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

What does physical therapy have to do with the jaw?

The title of this post is a question I usually get in social situations whenever I tell people about my job. Physical therapy is usually associated with "torturing" post-surgical patients (apparently this is how the patients see it!), treating patients for back pain following car accidents, or providing massage therapy and ultrasound for painful muscles and joints. Since most people don't consider the jaw to be a "joint" like the shoulder, knee or elbow, this is a frequently overlooked area of rehab.

I am lucky enough to have discovered group of health care providers who value my contribution to the overall care of patients with TMD. Whereas TMJ specialists introduce the concepts of recognizing muscle tension, avoiding chronic behaviors that stress and strain the jaw joint, and stretching/strengthening the jaw, it is my job to teach patients HOW to do some of these things. Since TMD is frequently a contributor to headache and neck pain complaints, I also provide rehab for these areas of management. I find that the team approach is vital to improving patient outcomes, especially for an area with so many contributing factors to pain.

I am flattered to have been invited to contribute to this blog - I will try to contribute interesting tidbits and information to increase the available information about this condition!

Invited guest writers - The Team..

Talking about managing chronic pain is always incomplete without discussions on the need for multidisciplinary team intervention to treat pain. To reinforce this idea and to add in their thoughts about this field,  I have invited some wonderful health care professionals, I work with, to contribute to this blog. I look forward to engaging comments and discussions on the upcoming posts.

“ A marathon to run…” – Fibromyalgia and TMJ

It was a routine follow-up with Ms. G. I have seen her every three months for the past four years. Each time the interview begins with the same question: “ How are you feeling today?” "I still want to run that marathon" she said.  For Ms. G, her days are usually in shades of bad, very bad or better and having a good day was a dream she cherished, like her dream to run a 10K marathon once her health improves.

Ms. G is our everyday woman with a career and family to balance and an avid explorer of the outdoors. She loves hiking up on trails along the north shore and skiing cross-country in winter. But in the past four years, she has mostly spent her time indoor, on her recliner or in her bed, suffering in pain – in silence; and it was on one of those days spent in her recliner she dreamt of running her marathon.

Ms. G has a diagnosis of fibromyalgia.  The term was used to describe widespread pain, more as a “waste-basket” term, up until recent research has suggested it to be chronic pain condition with its own unique central mechanism (In Neuroscience, the word “central” is always indicative of having a closer relationship to brain and the neuronal networks).  Over three to six million Americans have Fibromyalgia. Sometimes, doctors feeling the pressure to have answers for every illness, try to escape the responsibility to support their patients with illness that have no answers.  Ms. G’s experience with doctors was unfortunately that for her fibromyalgia. Ms. G also had jaw pain on and off, which interestingly overlapped with her pain flare-up. Even the act of opening her mouth and eating hurt. Fibromyalgia and TMJ pain are co-morbid or conditions that can co-exist more often than others. 

So, in Ms. G’s treatment plan, there was pain management for her TMJ disorder, there was a good dose of motivation three times a day to cherish her dream and one day her discharge summary is sure to include the story of her finishing her 10K run. Until then, we look for answers and give her support so as to give her more “better” days than “bad” days.

Do you know any one who has fibromyalgia? If you do, may be we can choose to be sensitive and supportive of their pain instead of mocking and blowing it off to be mental illness.  Because, their pain is as legitimate as their dreams… as real as your dreams.  If you are some one with Fibromyalgia, do share your experiences with your comments.