Jaw pain, headaches, and facial pain are all common and can have a profound effect on our quality of life. Lucky for us, we have an esteemed guest speaker on the show today to break these topics down and help us understand how we can overcome this pain.
Donald R. Tanenbaum, DDS, MPH, graduated from the University of Pennsylvania in 1978 and then received his DDS degree from Columbia University School of Dental Medicine, and his MPH degree from Columbia University School of Public Health in 1982. He has been practicing for over 40 years, providing guidance and care to patients with temporomandibular problems, facial pain, headaches and sleep related breathing disorders. Today he reviews some of the causes and treatments for these issues and explains their biopsychosocial nature. He also discusses the importance of identifying habits that can perpetuate pain and stop or modify them. He touches on bite plates, injections, PT, posture and ergonomics as all ways to alleviate pain.
Dr. Tanenbaum has co-authored a book for the public entitled, ‘Dr, Why Does My Face Still Ache?” and continues to give lectures to dental students and residents, medical grand rounds and to numerous dental societies and study clubs. Dr. Tanenbaum currently holds several positions, including: Clinical Assistant Professor at the School of Dental Medicine at the State University of New York in Stony Brook where he is the Director of the Orofacial Pain Course given to the third year dental students. He is also the Section Head of the Division of OrofacialPain/TMD/Sleep Medicine in the Northwell Health Department of Dental Medicine at the Long Island Jewish Medical Center; and Clinical Assistant Professor, Hofstra Northwell School of Medicine. Dr. Tanenbaum is a Diplomate of the American Board of Orofacial Pain, a Fellow of the American Academy of Orofacial Pain, and a past President of the American Academy of Orofacial Pain
Dr Tanenbaum currently maintains private practices in New York City and Long Island limited to the diagnosis and management of orofacial pain, temporomandibular problems and sleep related breathing disorders.
Connect with him:
www.nytmj.com
hello everybody and welcome to this week’s episode on fit as a fiddle today our guest is Dr Donald Tannon bomb the renowned Dr Donald Tannon bomb um Dr tanon bom and I have known each other for probably around fiveish years maybe six years um and we have finally finally finally got him on this podcast and I am so excited and thrilled that he gets to share his expertise um Dr chanom is a fellow graduate of Columbia University um he has been practicing for 40 plus years he has been treating all sorts of things um but his specialty and focus is patients with uh tmds which are tempero mandibular disorders Facial Pain headache sleep and related breathing disorders um he does a lot of continued training he is the author of a book that I think I now read about four or five years ago it’s called doctor why does my face still ache and it’s a great great book I recommend it to many many of my patients who have tmds um very informative and is a gateway for you to really understand your own health so I recommend everyone if you’re interested please go um and get that book online um Dr tanom also lectures he is the clinical assistant professor at the School of Dental Medicine at the State University New York in Stony Brook he is the director of the orofacial pain course he is the sectional head of the division of orofacial pain TMD sleep medicine and northwell Health Department of Dental Medicine and many many many more things that you can read in his bio but all of that is to say Dr tanom knows his stuff he’s really good at what he does he’s really good with patients patient outcomes helping patients feel like they understand what’s going on with themselves because I think a lot of when it comes to pain itself is really understanding the pain where it’s coming from what’s driving it and he is literally the best person to explain that to you in ways that are is just so so much more informative and can really help you in your journey overcoming that pain so welcome to the show Dr Tan bomb oh thank you for having me yeah so I’ll let you go ahead and start off by just introducing yourself a little bit more in terms of what you actually do on a day-to-day basis how does your uh practice look like where is it set up um and I guess like the most important things that you tend to see okay that’s a that’s a good place to start uh I guess from a background point of view this is something that I’ve enjoyed doing for the last 40 years got a taste of it um towards the midst of dental school and then created some opportunities uh to learn uh in the 1980s though there were some things happening in terms of um continued education there really weren’t any formal Masters or Fellowship programs so those of us that are in my generation self-trained uh whether or not by having some mentors uh spending time in other practitioners offices and then getting involved with other similar people and interests and then creating acmis and taking this thing from an early stage to where it is today um the the field that I’m involved with is now a specialty of Dentistry so three years ago after probably a 40-year battle uh the specialty of Oro Facial Pain was born the 12th specialty of Dentistry uh never had been present before um but ultimately a decision was made amongst those in political positions that it made sense to create a specialty and as a result over the last three years you begin to see more and more um University Hospitals and universities begin to create postgrad programs so you’re going to see more uh individuals looking at Oro Facial Pain as a career once leaving dental school and they’ll have places to go and train and as long as there’s a specialty every Dental student will know about it whereas formerly most dental students really didn’t know much about the problems and certainly didn’t know who to send to but once a specialty is established there’s a much better opportunity for uh the dental Community to a under understand that there are problems that now have people that are involved in solutions that being said the the umbrella is orofacial pain and underneath the umbrella are headaches which can be tension headaches or migraines you have temporal M the problems so problems related to jaw function and in that context these are orthopedic problems so people that have problem s with their jaw really have an orthopedic problem and symptoms therefore have to do with the presence of pain stiffness range of motion the presence of mechanical noises or instability so really no different than knees and hips and ankles and so the world of temperal mandibular disorders and the diagnostic classifications are really set up now in a way where we can distinguish what is a muscle problem from a tendon problem from a joint problem which may be just unstable to our Thad or maybe due to Lyme disease or another medical disorder and then we have outside of that category of TMD we have problems of uh nerve origin so Under the Umbrella of orofacial pain we see neuralgias people that have nerve pain which are very different than problems relating to the jaw and those problems can be episodic they could be continuous they can be due to traumas they could be due to Medical illnesses they could be due to to chemotherapy they could be due to so many things that leave muscles in a state of disarray giving rise to pain that has high intensity in the absence of lots of findings and then we see problems relating to extraction of wisdom teeth and placement of implants and when nerve injuries occur by chance not commonly but they do in fact happen and so you really have these three categories of problems um and then we see people that have lots of sleep Related Disorders so a patient who may have insomnia likely won’t have a good pain threshold over time because they’re not having sufficient sleep and then during sleep they may have some grinding or clenching of teeth which overwork the jaw some of our patients have breathing disorders which um leave them struggling to get air and so you see this big broad canvas of patients that come to our office many of them are very common very familiar and very helpable and then there those that are less so uh in the process of taking care of patients not only do we spend a a good deal of time on gathering information but we also reach out to the community so we have how our clinical psychologists physical therapists um sleep therapists and others that are out there to provide assistance and P patients that are struggling and we certainly work with headache neurologists that only see headache um that can lend a hand with medications and things like that so that’s kind of an overview of what we do uh patients come into the office and you spend most likely about an hour with patients on day one my goal has always been to figure out who the patient is attached to symptoms because after a while all the symptoms sound sound the same you have to figure out what the risk factors are that brought the patient to the necessity to seek care make a diagnosis and determine you know which of those categories the pain fits or the malfunction of the jaw fits and then begin to reach out into the office or to other practitioners for assistance in getting the patient better so that’s that’s a big overview yeah that that was very thorough that’s like taken straight out of a textbook almost it was perfect um and hopefully that gives listeners just an understanding that um you know it’s not just my jaw hurts but there could be many reasons why it hurts or why your head hurts um and the mechanism of what’s driving this pain is multifactorial I think that’s part of what you’re also getting at like there’s categories of these things and maybe some of them slightly overlap but they by diagnosing correctly we can actually treat better and as clinicians that’s the most important thing get a proper diagnosis understand the patient understand what’s going on with them what’s all the bioc psychosocial elements of this and categorize it in a way that we can offer treatment appropriately so on that note I would like to First focus on the jaw pain that arises or the you know kind kind of tmds that arise from The Chronic brism The Chronic clenching and the grinding and the stress which then drives headache um what are I guess my first part of the question is how does those patients typically present like you said you got to understand the like what are some of the common denominators that you seem to tend to find in those patients and what are some of the most effective solutions that you can offer in your practice or adjacent practices so so a couple things um I think what should be apparent is that clenching and grinding of the teeth as separate entities don’t necessarily do anything there are millions of people in this world whose teeth are together at night either in a static one position or the lower drum moving and creating sounds as the teeth clash and some people even put them together during the day and there’s a whole percentage of that population that never has a symptom they don’t even know what they’re doing they never have an ache they never have a pain they deny they even do it so the presence of a overuse of the jaw during the day and or a condition at night time that causes the teeth to be together more aggressively does not necessarily produce symptoms however if you think about um the jaw the lower jaw as a movable entity that’s why it’s an orthopedic problem and if you try to understand why orthopedic problems occur there’re really only a couple reasons so you can always start with trauma if you have an orthopedic system that sustains a trauma you can appreciate tissue injury pain limited motion instability so you have trauma but I would say that probably less than 5% or maybe less than 10% of patients that we see have actually had a traumatic event other than biting on something that was unexpectedly harder than they thought so they think they’re biting onto a soft piece of candy during the holiday season it’s not soft it’s hard and all of a sudden when they bite down they feel something up in one of their jaw joints they sustained an injury or somebody that has a eating disorder and has been vomiting excessively thrusting the jaw forward for months on end sustain sprains of their jaw somebody that had a general anesthetic procedure because of a an appendix that was ready to rupture and the putting of the tube down had to be done quickly an injury occurs to the TM joint keeping the mouth open for a lengthy dental procedure or a lot of dental procedures over a short period of time all of these things can create Orthopedic injury due to a trauma and we see those but they don’t dominate underlying medical illnesses so if I were to look at another reason why people have problems in these jaw joints or temperament with the joints it’s for instance they may have um some general laxity they have a systemic hypermobile condition so we see many patients these days that have double jointedness hypermobility ERS danow syndrome where their connective tissue is just not healthy and stable and as a result neither of the jaw joints we also see people that have a variety of rheumatologic conditions uh things like psoriatic arthritis gudy arthritis rheumatoid arthritis that create opportunities for breakdown within the hinges themselves uh we see people with Lyme disease and other infectious disorders that affect the temperament of the joints and you can go on and on so we see traumas and medical illnesses that can create Havoc within this system and create pain limited motion but if you really want to know um uh why we see most patients I think it’s a combin three a combination of three things overuse of the jaw coupled with emotional tension coupled with postural fatigue of the head neck region you put those three things together and and you can take a benign clencher and grinder that never had symptoms and now you add a lot of Life stresses all of a sudden the same clenching and grinding become symptomatic or they all all of a sudden have a good deal more postal fatigue of the head and neck that can make the grinding and clenching that produced no symptoms now begin to produce symptoms so we spend a good deal of time not look not only looking at overuse daytime behaviors but what it is that took that daytime Behavior and created a set of symptoms because we know that millions of people with that same behavior don’t have the problem so why does one group of nail biters have no jaw problems and another group are miserable right why does one group of patients who puts their teeth together during the day and they clench all day and have no problems where another group does so and and in your world the whole world of forward head posture and weak neck muscles why do some people have no symptoms and other people are a mess so I I think our goal has been to listen to what people have to say uh understand the history understand the examination and then at least postulate what we think are the risk factors that create a set of symptoms and then try to understand what’s been injured and what’s not and so that’s really where we spend our time um because the diagnoses that are available they’re limited and you can only have certain categories to pick from you just have to figure out the why and most importantly who that patient is that’s attached to symptoms uh you know if you even look at something like grinding and clenching of teeth you can have somebody that’s done that for years and now they’re 16 years old and they’re in school and they’re not performing well so what do they get Aderall coner they get drugs to create Focus or they’re diagnosed with ADHD and now they’re on a stimulant like sta or concer or riddlin which puts people in a state of fight or flight all the time so they may be performing better but their system is in high drive and all of a sudden the old clenching and grinding which never made a difference now is symptomatic and so those are the kind of things that I’m always looking for to see what’s changed you know what took the simple jaw click and Pop That Never Was symptomatic just aware it was present but no pain no locking and now it hurts and it locks so why did that happen was it just a matter of years or something else added to the equation and then of course um if we have these problems um are they muscle in nature in the jaw are they muscle and the attachment tendons so do we have a tendonitis do we have a joint that is unstable but unstable with inflammation is the shock absorber slipping in and out of place creating noise and locking you know th those are the kind of things that we we look look at and we try to figure out what the plan of action is to try to stabilize it and get people better um within the the time frame and means that they have I love that um I think the one of the things that just stood out to me that you just described is that you know taking a look at all of the factors we need to make sure that we identify the different components and then Target them individually I think that’s part of like what you were trying to say is it’s not just the brism so for example it’s not just get them Night Guard that’s not going to solve their problem um it’s more than that and so we have to figure out the whole picture figure out all the components yeah I mean certainly the night guard may be hugely critical to stop the impact or to diminish impact the bite plate doesn’t stop them from biting it just lets them bite in a better neighborhood the question is can you figure out the right neighborhood so that there’s less injury but then are things going on during the day I think what’s really overlooked in the world of TMD is what’s happening during the awake 16 hours everybody focuses on the sleeping eight but usually the awake 16 are really where Big Time damage occurs so yes you have to control nighttime injury can’t stop it necessarily but mitigate it and then figure out what to do during the day do we get people to breathe in a more uh mindful way do we get people to work on their core strength and their head position and postural stability uh do we get people to U learn that it’s not natural to keep their teeth together during the day to change their behaviors some people think it’s normal to live tooth to tooth whereas the teeth should never touch so if somebody exists in this world tooth to tooth it’s an acquired behavior well why is it there why is it now creating symptoms those are the things we go after and it’s really a function of when you get patience whether or not the tissue injury is early on mildly persistent or very persistent will determine whether treatment will help and in what type of time frame you know so if I have somebody who just has a recent problem for reasons that I can identify and we have a little bit of an acute sprain in the jaw joint for reasons that are understandable maybe somebody’s went on a diet now they’re chewing a lot of gum they never did before right or uh they change from a uh one diet to one that’s a little bit more um vegetarian in nature or they stop cigarette smoking or whatever they may do that’s changed some patterns if you can identify those things early on you can address the injuries but if the injuries are long-standing and chronic and persistent and there’s more inflammation and there’s more secondary guarding and compensation then the problems are more challenging and that’s where we typically always bring in physical therapists um because if in fact these things are um orthopedic problems why would this area not deserve physical therapy as much as a knee or hip So Physical Therapy we find to be critically important for Education uh to help people understand the relationship between the all the body segments and how they connect and how dysfunction at one level can create dysfunction elsewhere um ergonomics relating to work uh body sleep positions uh and even when they’re working out to begin to pay attention to what they’re doing when they’re working out or their teeth together the body mechanics pour that are creating spr brains and strains uh but that’s what these problems are so when you when you start looking at true temperament deep with the problems uh it is really a broad categorization with um a lot of information to be gathered to figure out the why who the person is what the risk factors are and what does the patient have to do to participate to get better these are never doctor fix me problems this is always a participatory uh type of situation where I need help for somebody to get better so if they’re not paying attention to daytime behaviors you know what am I going to do if they’re not changing their diet they’re not wearing the night guard they’re not doing the physical therapy of their exercises they’re not even taking a medication for a month to quiet the inflammation so if the patient doesn’t understand the education and doesn’t buy into the diagnosis and the why very hard to get people better yeah which is very hard totally hear you I see that all the time and like even outside of tmds like anything related to pain for anyone there’s a lot of the oh I’m going to go see somebody and they’re going to fix me um they’re going to put my I’m going to put my hands on them and then suddenly magically they’re going to get better and that is literally never the case literally never the case and so I have to describe I have to tell them usually when they ask me how long is it going to take to get better I say it depends on what you’re doing at home that I tell you to do it just completely depends if you do all the things very consistently here’s what the timeline could look like and if you show up to my office and the next time just show up as if nothing has happened and nothing has changed you’re never nothing is nothing is going to have changed that’s literally the answer yeah no very true um so that’s I mean I’m just trying to think um what would be most helpful for your listeners to try to understand about jaw problems uh certainly most most people know that if you seemingly have a jaw problem what’s the first thing they get when they go to a dentist is a bite guard and again very important at times but it may only be part of the problem and then there’s not just one type of Night Guard there could be four or five variations of a theme based on the diagnosis so if somebody just has a a muscle problem uh it may prompt us to deliver one type of dental Appliance if somebody has uh a certain amount of joint noise when when they wake up or their jaws actually locked when they wake up we need to make something to address that if somebody um describes a problem where they’re lower the bite has changed it may prompt the utilization of a different type of device so all bite plates are not the same not every TMD problem requires a bite plate um and it has to be complemented by the daytime hours so that people go to bed with a jaw that’s not been abused during the 16 hours because the appliance can only do so much so if the 16 hours unravels it you can only hope for so much kind of progress then of course there are strategies during the day to change behaviors that’s key so if we have a patient who has a lot of daytime behaviors we need to change those so that that behavior doesn’t overwork the jaw so nail and cuticle biting biting on pens and pencils biting the cheeks of the lip um all those things overwork the jaw uh they need to be addressed if people have you know some missing teeth that they’ve not addressed and are only chewing on one side of their mouth that needs to be addressed if people had a filling that fell out of place and as a result there’s an open contact between two back teeth and food is always getting caught between the teeth and they’re fishing the food out with their tongue all day long that needs to be addressed because the more the tongue works the jaw gets overworked because the the tongue is just a passenger of the jaw so all of these little things may create a problem if somebody has been increased on their stimulant medication maybe that needs to be monitored by a conversation if somebody is a crazy Insomniac and never sleeps we need to figure that out because somebody that doesn’t sleep doesn’t heal so those are all the key pieces um we we turn to uh lots of injection therapies as well just like any orthopedist or Physical Medicine rehab dockwood so we pick up needles a lot not because they’re Curative but they can sometimes begin to reverse the disease process and buy some time so we do a lot of what we call trigger point therapy or dry needling which basically you assault muscles that are in a state of tension trying to coax them out of it but trying to understand why they’re in trouble in the first place so whether it’s the muscles of the upper neck shoulders face and jaw we do a lot of we call dry needling or trigger points which is really done with the needle the needle is a treatment not the solution we put a little bit of Lidocaine in there for Comfort but the physical prodding of the needle and it could be up in the face the temples the upper neck and shoulders and then we may do that you know three or four times with three or four week intervals complemented by what changing be behaviors W watching the diet doing some physical therapy and exercises um if people have joint problems in the joints itself that may be chronic inflammatory disease um or they have chronic tendinitis uh we do something called Prolotherapy which is a kind of a resurrection of some old treatment out there about 50 or 60 years with people um put forward the concept that if you take something like dextrose sugar along with some lidocaine and you introduce the dexos into a tendon that was chronically inflamed the dextrose would actually create new inflammation now that doesn’t seem to make sense but sometimes when you create new inflammation in an old site it brings the body’s attention to the problem and all that is necessary for healing so we a fair amount of Prolotherapy in in insertion sites tendons ligaments joint capsules um there’s always steroid steroid is not a bad thing when used appropriately we certainly put some steroid in chronic tendinitis we use it in TM joints that are grossly inflamed or sprained or arthritic uh you have a whole new world emerging of uh regenerative medicine now where um you can begin to think about spinning down some somebody’s blood and taking certain fractions of that blood and putting it into a temperament deep with the joint still not the greatest science but it’s something we’re exploring we’re beginning to use the jur is not out but if every other joint system is being treated that way how could we not be doing it and so we’ve kind of leaned into that world and then of course everybody has the question about Botox should you know shouldn’t everybody get BOTOX for TMD um again Botox you know does a couple things it um reduces the ability of a muscle to contract aggressively so certainly a clencher and a grinder may think that Botox is the one and only appropriate therapy and sometimes it is sometimes we can put some Botox in somebody’s jaw muscles and diminish the force of contracture for two or three months um maybe break them out of cycle they still need to work on changing the behavior but sometimes it breaks the ccle uh Botox also works Beyond reducing muscle contraction by quieting nerve pain activity in muscles so the reason why Botox is used for migraines is because it actually diminishes the release of certain pain producing neurochemicals we have found that there’s a proportion of our jaw pain patients that the botox really is working more on the nerve mechanisms not the muscle H and you find that out because the people who who have the muscle problem I put some Botox in two times maybe three with three to six month intervals they get better and they disappear because we’ve shut the muscle down they’ve changed the behavior the other factors have been addressed and the muscles had to just get healthy those that keep coming back to me every three or four months every three or four months tells me that though they got great benefit as soon as the botox were off they needed it again it had to be more than a muscle problem it’s probably a neuropathic problem in the muscle and not the muscle itself so seeing a bit of a variation on that theme as well and certainly we are using more Botox now um in some of the upper neck muscles to deal with cervical dystonia um and and things like that so not uncommon now to start putting some Botox into the upper trapezius muscles and where they at the hairline and we use that often for people with jaw problems because the neck muscles are the primary recruiters of the jaw muscles into a state of tension so we done doing a bunch of that as well um clearly all this takes time to figure out um and so there’s a big canvas of treatments just got to figure out you know where they fit and again going back to you know who’s the person attached to this why are they in trouble can we figure out the risk factors and are they capable of helping us reduce the risk factor they may not be able to and then you kind of struggle a a along yeah yeah I love that so you talked about the night plates the bite plates the obviously all the education the um changing the daytime Behavior I like that term I’m going to start using that with my patients um because I don’t think I say it that way but I think it’s important for them to understand that yes they are awake most of the time we call it physical self-regulation we tell people to um just begin to get a glimpse of what you do during the day now whether or not it’s by downloading an app that provides a gentle chime or vibration every 5 10 minutes so if there are patients who admittedly are tooth to tooth during the day or always biting the nails and cuticles or always have their arms crossed or their shoulders up or hold their breath you need something to prompt their attention and so the prompter then gives them a series of things to do so we’ve added for most all patients this is a a breathing component to care now where we use a reminder the prompts and breathing to try to reduce fighter flight and increase rest and digest and get the vagus nerve and other parts of the nervous system to that are designed to cause more relaxation to be more engaged um and so that’s really a big part of of the day for many patients just becoming aware of what they do um and it’s remarkable sometimes just changing a behavior or a posture or a repetitive movement um what can happen after four to six weeks where people come back and they’re feeling better because they’ve just become more educated more aware more participatory and yeah they’re often surprised in how much less they hurt yeah I can think of two patients just very recently where I was able to observe that because I don’t do as many home visits now I ask patients to take have somebody take a picture of them when they’re in their natural working environment like a couple of minutes into them just settling into their space to take pictures from the back the side the front so I can see how they are and it was just so obvious somebody had their monitor on the right side and like a like a second monitor on the right side and their main monitor in their Center so what are they doing most of the time is they’re shrugging up their shoulder and putting it onto a armrest that’s way too high for them and then they’re basically just hun Ing and leaning forward into their left arm so they can turn around and work on their right screen which tends to be you know something that they look at like every few seconds almost and so I saw this and I was like we just like what are you doing we got to change the monitor like can we put it so they’re 50/50 and then you’re going back and forth and this is a way healthier more symmetric movement pattern that’s less into a range of motion in your cervical spine especially and there’s there’s just so many things we can do and then the same thing there was another patient who uh she didn’t have an home office she admittedly said I sit on the couch and I do my work and I said okay show me how you do it and she puts her computer onto the arm the rest of the couch that she sits on and just shrugs her body over it and kind of types in a in an asymmetrical way for like hours and hours and hours you know and so you just look at these big Stark asymmetries and then you can look orthopedically because they’re usually you just do a quick range of motion screen and you can see that there’s stuff in their hip that’s off and the way that their side bending to the right versus their left and their lumbar spine looks different and all of this just accumulates into this chronic state of overuse just because of Simple Pure postural dysfunction because of asymmetrical living habits working habits sleeping habits all that kind of stuff and so I think I love I love the way that you said you know the the words that you use and the daytime habits and all the things that they need to look at because on a Global level everything is connected and so if you can just make those changes initially that’s probably the most important thing like forget forget even coming to physical therapy and getting any kind of exercise done because the way I always say is if you do three sets of 10 of this exercise I told you and then the whole rest of the day you go and live in that same asymmetrical weird posture it doesn’t matter the it doesn’t net out to make any sense and you might as well have not done it you hold a stretch I told you to do it three times a day for one minute it doesn’t matter if 23 hours you’re sitting in a particular way or working and moving in a particular way you know oh very true um muscle systems Orthopedic systems easily get exhausted they become unstable they become symptomatic and then they don’t function well and if they’re continually insulted you don’t heal if you don’t heal you don’t feel better so you know in this world of TMD problems it’s all about tissue healing and the question is what’s injured how badly is it reversible and what’s going to take it to heal and then how do you maintain that uh and you know look none of us know for sure where people go long term we get lots of people better we discharge a lot of people as you do I’d love to know where they are a year year and a half later whether or not they’ve held on to all the things that they’ve modified and changed um but sometimes long-term followup is really hard to to to really figure out the why but it sounds like if you discharge them they’re doing better at least that’s what I hope and pray every once in a while they’ll come back and be like I think I need to tune up you need to remind me of everything we talked about no question three years later we have a lot of patients that come back um whether or not it’s for you know us to check their Dental appliance that we’ve given them to deal with sleep bruxism and clenching and grinding and they feel that if they come back twice a year for us to resurface it rebalance it it makes a big deal now we also May reinforce some of the other Concepts that we’ve shared with them uh there’s some people that come back to us every you know two to three months for a little bit of dry needling of their neck and jaw muscles because they feel if we do that they don’t take adolin leave and Tylenol it just helps enough they don’t have to do that uh so there are a lot of scenarios like that I sometimes I see people that come they’ve seen me you know once a year for botox for three years in a row once once a year just when they feel like they may be getting over the edge that’s hardly excessive of use of it it’s probably appropriate for that individual um While others may get it once or twice have a satisfactory result and move on uh and the same thing with physical therapy right need to tune up need a reminder about ergonomics need to go back to those exercises or to learn how to do them properly um you know all important yeah so I’m going to ask you a question that I I think it’s a tough question for me to always answer um and I’m curious to hear what your answer is when patients ask you this so when it comes to Lifestyle Changes um you know I get this question all the time from head to toe if I’m treating somebody with chronic back pain or chronic this pain or chronic that pain they’re like do I need to stop doing ex activity that’s been making it worse right and so especially if that thing is either their lifestyle their livelihood or their passion it can be tricky when it comes to the TMJ specifically I get questions like so can I never eat into a hard Bagel or a big burger ever again because I know we’ve been doing PT for a while and it gets so much better and you know we start to grade our eating into a small slightly soft carrot and we start greeting it and then I want to go eat that burger so I just go into it and it gets me back into a bit of a regression and so they come back after that happens like one or two times they’re like so does this mean I just can’t eat it anymore what is your answer to that I’m C curious to learn from you how do you answer I look at it like any Orthopedic problem you know if somebody’s had a bad sprain of their knee right one would think that a full healing has occurred Through Time medication rest physical therapy exercises if healing has occurred and the repair has occurred one would think that they should be able to go back to tennis etc etc right that’s kind of how look at this I look at this as an orthopedic problem I find that most people that really have pain with eating is because they have a joint problem they don’t have a muscle problem muscle problems don’t really kick off Mo unless you have something in there like beef jerky where you really got a plow to go through it but the patient who really has pain with chewing I typically think it’s really more of a intracapsular problem in the joint which means in order for them to be able to get back to what they want to eat that inflammatory process that ligament is instability really has to be managed properly and so there may be care avenues that have not yet been pursued which has not fully addressed the injury which has left left them fragile and susceptible to eating related symptoms because people say to me am I ever going to eat a bagel again well there’s some treacherous Foods out there like Bagels well maybe not maybe a fresh one that’s steaming out of the oven but a two-day Old Bagel I don’t think so or dried fruits or dried meats or baguette breads from France you know there are certain things that really require a lot of coordination and stability and health so if you have a joint injury joint that has really lingered and is much better on a daily basis I still tell people to really um be cautious with that um and then they may need some more direct therapy into that joint so if the joint’s not getting better there may be a different type of dental Appliance they need maybe they need some an injection into the joint right maybe they need to change their behaviors a little bit more um don’t yawn so much so what yawning is an interesting thing we really focus yawning is really treacherous for people with joint problems so the two worst places for your jaw or teeth together and widest apart together you’re just creating basically a fist in your face which can’t be a good thing and opening too wide you’re putting those ligaments at risk that may already be in trouble so we spend a lot of time having people at least try to reduce the extension so tongue to pallet is common if you stick your tongue to the roof of your mouth you leave it up there really can’t open wide that’s really important um yeah so wide mouth opening is an issue um but I believe that there needs to be some degree of caution with eating and if so it’s probably because the joint injury has lingered to some extent yeah you know there’s this whole other conversation which depends on how old and how gray you are determines how easy it is to have we still see 70% of women in our practice with TMD problems so the whole concept of intimacy is not nothing and it’s sometimes hard to talk about particularly if an 18-year-old comes with her mother whatever it may be but it’s real stuff so there’s no question that issues of intimacy can be very injurious to a TM joint and once injured how does it get better gotta stop new injury so you have all those issues too that need to be discussed at times or at least framed in a way that’s not embarrassing but nonetheless discusted because no question it’s a risk factor and so all these things may determine whether or not somebody impact to eating right yeah absolutely I’m I’m also pelv FL physical therapist so all this is right under my right under my Lane of fire for people right under your line of fire yes and I always say no no information is too much because everything you tell me actually is only going to help me even if you think it’s weird or you think it’s crazy it’s not I mean if you look if you look at our population of patients yeah they have TMD and they got gastrointestinal distress they got pelvic floor and they got neck problems they got sleep issues they have so many tangential comorbidities sometimes challenging to get them all under control yeah the simple ones are the simple ones yeah I actually always find that a patient that comes to me with pelvic Flor dysfunction or TMJ vice versa when I discuss to them about the other joint often they will have an issue there that they didn’t even know could get addressed and they’ll realize that sometimes there is there is something to be said about over clenching overg guarding High you know intensity of muscle activation that the inlet and the outlet kind of both contribute to in some capacity and so often I treat these people with the my first exercise like yours always being diaphragmatic breathing how do we do a top- down approach of like where do you get your neck and head into a better position how do you relax your jaw how do you take a diaphragmatic belly breath in how do you relax your pelvic floor muscles and how do we coordinate that whole thing together so that we can address all components from top to bottom in a healthy way because I find that they’re they’re sometimes very related and they can they can come in tandem together no no question about it um you I’m sure that people’s mural you know neural systems and Regulatory systems are just thrown off and they lead to physical related ailments and symptoms yeah absolutely these things are I know well Dr tanon bom I want you to take an opportunity to say anything else that you’d like to for our audience um anything else that you feel like is the biggest takeaway or the most important things that you may tell your any patient that walks through the door like over and over and over again um I know you’ve said quite a few of them but is there anything that you want to add to that as we close up here today you know I think the key for our practice is to uh listen um validate I think validation is huge particularly if people have been searching for answers and haven’t found any uh so we listen we validate we give a diagnosis that’s understandable we try to discuss the risk factors that are present that may have driven it and let’s try to address the ones that are addressable give some hope and optimism um and always add a participatory piece so that being a level of involvement uh sometimes we we set expectations early on so whether or not we think we can help somebody all the way or 70% 40% for some people with chronic persistent problems that’s enough uh so I think you need to set those expectations early on but for the most part particularly if we’re focusing on this TMD world um these are common familiar helpable problems many of them have pretty clear-cut straightforward Solutions some require a little bit more every now and then you have a surgical problem as with any other joint system and that’s not a bad thing it’s sometimes a necessary thing um but certainly I I think getting patients really understand what they have why they have it what it means going forward is probably the most important thing yeah yeah I love that so where do people find your practice and how do they get in touch with you if they want to learn more ah well we’re you know we have two we have more than two offices now so we kind of rebranded this whole thing two years ago so um it’s now called New York TMJ in Oro Facial Pain so took it a little bit out of my name and we have a bunch of young docs in there now so if you look at my city office uh we have um two new docs over the last you know year and a half um John Dinan who was a graduate of a training program in in the uh in the Air Force in Navy he’s actually an Air Force graduate but did a training program in the Navy he’s SE our practice in the city and Amy worful young lady uh that’s been with us about 16 months now um and she is um seeing these patients and um a lot of confidence and caring ability and then we have a practice up in White Plains so Steve syrup Steve’s been in New York forever as well 40 years with me he’s goingon to be finishing up in New York by the end of March and just seeing patients in White Plains two days a week we have my office out in hog uh which is out in Long Island and there’s a new office in Woodbury where I brought a young fellow from UCLA who was trained in a master’s program at UCLA in Oral Facial Pain Dr fak he’s with me four days a week and then John Dinan is also in a Ridgefield New Jersey office that we just open so lot more accessibility lots of Youth and energy I love that and it allows me to sit home and get better from my my knee surgery for sixs well I’m so happy that you’ve found that and I I’ve met uh Dr warl and is she’s amazing um so I’m I’m very glad that you have a team of these amazing people and for listeners you know it just you can literally Google um Dr Tannon Bomb Dr Donald Tannon bomb you’ll find all this information on his website too which I’ll put down in the show notes um and like I mentioned he has a book that I think people should definitely definitely um take a look at it’s called doctor why does my face still ache and he covers some of these things and um and More in in in detail so I hope that this podcast has inspired you guys if you are coming here because you have some level of orofacial pain and some capacity I hope that you are able to learn a little bit about that and able to seek care and treatment because you don’t you know you’re not alone there are literally people who specialize in this world and do a really good job at it so I hope you get the care that you need and if you want more information you can definitely reach out to either of us so we can point you in the right direction um and to the right resources um so Dr tanom thank you so much for your time today and for making uh making it happen because I know we’ve been at it for a long long long time to do this but it worked out and I’m sorry it’s at the expense of your knee surgery but here we are thank you so much and look forward to shatting soon