The skill set of a "good doctor"..

Each one of us have been through this process ourselves when we go to visit a doctor...Whether it is a routine wellness check up or a sick visit, each time, the visit reinforces the trust or lack there of based on our interactions with the doctor. The initial appointment is all about gauging the trust factor. Its based on the biography of the doctor we "google" up, the doctor's chair-side manner, but most importantly the doctor's ability to instill the confidence in us with respect to the treatment course. That confidence is distilled from clarity in their clinical decision making, what they call as "thinking on their feet".

In my teaching world to budding dentists, I talk to them extensively about building their strength in listening to the patients- both to their verbal as well as their non-verbal communication, synthesizing the information they gather during the interaction to arrive at a clear, treatment course based on quick distilled clinical decision making process.

To my joy, I see the medical education here reforming. Now, in their interview process for future doctors they have started to look for just this ability- the ability to "think on their feet"- decision making.

This article recently published in NY Times, gives an insight into this refreshing change:
http://www.nytimes.com/2011/07/11/health/policy/11docs.html

As much as academic training and textbook knowledge empowers a professional, it is their ability to integrate that training in a clinical setting with good listening skills, and arrive at clear decisions  that makes him or her a good doctor.

So, your next doctor visit how do you know he or she is a "good doctor"?

- Professional demeanor (chair-side manner)
- Professional training biography
- Confidence that instills trust in you, through eye contact and  body language.
- Clarity in educating you with the diagnoses
- Good listening skills and taking the time for that.
- Effective communicator of the course of treatment based on a clearly thought out clinical decision making path.

From one doctor to another....

I recently listened to an inspiring interview of a physician on the radio. It was one of those "highway moments" where you want to pull over because what you are listening to is so insightful and calls for all your attention.


Dr. David Loxtercamp , or simply "the country doctor" as he likes to call himself shared his inspirations and experiences which I see deeply resonate with myself in my clinical practice and I'm sure my colleagues can relate to as well.  You can listen to his interview and discussion here.


I have shared some of the quotable quotes that I carry with me now, since his conversations.  I have even taken the liberty and borrow it for my patients, but always try and reference him.

• "Health is not a commodity. Risk factors are not disease. Aging is not an illness."
•  "To fix a problem is easy, to sit with another suffering is hard."

• "Patients cannot see outside their pain, we cannot see in, relationship is the only bridge between. Time is precious; we spend it on what we value."

And two of my most favorite quotes:

• "The most common condition we treat is unhappiness. And the greatest obstacle to treating a patient’s unhappiness is our own." 
• "The foundation of medicine is friendship, conversation and hope.”

For anyone interested in knowing more, I recommend his book, "A Measure of Days: The Journal of a Country Doctor". Its definitely biographical as the title suggests, so be prepared for a slow, but interesting read.

Softer food, smaller bite-size - but of course follow the new USDA food plate guideline!

Summer is the time for corn-on-the-cob, but for someone with recurrent jaw pain and jaw locking symptoms, the thought of biting into corn-on-the-cob can be unpleasant and at time fear-invoking due to the risks associated with a painful jaw locking. 

To our Temporomandibular joints (TMJs) , activities such as yawning, taking a bite off a sandwich, can be extremely demanding in joint stability, integrity and conditioning. Also, chewing movements that are complex, whether it is chewing gum, meat or crunchy foods like carrots, can be demanding in terms of the musculoskeletal endurance.

The common advice that facial pain clinicians give for painful jaw symptoms is the recommendation to eat softer foods in smaller bite-size. Why softer food and not soft-soft food or hard foods? - The chewing system of TMJs and muscles need to stay active to the right extent avoiding fatiguing risks as well as avoidance-related muscle guarding and/or disuse risks. Why smaller bite-sizes? - For smaller bite-sizes, the range of motion of these ball-and-socket joints is limited to a mostly symmetrical hinge movement which facilitates stability thus avoiding a risk for locking with unstable extremes of range of motion.

So, with the new USDA plate replacing the food pyramid, which I'm all in favor of by the way, keep in mind to not take for granted, those well oiled biomechanical powerhouses in your face that help you enjoy your fruits, vegetables, grains and protein, one small soft bite at a time!

Does Ritalin/Adderall cause teeth grinding?

This is a question that gets frequently asked by my patients.  Attention deficit Hyperactivity disorder (ADHD) is the most common neuropsychiatric disorder diagnosed in children but more and more adults are also being diagnosed with this condition. Patients with this diagnosis also tend to have other comorbid disorders such as anxiety and obsessive compulsive disorder. Ritalin (Methylphenidate) and Adderall (Dextroamphetamine) are medications that have gained clinical traction for their effectiveness in the management of ADHD.

Based on systematic clinical observations, patients with ADHD tend to have higher co-occurrence of oral habits such as nail-biting, teeth clenching, a phenomenon also known with anxiety disorders. So, these patients on Ritalin or Adderall may already have a higher tendency for oral habits of teeth clenching or teeth grinding.

With respect to Ritalin and Adderall, teeth-grinding is not listed as one of the significant side effects by the manufacturers. The side effect listed is "involuntary muscle contraction" which can be only vaguely correlated for jaw clenching/ or teeth grinding. Indeed scientific research is also lacking in evidence for direct correlation.  However, plenty of anecdotal evidence exists, as well as published case reports suggesting that Ritalin especially can contribute to increased teeth grinding.

So what can we conclude?

• If you are diagnosed with ADHD by your physician, and are on either Ritalin or Adderall, inform your dentist about the new medication so that your dentist can observe for teeth wear pattern.
•  If you already know you grind your teeth, and you are beginning a new medication, obtain a night time mouthguard for teeth grinding through your dentist/facial pain specialist who can monitor your oral health and behavior for you.
• If you have ongoing TMJ disorder and you are beginning to take Ritalin or Adderall, inform your specialist on the new diagnosis and treatment plan, as increased bruxism can also potentially aggravate your TMJ disorder related symptoms.

Listing some references on this topic:

- Behavioral and orofacial characteristics of children with attention-deficit hyperactivity disorder during a dental visit, J Clinc Ped Dent (2006), vol. 30 iss. 3, pg. 183.

- Adverse response to methylphenidate in combination with valproic acid, J child & Adolesc Psychopharmacol (2000), vol. 10, iss. 1, pg.39.

Not coping with stress may increase teeth-grinding

An article that appeared in Time magazine cites a single study discussing the relationship of poor stress coping to increased teeth grinding. Both doctors and the scientific community have known this connection for years.

You can find the original Time Magazine article here:-

Not coping with stress may increase teeth-grinding

Although up to 70% of people who grind their teeth do not report having jaw pain or other TMJ disorder related symptoms, some people do experience jaw pain, and grind their teeth and recognize their difficulty in coping with stress.

The enamel (the outermost layer of our teeth) wears down in a distinct manner if you were grinding your teeth and this can be identified by your dentist. So if you recognize recent difficulty to cope with stress and you are experiencing jaw pain or headaches, talk to you dentist.

Teeth grinding as a response to stress is believed to a subconscious reflex driven by a part of our brain called the limbic system that co-ordinates all our primitive responses to stress. Cognitive Behavioral therapy and relaxation therapy through a trained health psychologist are very effective strategies  to decrease the distress from the teeth grinding behavior. Unfortunately, due to the social bias regarding these treatment options, people hesitate to seek the support. But with more scientific data shedding light on the benefits of these treatment options,  and with more and more health care professionals becoming aware of those benefits, patients can seek support from their dentists and doctors more readily.

So, thank you Time magazine for not feeding into popular myths but really featuring what is clearly important information that needed validation.

The headache connection..

In my clinical practice, I have learned to be not surprised by the many patients having TMJ related headaches. Yes. Headaches go hand in hand with TMJ disorders. About 80% of the patients with a TMJ disorder and or any other facial pain complaint have concurrent headache complaints.

How will I know my headache is related to my TMJ disorder?

Headache related to a TMJ disorder usually presents as a dull, pressure, ache that usually occurs in the temple region of your forehead, that may get worse with jaw movements, especially with the clenching of your teeth. All headaches need to be first evaluated by your family physicians before being treated as being related to your TMJ disorder.

How common is it to have a headache along with jaw issues?

Believe it or not, up to 80% of patients with jaw pain, experience headaches and most of the patient in treatment for their jaw pain, report a concurrent improvement in their headache symptoms.

I have migraines. Could those be related to my jaw/TMJ problem?

Clinically, patients do report more frequent severe headaches like migraines if their jaw pain has worsened in intensity. After having addressed their migraine complaint medically with a Neurologist, it is adviced to explore the possible association with their TMJ complaint with a TMJ and facial pain specialist.

I know I get a headache and I know its related to me clenching my teeth. Now what do I do?

Talk to your family doctor, or even your dentist. They may be able to refer you to a local TMJ/facial pain specialist for further help. Headache related to TMJ disorders,  commonly occurs because of tensed muscles in your temples that are really your jaw muscles located up there. So, a specialist would either make you a mouthguard known as a "Splint" to prevent the teeth clenching from contributing to a headache or may use physical therapy techniques to relieve the muscle tension and or use other tools including medications.


Until I get to see a doctor, what can I do to help myself?


First and foremost if you have a new headache that is severe, and you notice nausea, vomiting or blurred vision, PLEASE SEE YOUR DOCTOR ASAP. 


For a headache that feels like a "regular" tension headache, applying moist heat/cold, eating soft foods, avoiding chewing gum and consciously unclenching your teeth are all comforting to the muscles.

For further information, the American Headache Society (AHS) has useful information for patients suffering with headaches and the link to their website is posted on the side bar in this blog page.

For the official AHS summary for Temporomandibular disorder and Headache, you can click here:

http://www.achenet.org/education/patients/TemporomandibularDisordersandHeadache.asp