Self Care Program for Temporomandibular Joint Disorders (TMJD)

The joint that connects the jaw with the skull is called the Temporomandibular Joint (TMJ).  The initials refer to the joint itself, and do not refer to a diagnosis. (Everyone has two “TMJs” but no one has “TMJ”). 

Like any joint (hip, shoulder, and wrist), the TMJ can be strained or injured.  The injury can be the result of a specific trauma to the jaw or can result from prolonged low level trauma from oral habits such as night-time tooth grinding.  Stresses (physical or psychological) can also result in tensing of the joint, which can result in jaw pain or clicking. 

Once a joint or muscle is strained, it can be easily re-injured – like a sprained ankle which is subsequently more prone to injury.  Because we use the jaw for so many activities including talking, eating, yawning, and laughing, the joint and the muscles are constantly moving.  Therefore, TOTAL relaxation of the jaw joint and surrounding muscles is difficult.  However, allowing the jaw muscles and joints to be in a relaxed position is very manageable with practice.  Regular attempts to relax the jaw muscles, and avoidance of activities that would overwork the area, will be helpful to reduce the pain and prevent additional strain to the area.  The following suggestions should help:

  1. Eat a PAIN-FREE diet.  Do not chew gum – the repetitive chewing motion involved with gum chewing places a great deal of activity on the TMJ(s).  Avoid hard foods, such as French bread or bagels.  Avoid chewy foods, such as steak or candy.  Cut fruits into small pieces and steam vegetables.   Cut up food with a fork and knife if biting into food hurts.  Chew with your back teeth.  Eat anything you want as long as it does not cause pain or locking in your jaw.  If “soft” foods cause pain, put any food you like into a blender and start on a grind setting.  Blend the food into the chewiest consistency that does not cause pain or locking in your jaw.  Do not stay on a soft diet too long by periodically increasing the consistency of your diet as tolerated.  Discuss the details of your diet with your doctor periodically. 
  2. Apply moist heat for 15-20 minutes two to four times each day to the painful area.  For example, microwave a gel pack or hot water bottle and a wet towel until they are very warm.  Wrap the towel around the gel pack/hot water bottle and put it on both sides of your jaw going under your chin, or treat one side and then the other side of your jaw.  This heat treatment should feel very warm but comfortable.  Some people respond better to cold treatments.  Try using ice wrapped in a very thin cloth (or no cloth) for 5-10 minutes two to four times each day over the painful areas of your jaw muscles and/or TMJ(s).  The ice may initially give you a “burning” sensation – this is normal.  Keep the ice on the painful area only until you first feel some numbness, and then remove it.  Heat or ice can reduce joint or muscle pains and relaxes the muscles.  You may also find that cold followed by heat is useful.  Experiment. 
  3. Chew your food on both sides at the same time to reduce strain on one side.  Specifically, cut your food into its normal size and cut that piece in half.  Then put one piece on both sides of your mouth and chew.  This will take practice.
  4. Avoid caffeine.  Caffeine is a “muscle tensing” drug and can make your muscles feel tighter.  Caffeine or caffeine-like drugs are in coffee, tea, soda, chocolate, and some aspirins.   Decaffeinated coffee typically has half as much caffeine as regular.
  5. Avoid oral habits that put strain on the jaw muscles and joints.  These include teeth clenching, teeth grinding, touching or holding the teeth gently together, biting cheeks/lips, pushing your tongue against teeth, or jaw muscle tensing.  Also avoid biting on objects like pens or pencils.  DO NOT CHEW GUM.
  6. Avoid resting your jaw on your hand.
  7. Avoid activities which involve wide opening of the jaw such as yawning.  When you feel like yawning, put the tip of your tongue hard against the top of your mouth and let your mouth open as far as it can without letting your tongue off the top of your mouth.  You can also put your hand under your jaw to limit the opening.  Prolonged dental treatments with your mouth open should be avoided, if possible, until the pain has been reduced or eliminated.
  8. Avoid stomach sleeping since this puts strain on the jaw and neck muscles.  Sleeping on your side is ok as long as you do not put a force on your jaw.  Sleeping on your back is best. 
  9. Use anti-inflammatory and pain-reducing medications like ibuprofen, Tylenol, and aspirin (without caffeine) to reduce joint and muscle pain as per your doctor’s suggestions.
  10. Calcium is very important for the healing and health of your TMJs and jaw muscles.  Calcium comes in many sources including dairy products and certain vegetables.  Supplements can be used in the 1200 mg per day range.
  11. Tongue up on your palate, teeth apart and jaw muscles relaxed.
    The teeth should not be touching/resting together except occasionally they would touch
    lightly with swallowing.  We suggest that you closely monitor your jaw position during your waking hours so that you maintain your jaw in a relaxed, comfortable position.  This involves placing the tongue lightly on the top of your mouth wherever it is most comfortable while allowing the teeth to come apart, relaxing the jaw muscles.  Often putting your tongue gently on the top of your mouth where you softly say “n” is a comfortable position. 

**  RECOGNIZE THAT THIS IS NOT A LIFE-THREATENING SITUATION, EVEN THOUGH IT CAN BE VERY UNCOMFORTABLE.  INJURY TO THE TMJ AND JAW MUSCLES IS EXTREMELY COMMON, AND LOCKING OF THE JAW IS NOT UNCOMMON.  MOST OFTEN THESE SYMPTOMS WILL IMPROVE OVER TIME.  CHANGING HABITS, RELAXING THE AREA, AVOIDING ADDITIONAL STRAIN OR INJURY, AND DOING THE ABOVE SHOULD SPEED UP YOUR RECOVERY CONSIDERABLY. 

Halloween Candies – Which treats are OK if you have braces?

halloween braces

Let’s face it – most children and teenagers are going to eat sweets on Halloween, and an occasional indulgence won’t be the end of the world for their teeth.  But some Halloween treats are better than others, especially if braces are being worn.

With any sugary snack, the longer it is present in the mouth, the greater the potential to cause cavities.  That is why the worst things for teeth are hard candies designed to be sucked for a long time.  Things like lollypops, hard candies, and jaw breakers are among the worst culprits for causing tooth decay, whether or not braces are present.  Similarly, sticky sweets like taffy, caramel, tootsie rolls and bubble gum are difficult to remove from the teeth and can remain in the mouth for minutes or hours, leading to cavities. They also tend to get stuck under the braces and are difficult to brush away.

Crunchy treats are not necessarily bad for teeth, but they are bad for braces. Hard pretzels, nuts, and potato chips can break your braces if not eaten carefully. Similarly, candies with a hard shell that are designed to be crunched can break your braces (this includes smarties and M&Ms).

So which treats are acceptable for those with braces? Plain chocolate bars (no nuts or caramel), or chocolate bars with wafers are less likely to break braces and cause cavities. Examples of these include Kitkat bars, Aero bars, Coffee crisp bars, and others. These treats are less likely to cause problems (provided they are eaten in moderation and are followed by good brushing and flossing).

So for those of our patients who celebrate Halloween, we hope you have a great time trick-or-treating! Go ahead and enjoy some delicious treats, but please choose them wisely. And if you do accidentally crunch on something you shouldn’t, we are open the day after Halloween ☺

But Doctor… I just want my 6 front teeth straightened

straighten front teeth

When patients come to my office for a consultation, the first question I ask is what bothers them about their teeth.  Almost always, the answer is that they want their front teeth straightened, preferably as quickly as possible.  They are often surprised (or even frustrated) when the plan I create for them also addresses their back teeth and their bite.

“But doctor,” they ask, “I just want my 6 front teeth straightened.  Why are you making a plan that is unnecessarily complicated and prolonged?  I don’t really care about my bite or my back teeth, so wouldn’t it be cheaper and quicker for you to just do as I ask?”

And the answer is that, yes, it would certainly be cheaper and take less time to just straighten the 6 upper front teeth.  But that doesn’t mean it would be a good idea.  You see, when we move teeth from their natural position into an artificially straight position (which is what orthodontists do), if we don’t account for the bite we could end up creating all sorts of problems.

Straightening teeth without treating the bite can create overbites, underbites or crossbites – all of which can damage the teeth.  It can cause gum problems or jaw aches.  It can cause the teeth to protrude (stick out) or slant and make the smile look unappealing.

The reason we orthodontists care about your bite is not because we want your treatment to take longer or cost more, but rather because we know that if we don’t take your bite into consideration you may not be happy with the final results, and your dental health may be negatively affected.

Unfortunately, there are products on the market that are designed to just straighten the front teeth without addressing the bite.  These are usually offered by general dentists who lack the orthodontic training to understand why they are not a good idea.  Such products include “6 month smiles” which promises straight teeth after 6 months, but makes no guarantees about the bite.  They also include Invisalign, if done by non-experts who are not able to correct bites with aligners.  Dentists offering these services don’t often explain to patients why they SHOULD care about their bite, or what can go wrong if the bite is not addressed.

In today’s customer-driven market, patients expect to get what they ask for without necessarily knowing the implications of their requests.  They may find a practitioner willing to treat only their front teeth, but eventually discover that doing so leaves their teeth in a worse state than they started with.  Think about it this way – if straightening your front teeth without correcting the bite was a good idea, orthodontists would be happy to do it for you!  We love happy patients!  But if our training and expertise tells us that doing so would not be a good idea, patients would be wise to listen.

My Child is a Thumb-Sucker. Should I Worry?

When people find out that I’m an orthodontist, they often ask me questions about their children’s habits – and specifically about thumb sucking.

Thumb sucking is common among children.  In fact, fetuses are often seen sucking their thumbs when ultrasounds are performed during pregnancy.  At a young age, thumb sucking does not pose a threat to the teeth. However, if thumb sucking continues into later childhood it can lead to orthodontic problems – namely, it can cause the teeth to become crooked, it can affect the growth of the jaws, and can cause severe problems with the bite.  The longer the habit continues, the worse the problems become and the more difficult they are to correct.  So, depending on your child’s age, thumb sucking may be more or less of a concern.

What can thumb sucking do to the teeth?  THIS:

Thumbsucking
The bite of a 14 year-old thumb sucker – note the extreme mal-alignment and lack of proper bite

So, should you be worried about your child’s thumb sucking habit?

Here is an algorithm to help you decide:


Don’t worry about it. Thumb sucking is perfectly normal at this age, and will not likely result in damage to the teeth or bite

Don’t worry about it.  Thumb sucking is perfectly normal at this age, and will not likely result in damage to the teeth or bite

thumbsucking-ages-_ages 3 - 5

Don’t be overly alarmed, but gently encourage your child to stop the habit, without shaming or pressuring.  If the habit is stopped before age 5, there will likely be no permanent effects on the teeth and bite.  Consider a sour-tasting nailpolish to help the child stop the habit.

thumbsucking-ages-_ages 6 - 9

Thumb sucking at this age will likely affect the teeth and bite, and the habit should be stopped as soon as possible.  Visit the orthodontist to consider a habit-breaking device (see below).

thumbsucking-ages-_ages 9 +

Thumb sucking will lead to severe problems that will require braces, tooth extractions, or even jaw surgery to repair.  Prompt action is required.


What will the orthodontist do?

If your child is over 6 years old and is having trouble stopping the habit (or sucks while sleeping), the best course of action is for the orthodontist to make a thumb-crib appliance.  This appliance consists of a metal mesh which spans the roof of the mouth and is cemented in place.  It is invisible (hidden on the inside of the mouth), and is not sharp or painful.  With it in place, if the child attempts to suck his thumb, it no longer fits comfortably in place.  And because it no longer feels soothing, the thumb sucking habit will stop. The appliance is cemented in place for at least 6-8 months to prevent the habit from recurring.  If the habit is stopped early enough, the damage that it caused to the teeth and bite should largely reverse itself, or be correctable with braces.

Thumb sucking thumb crib appliance
Example shows a Thumb Crib Appliance which is used to help children who habitually suck their thumbs to break the habit.

So whether or not you should worry about your child’s thumb habit largely depends on the age of the child.  Please use the algorithm I’ve provided, and share it with your friends.  The more parents are aware of how and when to treat thumb habits, the better the outcomes will be for their children.

So what makes your teeth crooked anyway?

We see a large number of patients who complain that their teeth are crooked and they want to have  better smiles.  Naturally they come to see an orthodontist such as myself to help correct this issue, and when they visit they often ask “so why are my teeth crooked in the first place?  What caused this to happen?  Is it genetic?”
While it’s true that genetics do play a role in the development of your teeth and if your parents had an overbite or an underbite you might very well inherit the same trait, genetics are certainly not the only contributing factor.  Some bad habits such as clenching your teeth (stress) or tooth grinding or even thumb sucking in small children can lead to tooth alignment issues.  Here are some examples:

When a child sucks their thumb: 

This tends to make the top jaw narrow and even push out the top front teeth causing them to stick out (often referred to as buck teeth).
When a child pushes their tongue against their front teeth: Referred to as tongue thrusting, this can cause pressures behind the teeth which ultimately can lead to pushing the them forward causing them to stick out.  A similar issue can arise from extended pacifier use in very small children , if not caught in time and corrected this can certainly lead to undo pressures on the jaw leading to tooth problems.

Knocked out teeth: 

Accidental tooth loss in children as may occur while playing sports, can easily lead to crooked teeth if the underlying adult teeth fail to come in properly.  This is one of the reasons why it’s so important to be seen by your dentist regularly so they can catch these things early enough to correct them and if an Orthodontist is needed, they will refer you to the office so a custom plan can be devised for you or your child.

Not flossing:

In adults, something as simple as not properly flossing can cause teeth to become crooked over time!  When deposits harden on your teeth (known as tarter buildup) this has the effect of pushing the gums away from the teeth which would be otherwise closely in contact with the teeth.  Over time, this can loosen the teeth and cause shifting.  That’s another reason why you absolutely should be regularly seen by a dentist.  Bone loss beneath the gumline (which is a serious issue) greatly contributes to this same problem because the teeth simply have less material holding them in place and they become loose and then eventually will shift.  In this case, an adult patient is likely looking at an underlying Periodontal issue and should be assessed immediately.

In summary, Prevention is key!

All these examples point to prevention being one of your biggest assets when maintaining a healthy smile.  There are daily steps you can take to ensure you have the best chances of avoiding crooked teeth.  Here’s a brief guideline that you can follow, but remember, you may just be in that camp of people that has underlying genetic predisposition to certain alignment issues that really require the assistance of an orthodontist to properly correct.

Steps to take to help reduce the risk of crooked teeth

  1. See your dentist or independent dental hygienist for regularly scheduled cleanings  and checkups.  Knowing, really is half the battle!
  2. Make sure you are flossing!  If you have children, instil in them this critically important oral care habit.  Learning it early can help save them much grief later in life.
  3. Invest in a mouthguard, for you and your child while playing sports!
  4. See the orthodontist by age 8 for a consultation in case any preventive work is needed.  Remember, catching potential issues early can help save you both time and money down the road.

So what’s the deal with wisdom teeth?

Before I place braces on any patient, I take a panoramic x-ray to assess the teeth and jaws. And almost always, I discover wisdom teeth developing beneath the gums, behind the other molars. When I tell patients that they have wisdom teeth, I often see a look of dismay on their parents’ faces. Perhaps they remember having their own wisdom teeth removed – or more likely they remember being swollen and eating mush for 3 days. They assume that because their children have wisdom teeth, they will need to get them removed. And this isn’t always true!

In the old days, wisdom teeth were a lot like tonsils – doctors removed them because they were there. But the thinking has changed about wisdom teeth over the past few decades, just as it has for tonsils. These days, we only recommend removing wisdom teeth if we see a problem associated with them or if we believe a problem is imminent. Such problems include infections of the teeth or gums, or damage to the adjacent molars.

“But won’t my wisdom teeth push my other teeth crooked?” you may ask.

And the answer is that they are unlikely to do so, because when braces are finished every patient gets a set of retainers to keep the teeth straight. As long as you are wearing your retainers, your teeth should remain straight, regardless of your wisdom teeth. Of course, if you aren’t wearing your retainer, your teeth may go crooked with or without the influence of your wisdom teeth.
So, the fact that your child has wisdom teeth developing does not necessarily mean that those teeth will need to be pulled, nor does it mean that the teeth will go crooked again unless you have them removed. Rather, the best thing to do is to see your orthodontist for yearly retainer checks, and have a panoramic x-ray done at age 16. Hopefully the x-ray will show healthy teeth developing normally, and extractions won’t be necessary. And if it turns out that the wisdom teeth have to be removed don’t worry…..they may remove the teeth, but your child can keep the wisdom ☺