEMENT files describing different ways the problem can be managed professionally or at home.
MUSCLES - produce most of the symptoms, but muscles are responding organs. They rarely start problems. When a TMJ is inflamed, the jaw muscles splint to try and protect that TMJ, like your leg muscles limp when you walk on a swollen ankle. When the jaw muscles don't have a healthy platform to rest on and exercise against, they become hypervigilant. They cannot relax enough to allow good resting circulation, and they accumulate waste products 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 power natural mandibular advancement that creates adequate space for airway passage.
ORAL APPLIANCES - of various types are usually provided by dentists who offer TMJ treatment, but these oral appliances 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 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. Oral appliances with tall stable bite surfaces can treat tight jaw muscles by stretching them, but these appliances also do not address the cause of the tightness. Oral appliances that reposition the mandible can provide short term relief by temporarily inserting an improved platform for the mandible to rest on and exercise against, but they don't improve the facial growth pattern ultimately responsible for the underlying strain.
ORTHOPEDIC APPLIANCES - can eliminate the symptoms on both a short-term and long-term basis by protecting the joints, rehabilitating the muscles, and 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 no longer 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.
BITES - affect the core pathology and the facial growth pattern behind it, because the bite functions orthopedically as a joint between the upper and lower jawbones. However, dentistry has been unable to understand bites or the role they play in TMJ disorders and sleep apnea, because dental researchers have never understood how the bite works together with the postural system or how the bite affects the lifelong pattern of facial and jawbone growth, which determines how well the parts of the jaw system end up fitting together. Without an understanding of how the bite works, most dental authorities warn dentists to simply avoid treating it.
TMJ INFLAMMATION - Most TMJ disorders undergo an inflammation phase, usually within months or years after the disk became dislocated. When inflamation is present, it must be addressed before treating 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 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 in TMJ disorders. If the bite does not provide a comfortable platform for the mandible to rest on and work against, the jaw muscles stay tight, because they cannot fully relax. If a bite is displaced, it also 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, a strained bite produces a strained jaw posture.
BODY POSTURE - is always affected, because your jaw is part of your neck, your mandible is part of your 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 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.
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.
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 their success rate is only about 50%; 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 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. Once we understand the root 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 be made up or 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 - $300 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 are included in the file ORTHOPEDIC TMJ TREATMENT under the tab TREATMENTS and also in the descriptions for various appliances. The fees have a range, because they require more time and effort in some cases. It feels fair to charge for the appliances as tools, which come with complete advice on how to use them as well a follow-up communication, than to charge a large case fee for everyone to accomodate a few people who require more time and effort.
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