TMJ From Scuba Diving Or Snorkeling
February 27, 2017 — by Dr. Donald Tanenbaum

tmj from scuba diving, michael sinkin dds

During this time of year it is common for my practice to see many patients who experience symptoms of TMJ from scuba diving or snorkeling. In fact, it has been reported that between 15%-20% of the people who scuba dive or snorkel have some level of jaw problem.

To find out why, you first must understand the temporomandibular joints (TM’s) and how they function. Your TMJs are the hinges that connect your upper jaw to your lower jaw. They enable you to open and close your mouth in a smooth, unrestricted way. When functioning properly, your TMJ’s allow you to chew, talk, and yawn in comfort.

But because the TMJ’s are moved by muscles and stabilized by ligaments, any problem with those muscles and ligaments will have a negative effect on the function of your jaw and your comfort. People whose TMJs are overworked may experience pain, limited jaw opening, joint noises and sometimes even a change in the way their teeth come together. The symptoms are very similar to an overworked knee.

TMJ From Scuba Diving Or Snorkeling Is Very Common. Here’s Why:

Whether you scuba dive or snorkel, your lower jaw must come forward to secure your breathing mouthpiece in place. It’s a very awkward position and when held for a long period of time, it fatigues your muscles and strains your ligaments. The result can be soreness, pain and limited jaw function.

New divers are at the greatest risk for TMJ from scuba diving or snorkeling. The novice has a tendency to fiercely grip down on the mouthpiece for fear of it slipping out of place. This forceful clenching can set jaw problems into motion. And a poorly fitted mouthpiece is often a culprit, too.

Prevention & Treatment of TMJ from Scuba Diving Or Snorkeling

If you are a new or inexperienced diver here’s some advice: try to maintain a loose grip on your mouthpiece and always make sure it fits properly. (If you suspect it doesn’t…don’t use it! Trade it in ASAP.) If mild symptoms start to occur, don’t dive for a day or two. Try anti-inflammatory medications such as Advil or Aleve, if tolerated. And ice packs on painful areas for seven minutes several times a day can also help.

If experience severe symptoms and just a day or two off from diving doesn’t improve your condition, you should see a dentist who focuses on temporomandibular disorder. TMJ is the result of tired, tight, injured or sore muscles, inflamed tendons, or compromised ligaments, bone and cartilage. As a result, TMJ treatment is similar to what is offered by an orthopedist when managing a knee problem.

Here are some of the ways we treat patients with TMJ from scuba diving or snorkeling at my practice:

  • Limiting the overuse of the jaw by dietary restrictions
  • Identifying strategies to reduce daytime habits that may prevent healing such as clenching, nail and cuticle biting, gum chewing
  • Medications to reduce inflammation and muscle tension
  • Supporting the injured joints or muscles with an oral appliance
  • Home jaw exercises and self massage of jaw muscles 
  • Physical therapy if needed
  • Trigger point injections for pain and tension in the jaw muscles

It’s best to avoid TMJ from scuba diving or snorkeling by taking precautions such as loosening the grip on your mouthpiece and making sure it fits properly. Stop your diving activities if symptoms start and seek care to assure healing. The vast majority of our patients do heal and happily resume their diving activities after several months.

The Connection Between Tinnitus and TMJ
November 2, 2016 — by Dr. Donald Tanenbaum

the connection between tinnitus and tmj, donald tanenbaum


My dental practice has a unique focus. The majority of our patients come to us suffering with TMJ problems. The TM joint is the hinge connecting your jaw to the temporal bones of your skull, which are in located in front of each ear. Healthy function of this joint enables you to chew, talk and yawn. When the joint is inflamed, strained or unstable it can cause pain, limited jaw motion and a variety of jaw noises during motion. When the muscles that move the TM joint are compromised, similar symptoms may result, as well.

There is a connection between tinnitus and TMJ problems, too, and we see patients in my practice looking for relief. But before I get into the explanation of how tinnitus and TMJ are linked, I want to be sure you understand the nature and causes of tinnitus itself.

The connection between tinnitus and TMJ is real.

What Is Tinnitus?
Tinnitus Definition: The annoying sensation of hearing a sound when no external sound is present. Patients describe these sounds with words such as ringing, humming, buzzing, roaring, clicking and hissing. This sensation is constant for some people and intermittent for others, and it can be in one or both ears. For some sufferers the intensity of the sounds can vary from day to day while for others it is without fluctuation in intensity.

What Causes Tinnitus?
There are many known causes of tinnitus that include identifiable damage to the inner ear hair cells, age-related hearing loss, exposure to loud noises, earwax blockage, and changes in the health of the bones in the middle ear. Less commonly, tinnitus can be associated with Meniere’s disease, trauma to the head and neck region, and/or TMJ disorders. For some people, however, the cause is never discovered.

What Is The Connection Between Tinnitus And TMJ problems?
TMJ problems are essentially orthopedic in nature. The common symptoms of TMJ are many and can include pain in the jaw muscles or specifically in the jaw joints, limited jaw motion, jaw muscle tension and tightness, jaw joint clicking, popping and or locking, headache pain in the temples, and/or a bite that doesn’t feel normal. Tinnitus is a less common symptom. When TMJ problems, however, affect the ear, symptoms can be pain, stuffiness, and/or tinnitus.

The onset of these symptoms may be due to underlying medical disorders, emotional stress which drives muscle tension, disrupted sleep, traumatic events, periods of sustained jaw opening, sleep bruxism, and daily overuse behaviors and or neck postures. All of these factors can result in joint sprains, muscle strains, muscle spasm and /or inflammation.  Less common origins include a “bad bite.”

connection between tinnitus and tmj, donald tanenbaum











Why TMJ Problems Can Lead To Tinnitus (Or Make It Worse)
1. The nerves that serve the jaw muscles and jaw joint are also responsible for the function and tone of muscles that determine the size of the Eustachian tube and tone of the tympanic membrane. Alterations in the function of these two structures can be responsible for tinnitus.

2. There is one specific ligament connecting a middle ear bone (the malleus) to the jawbone.  When a TMJ problem changes the position of the lower jaw the malleus can be altered in its function due to ligamentous traction and that can lead to tinnitus.

3. The main nerve supply from the TM Joint has been shown to have connections to parts of the brain involved with hearing and the interpretation of sound. If TMJ problems alter the function of this nerve, it‘s quite possible that the brain will interpret normal sounds as abnormal and patients report tinnitus.

4. Worth mentioning is that because TMJ problems are often associated with neck problems, evaluations of the neck must be also part of an overall assessment. There is evidence that nerve endings in the neck make connections to the hearing centers of the brain. Ear symptoms therefore, have been shown to emerge as a result of long-standing neck problems or those created by acute trauma.

Determining If A TMJ Problem Is Driving Tinnitus Symptoms
Try to determine if your tinnitus symptoms are influenced by moving your jaw (chewing, yawning, talking, opening it widely, sticking it forward). It you notice a link, then it’s very possible that TMJ problems are at the root of your tinnitus. The same is true for head and neck movements.

TMJ Neck Treatment To Help Tinnitus
If your tinnitus is related to your jaw or neck, dealing with these problems will be very helpful. There are a host of treatment strategies available including reducing overuse behaviors and or postures (such as teeth grinding, nail biting, frequent computer work), exercises, home TENS therapy, muscle injections or dry needling techniques, Botox, the use of oral appliances to support your jaw joints and jaw muscles (especially at night), physical therapy, medications, meditation, mindfulness training, and diaphragmatic breathing instruction.

These treatments, if found to be helpful, may require several weeks or months to see maximum results.

As I mentioned before, tinnitus can be caused by damage to your inner ear, hearing loss, exposure to loud noises, earwax blockage, and more. If your doctor has not found a link between your symptoms to any of the above, it may be time for an assessment of your jaw and neck structures. There may, indeed, be a connection between your tinnitus and TMJ problems.

Here’s a directory of orofacial pain professionals around the world: American Academy of Orofacial Pain.

You can get more information about TMJ and ear problems here: TMJ and its Relationship to Ear Problems and Sinus Symptoms


Dr. Donald Tanenbaum is a dentist with offices in New York City and Long Island, NY. He is uniquely qualified to diagnose and treat facial pain associated with jaw problemsTMJreferred painnerve pain, and migraines. You can contact the office here.

Botox Injections For TMJ – 6 Things You Need To Know
October 6, 2016 — by Dr. Donald Tanenbaum

botox injections for tmj, dr donald tanenbaum, tmj doctor nyc

During the past few years in my practice as a dentist who focuses primarily on TMJ and orofacial pain problems, I have seen a lot of success using Botox injections for TMJ to treat muscle pain and oral nerve pain.

Botox is not suitable for every patient, however. Care must be taken as to when to use it, how to use it, and who is a good candidate. If you’re considering Botox as part of your treatment for TMJ problems, jaw pain, pain in or around your teeth, or because of a change in the shape of your jaw, please read on:

6 Important Things You Need To Know About Botox Injections For TMJ

  1. Botox is Not a First-Line Treatment for Jaw Muscle Pain
    First-line treatment for jaw muscle pain (and spasm or tightness) is dictated by a careful evaluation to identify why you have symptoms in the first place. For example, it may be necessary for you to change some daytime habits, postures and behavioral tendencies that fatigue the jaw and neck muscles.Or if you clench or grind your teeth at night you may need to wear a protective night guard. In addition, you may get relief from medications, home jaw and neck exercises, breathing exercises, meditation, a change in your diet, or all of the above.Muscle injections or dry needling would be next in line along with visits to a physical therapist, chiropractor or osteopath who would work to promote muscle comfort. The bottom line, however, is that you the patient, must participate in the process of getting better and Botox will not produce the desired goals if the underlying reasons for your pain have not been identified and dealt with.
  2. Botox Will Not Ease Certain Types Of Muscle Pain
    There are times when muscles hurt even though they have not been overused. When life circumstances, emotions or thoughts cause your muscles to tighten and ultimately ache, then Botox injections for TMJ will not likely help. Instead, counseling, talk therapy, cognitive behavioral therapy, and the like may be the right strategies to pursue.
  3. If You Currently Wear a Night Guard
    If you currently wear a night guard and still have morning symptoms of muscle pain or tightness, joint noises, locking, and/or pain, you may be a good candidate for Botox. This is particularly true if you find yourself biting hard on the guard when you wake up in the morning. Keep in mind however, that Botox will be most helpful if you continue to wear your night guard. Two strategies are better than one in this scenario.
  4. If You Can’t Tolerate A Night Guard
    If you have simply cannot tolerate a night guard (and have tried various types, with your dentist’s guidance) Botox injections for TMJ may provide meaningful benefit.
  5. If Your Jaw Muscles Are Too Big
    If your jaw muscles are just too big and visibly over-built, Botox may be an option. One of the predictable things that Botox does is reduce muscle bulk when used over time. Botox has been shown to be effective in producing a flatter and more natural-looking profile.You will likely need three Botox sessions in three-month intervals to achieve the best results. However, jaw bulk may creep back if the reasons your muscles become larger have not been identified and dealt with.
  6. If You Experience Persistent Oral Nerve Pain
    Small quantities of Botox may be helpful if you experience persistent pain in your gum tissue, at the site of a tooth or tooth extraction, or at other sites around your face. Nerve pain inside your mouth or in your face is often due to electrical discharge from the trigeminal nerve. Botox injections for TMJ into the painful sites (often called trigger zones) can provide real benefit, especially if you don’t respond well to oral medications. In spite of being relatively new, this type of treatment is showing promise.

In Conclusion

Botox has become a helpful component in the management of TMJ, jaw muscle pain and oral nerve pain problems. The important thing for you, the patient, is to understand that Botox injections for TMJ are not a cure-all. Careful assessment by an experienced practitioner remains the key to making treatment decisions that will result in a long-term positive outcome. If you choose Botox as first-line therapy without understanding the origins of your pain, you will likely be out of pocket quite a bit of money with nothing to show for it.

Related reading:


Dr. Donald Tanenbaum is a dentist with offices in New York City and Long Island, NY. He is uniquely qualified to diagnose and treat problems associated with facial pain, TMJ and sleep apnea. To make an appointment for a consultation, call: Manhattan: 212-265-0110, Nassau & Suffolk counties: 631-265-3136.


Can Braces Cause TMJ?
September 20, 2016 — by Dr. Donald Tanenbaum

can braces cause tmj, donald tanenbaum, temporomandibular
TMJ problems can be a real burden that leads to pain, limitations on eating and embarrassing jaw joint noises. In my practice as a dentist who focuses primarily on TMJ and jaw problems, patients often ask me, “Can braces cause TMJ?” Although there’s no easy answer, I’ll do my best to explain.

Can Braces Cause TMJ? Three Scenarios

If you’re concerned that braces are the cause of your jaw issue, you’ll likely fit into one of the following three scenarios:

Scenario 1: You finished orthodontic treatment less than a year ago and suddenly you have TMJ symptoms.

Let’s give this scenario some thought as there may be some concerns about what we call new bite relationships. Think about this: your teeth have been moved and have had to settle-in to new positions. That means your jaw muscles, tendons, joint ligaments, cartilage, bones, lubricating systems, and shock-absorbing disc all had to adapt to the new environment. Thankfully, most people experience no problems with this process.

But in some people the end orthodontic result can lead to asymmetric tooth contacts or tooth contact patterns that force the lower jaw into an awkward position when the teeth are brought together. Therefore, the jaw is consistently forced into postural positions while chewing that lead to sprains and strains. If this scenario occurs in a person who has daytime behaviors that prompt tooth contact or who has a history of night clenching or grinding, these awkward bite postures will have a greater impact and can lead to even more severe TMJ symptoms than are caused by the behaviors themselves.

If you fit into Scenario 1, the answer to the question, can braces cause TMJ? is Yes! You should to return to the orthodontist or dentist who moved your teeth. There’s a chance that to “shore up the foundation” a short phase of orthodontics or some dental procedures to provide more tooth contact symmetry can do the trick. If you don’t feel your complaints are being taken seriously, a second opinion is recommended.

In addition, you may need change your daytime over-use behaviors such as teeth grinding or clenching, wear a protective oral appliance at night, and perform jaw exercises. It’s important to identify any other risk factors that could play a role, as well. (See a list at the end of this post.)

Scenario 2: You have braces now and your TMJ problems just began.

Regardless of whether your braces are the traditional or the Invisalign-type removable aligners, if you experience occurrences of pain (beyond what’s expected during orthodontics) or joint noises and/or locking, you must report your symptoms to your orthodontist or the dentist providing your treatment. Your braces might not need to be removed, but instead adjusted to make sure your jaw is no longer stressed.(Also, it is important to be sure that the orthodontic process is not being compromised by outside factors, such as those that are listed at the end of this post.

Scenario 3: You had braces, but they were removed many years before your TMJ problems began.

Can braces cause TMJ if they were removed years ago? It’s unlikely that braces removed years before your jaw symptoms first started could be the primary or exclusive cause of TMJ. In fact, the vast majority of studies conclude that even if one’s bite is “off” for decades (one’s natural bite or an orthodontically-created bite) there is little chance this single factor is the cause of TMJ problems.

If your long-ago removed braces are not the primary reason you have TMJ, then what is? Something clearly has happened, likely over a long period of time that caused fatigue and overworked, sprained, or traumatized your jaw muscles and joints.

If you were my patient, I would conduct a full assessment and start by asking you some very important questions that fall into four distinct groups:

1. Did You Have An Injury?
The TMJs and associated jaw muscles can be injured the same way knee or elbow structures can. Were you injured on the athletic field or in a car accident? Did you have a recent medical procedure that kept your mouth open for a long period of time or in an awkward position? Did you notice sudden jaw pain or popping while eating, yawning, playing a musical instrument, or even singing? Did you recently have dental work performed or a challenging wisdom tooth removal that could have compromised your jaw structures?

2. Do You Over-Stress Your Jaw?
Over-use behaviors and head postures can impact the structure and stability of your jaw muscles and temporomandibular joints (your TMJs). Do you chew gum or bite your nails, cuticles, or pens? Do you hold your eyeglass frames between your teeth? Do you grind or clench your teeth at night and/or during the day? Do you have work-related neck strain? Do you have longstanding neck symptoms that include pain and muscle tightness?

3. Has Your Health Changed?
Changes in the your medical health can also be a source of challenge to your jaw. Are you on a new medication? Have you stopped smoking? Do you have a new neuromuscular, rheumatologic and/or autoimmune disease? Are you profoundly depressed or have anxiety? Have you been diagnosed with a chronic illness? Do you have problematic insomnia, migraines or fatigue? Have you changed your diet to one that requires more consistent chewing of tougher foods? Even merely being concerned about your health is sufficient to initiate jaw muscle tension and pain.

4. Are You Stressed-Out?
A fatigued, conflicted, and unhappy brain is a source of muscle tension and can have a negative impact on your nervous and immune system. That can lead to a lower threshold of pain. Do you have ongoing challenges at home and or at work? Are you caring for a sick child or parent? Is your marriage in trouble? Are there financial worries? The list of critical life matters that can cause changes in the way you sleep, breath and hold muscle tension throughout your body are endless. Any of these changes can cause jaw-related symptoms.

If you answered yes to any of the above, your TMJ symptoms are likely the cause of a number of factors. It is crucially important to discuss these with the orthodontist or dentist who is handling your case.

So, the answer to the question, “Can braces cause TMJ?” is “Yes, sometimes!”

If you are considering braces for yourself or your children, inform the dentist or orthodontist of any jaw problems before you start treatment. A thoughtful practitioner will make a careful assessment of the history and clinical characteristics of every patient before determining how to proceed.


For more information on TMJ and jaw pain, link here:
Temporomandibular Disorder
Jaw Problems


Is It TMJ or Fibromyalgia?
July 21, 2016 — by Dr. Donald Tanenbaum

Is it TMJ or Fibromyalgia, donald tanenbaum, tmj

The majority of patients in my practice arrive complaining of TMJ pain. For many their pain is over the jaw joints. While others complain of pain only in their jaw muscles. These separate, but related, pain sites represent the components of a true TMJ pain problem. In fact, whether the pain is focused over the joints or in the muscles, it’s almost always the result of very specific factors such as teeth clenching or grinding during the night or day, daytime behaviors such as nail or cuticle biting, poor sleep, strained respiration, and/or chronic stress and challenging life circumstances.

I do see many patients, however, who experience severe pain in the jaw and face, but who display no evidence of common risk factors typical in the patients who have TMJ pain due to a temporomandibular disorder. For these patients, their pain is real but the cause is different. A very large percentage of them have a diagnosis of fibromyalgia in their medical history.

Is it TMJ or Fibromyalgia?

Although a full understanding of fibromyalgia remains unclear, fibromyalgia patients typically have a very low threshold of pain throughout their entire body. The best analogy is to imagine what it feels like to put on a shirt when your back has been burned from multiple days at the beach. That’s what it’s like to have fibromyalgia. All the time.

As a result common activities such as chewing, yawning, talking, or even putting their face on a pillow produces face and or jaw pain. This daily pain may often leads them to brace the jaw muscles and fatigue them. This can result in motion limitation and thus mimics a common TMJ problem.

Treatment strategies for fibromyalgia patients are markedly different than for typical TMJ patients.

When I work with typical TMJ patients I can isolate the factors that caused their problems in the first place and then help to control them. But if you are a fibromyalgia patient, it is much more challenging to manage your face and jaw pain. Treatment must focus on helping you acquire higher pain thresholds.

Through research we’ve discovered that meditation, diaphragmatic breathing, restorative yoga, exercises, a positive outlook on life, and even laughter can all be beneficial for fibromyalgia patients. In addition, certain medications show promise – particularly those designed to enhance your own pain inhibitory systems by helping restore and/or bolster levels of serotonin and endorphins. Injections of Botox coupled with frequent jaw motion exercises also show promise for specific jaw muscle pain in fibromyalgia patients.

In summary, facial pain symptoms are not always the same and require careful assessment before conclusions are reached with regards to  diagnosis and treatment strategies. In my practice we see progress with both the common TMJ sufferer and those with jaw pain due to  fibromyalgia.

If you’re in pain and are are need to know if it is TMJ or fibromyalgia, and you live in the New York City area, please feel free to call my office for a consultation. Outside the area you can find a list of professionals through the American Academy of Orofacial Pain.

Dr. Donald Tanenbaum is a dentist with offices in New York City and Long Island, NY. He is uniquely qualified to diagnose and treat problems associated with facial painTMJ and sleep apnea.

What Is An Orofacial Dentist?
June 29, 2016 — by Dr. Donald Tanenbaum

What is an orofacial dentist


If you’ve never heard the term orofacial dentist, I’m not surprised. I’m one of only a few hundred formally trained orofacial dentists in the United States. That’s because orofacial dentists have not been terribly visible on the health care playing field. But that is changing.

Orofacial dentists like me treat patients who suffer with pain of muscle origin, joint origin, and nerve origin that is focused in the head, neck, mouth, face and jaw area. For example, we treat people who have chronic tooth and gum pain despite multiple dental evaluations and treatment. We treat very challenging problems related to the TM Joints which are characterized by pain, limited mouth opening capacity, jaw clicking and jaw locking (commonly called TMJ). Patients come to us with problematic headaches seeking additional care to complement treatment by their physicians and other health care providers. And in many cases, we see patients with pain in the nerves that supply the teeth, gums and other facial tissues.

At times we also are called upon to diagnose and or treat patients with complex medical problems that result in facial pain.

Why don’t more people know about orofacial dentists?

Because this specific area of dentistry has not been granted “specialty status” by the American Dental Association. It is specialty status programs in dental schools that enable dentists to become oral surgeons, endodontists (root canal), periodontists (gum therapies) and orthodontists (braces). Although efforts have been made at both the national and state levels to push through specialty applications for my field, success has so far been elusive.

And that’s why orofacial dentists are difficult to find. Patients who are in pain often seek advice from their primary care physicians, ENT doctors, neurologists, and oral surgeons. Sadly, these patients are often told that either “nothing is wrong” or they are provided care that falls short. That’s because all dimensions of their pain problem have not been considered.

In my office I see suffering patients who have been in pain for months (sometimes years) before they finally find their way to me.

To help our patients, orofacial dentists rely on a wide variety of treatment options including education, medication, therapeutic injections, oral appliances, and muscle and joint rehabilitation therapies. Patient education is crucially important in my field as many of the problems we treat in the jaw muscles and joints are the result of daytime jaw overuse behaviors and sleep related teeth grinding and clenching. Most orofacial dentists have a strong relationship with physical therapists, clinical psychologists, pain management physicians, psychopharmacologists, chiropractors and even acupuncturists and leaders of meditation programs. All of these together allow us to successfully care for our patients’ individual needs.

And here’s the big bonus of going to an orofacial dentist: We often validate the fact that your pain is not only real but is also helpable despite past treatment failures. I believe that just knowing that there’s an answer starts making my patients feel better right away.

I predict that in not too many years orofacial dentistry will finally achieve the specialty status it deserves. Not only will patients be better informed and have more access, but more dental students will more often choose it as their field of concentration.

If you or someone you know has been suffering you can find an orofacial dentist in your area by linking to the American Academy of Orofacial Pain at

Dr. Donald Tanenbaum is a dentist with offices in New York City and Long Island, NY. He is uniquely qualified to diagnose and treat problems associated with facial painTMJ and sleep apnea.

Botox For Jaw Reduction: The Real Story
June 2, 2016 — by Dr. Donald Tanenbaum

BOTOX for jaw reduction, bettheny frankel, donald tanenbaum, tmj, bruxism

News Flash! Bettheny Frankel Explains Why Her Face Has Changed: “I Get Botox In My Jaw.”

That headline has been winding its way through the web in the past few weeks. I must admit that when I first saw it I had no idea who Ms. Frankel was (I had to ask my wife). But as an expert in jaw problems and Orofacial pain, and one that uses Botox for jaw reduction in my practice, the headline stopped me in my tracks. It’s a topic discussed at lectures and in medical journals, but I have never seen it in mentioned in mass media before.

The article goes on to explain that the reality TV star was encouraged by her dermatologist to consider getting Botox injections in her jaw. The goal was to reduce the size and shape of the jaw. It had become bulky as a result of many years of tooth grinding.

Now, if you are about to jump on the phone to your dermatologist and ask about injections of Botox for jaw reduction you need to know a few facts: 

Here’s how your jaw works: The masseter muscles (define your jaw profile) combined with the muscles in your temples and the jaw joints (the “TMJ”s) all work together to enable you to open and close your mouth. They help you to chew and to speak. But…when they are used too much all kinds of problems can occur. These problems can be sore jaw muscles, headaches in the temples, sore teeth, jaw clicking and locking, diminished jaw motion, ear pain that occurs without an ear problem being identified, and more. What’s more, the size and shape of your jawline can change.

That’s what happened to Bettheny Frankel.

While Botox has a prominent place in my arsenal of treatment methods, Botox alone cannot change the behaviors or risk factors that can cause your jaw to change shape. Botox doesn’t cure the source of the problem. In order for that to happen, you must stop overusing your jaw muscles.

For the average person over-use activities are teeth clenching and grinding. This can happen during the day (called Awake Bruxism) or at night (Sleep Bruxism). Or both.

In addition there are many daytime jaw overuse behaviors. Chewing gum, biting your nails or cuticles gnawing on a pencil, or simply clenching your teeth together will engage your muscles.  When your teeth come together, you are making a fist in your face. Imagine what can happen after hours of making that fist on a daily basis!

During sleep, teeth clenching and grinding can occur for a multitude of reason, most of which are out of your control.

Here’s the good news: Jaw over-use behaviors during the day can be changed. In addition, we continue to get better at identifying the risk factors that may be driving your sleep bruxism. Experienced TMJ/Orofacial pain dentists, like me, have gained valuable insights into these problems leading to effective treatment strategies.

The treatment options can range from natural supplements, sleep hygiene programs, prescription medications, deep breathing exercises employed during the day and before bedtime, formal meditation training, oral appliance strategies that introduce different appliance designs during the course of the week, jaw and neck exercise programs and injections. These injections can include the use of Botox.

Here’s the bottom line: Botox after several injection sessions can prevent the jaw muscles from contracting forcefully. That leads to more slender and less bulky muscles. Botox injections can return your face to its previous proportions. But, if you want long-term success Botox must be surrounded by other supportive and complementary care. Because…if you don’t stop and/or reduce your daytime jaw muscle overuse and sleep bruxism, your jaw muscles will inevitably bulk up again.

So, go ahead. Talk to your dermatologist about Botox for jaw reduction. But also get a referral to a TMJ/Orofacial pain dentist who will help you maintain your normal jawline for life.

Good luck!

Read about the various methods used to correct jaw over-use behaviors:
TMJ Treatment
Can Bruxism Change The Shape Of Your Face? 
Case Study: 10 Years of Teeth Clenching 
Can TMJ Patients Get Better? 

Chronic Orofacial Pain – The 60/40 Rule
May 27, 2016 — by Dr. Donald Tanenbaum

Chronic orofacial pain, donald tanenbaum,

Every morning upon my arrival at work I glance at the list of patients due to be seen that day. My patients are primarily people who seek treatment for chronic orofacial pain. Some of them will be scheduled for a follow-up assessment and/or treatment. Others are first-time patients who seek answers to a problem that has recently emerged. And some are looking for answers to a chronic problem that has lingered despite self-directed care and/or prior interventions by other medical, dental, and health care providers.

With the knowledge that many of these patients suffer from headaches, muscle- and joint-related jaw disorders, persistent and stubborn toothaches, and/or nerve pain disorders, you would be right to assume that the treatment options for each would be very different. In some ways that thinking is accurate. To care for each of these problems the treatment choices and sequencing will vary to a considerable extent.

However, if success is to be realized there is one crucial element that must be considered. I call it the 60/40 Rule in the treatment of chronic orofacial Pain.

The 60/40 Rule In The Treatment Of Chronic Orofacial Pain Explained

The 60/40 Rule is this: the patient and the provider must share the responsibility of implementing the care plan. Sometimes the patient will do 60% of the work and the provider will do 40%. Sometimes that will be reversed. It all depends upon the nature of the patient’s problem.

I allude to this concept in my book Doctor, Why Does My Face Still Ache?Many of my colleagues who devote their energies to treating TMJ and chronic orofacial pain patients also embrace this concept. However, recently at a conference sponsored by the American Academy of Orofacial Pain it was asserted by one of the keynote speakers that an 80/20 Rule in regard to the treatment of chronic orofacial pain is the correct ratio. In his mind the patient should be responsible for 80% of the work and the provider for 20%. Though this an understandable goal, clinical research, which has consistently concluded that only 25% of chronic pain patients will only do 50% of what is required to make progress this 80/20 Split appears to be an unlikely reality

In my practice the 60/40 Rule has been most helpful when treating patients with facial and jaw pain of muscle/ joint origin, often called TMD problems. The origin of their problems is related to persistent tightness and fatigue of the jaw and neck muscles combined with overuse-driven instability of the temporomandibular joints.

A multitude of risk factors are most often associated with these problems which include life circumstances, tension, emotions, acquired behaviors, food selections that overwork the muscles and TM joints, habitual and work-related postures, poor breathing dynamics, and loss of sleep quantity and quality. Taken all together you can readily see how the 60/40 Rule of shared responsibility makes sense.

Thankfully, I have an arsenal of treatment options at my disposal to help patients get relief from chronic orofacial pain.

Here are some of them:

  • Postural retraining
  • Daily home exercises
  • Home muscle massage
  • Elimination of destructive daily behaviors and habits
  • Diaphragmatic breathing strategies
  • Formal meditation training
  • Movement therapies such as Feldenkrais or The Alexander Technique
  • Improvement in sleep quantity and quality
  • Medication
  • Oral appliances that support and rest muscle and joint injuries

This collaborative approach between the patient and the provider is essential for success. When the responsibility is shared, patients own their successes and in addition, are more open to share their disappointment if treatment fails.

The 60/40 Rule in chronic orofacial pain treatment ensures that patients are fully engaged in their own treatment and this sets providers free from an expectation that they are fully responsible to fix or cure a chronic problem that may not have an easy solution. The 60/40 Rule must be explained at the outset of treatment when both patient and practitioner are the most focused on the challenges that lie ahead. This is particularly true if the patient has experienced treatment failure in the past.

As new knowledge indicates that chronic pain problems are best treated with interventions that confront the nervous system, the immune system and the emotional brain, a collaborative approach to care is now even more critical. Patients and providers that embrace The 60/40 Rule will be the beneficiaries of treatment that is both successful and lasting.


Dr. Donald Tanenbaum is a dentist with offices in New York City and Long Island, NY. He is uniquely qualified to diagnose and treat problems associated with facial painTMJ and sleep apnea. To find an orofacial pain expert in your area, link to the American Academy of Orofacial Pain here:

TMJ Problems During Invisalign Treatment
May 16, 2016 — by Dr. Donald Tanenbaum

TMJ problems during Invisalign, TMJ, donald tanenbaum, tmj doctor, invisalign


Modern technology has changed nearly every aspect of dentistry during the past ten years. The world of orthodontics, in particular, has seen incredible advances that allow teeth to be moved in a revolutionary way. Because of software technology dentists can now simulate the tooth movement steps that are necessary to go from starting point to end point before treatment has even begun. This remarkable technology is known to most of us as Invisalign.

Invisalign has not only changed the way teeth are moved, it enables many more dentists than before to offer tooth movement services. This is a huge shift in the way orthodontic treatment is delivered. And for millions of people Invisalign is more desirable than traditional braces. Therefore, it’s not surprising that along with the wonderful outcomes of Invisalign, some problems would arise.

More Patients Experiencing TMJ Problems During Invisalign Treatment

My practice is made up mostly of patients that suffer from disorders of the temporomandibular joint, most commonly referred to as TMJ. One of the significant risk factors that may initiate a TMJ problem is the presence of frequent and aggressive tooth contact during the day and at night. These tendencies are called awake bruxism and sleep bruxism respectively. Before the popularity of Invisalign I normally saw a small proportion of patients every year that were actively involved with orthodontic treatment.

But recently I have seen an influx of patients with TMJ symptoms that emerge during Invisalign treatment. They represent all ages: teens, adolescents and adults. And they arrive with a combination of jaw muscle problems and jaw joint-related problems. From treating these patients I have begun to see a pattern emerge. Let me explain:

Patients in Invisalign treatment must wear their upper and lower aligner trays on a nearly full-time basis. The only exception is while eating. These clear aligners are made from a very rigid material that is relatively thick. Consequently, they take up a considerable amount of the free space between the upper and lower teeth, even when the jaw is in a relaxed position. For some patients the upper and lower aligner trays are always in contact, which means their jaw muscles are always contracted in braced state. Over time these contracted muscles can become sore, painful and tight. In some cases the jaw joint gets involved as well with symptoms such as popping, clicking and locking. And that’s what happened to Paula.

Paula is a 56-year-old who arrived at my office in a state of panic. Her jaw had locked and she was in considerable pain. Paula told me that only two months into her Invisalign treatment she had begun to experience jaw tightness and jaw joint noise upon arising every morning. Reporting it to her dentist, he assured her that her problem was likely not related to Invisalign, as he had “never seen this before.”

Although concerned, Paula pushed ahead with Invisalign until one morning she woke up in tremendous pain with a locked jaw. During our consultation it became apparent to me that her Invisalign trays had prompted her to her jaw in a braced jaw position during the day and a clenched position at night. Because Paula’s history revealed no other risk factors, it is likely that her jaw muscles and jaw joints were compromised due to repetitive overuse.

Paula is not the only patient I’ve seen in the past few weeks with TMJ problems during Invisalign. Take into consideration Nicole, who is 13-years old. Nicole had a minor jaw click before starting Invisalign. She wore her aligners for only a short period of time before her minor click became out of control and she was in tremendous pain. During her consult I recognized that with the aligners in place, Nicole could not maintain a relaxed jaw posture. It is, therefore, easy to understand why her previously minor jaw problem had escalated during Invisalign treatment.

Many people have a history of tooth clenching or consistent teeth contact before they ever enter into Invisalign treatment. And some people don’t even know they do it because they don’t experience the typical symptoms. For these folks the introduction of Invisalign trays makes it very hard to maintain a neutral and restful jaw position and the risk of TMJ problems is very real.

How To Prevent TMJ Problems During Invisalign Treatment

The best way to prevent TMJ problems during Invisalign treatment is to ask your dentist some very specific questions before you make the decision to go ahead. Here are some sample questions:

  • YOU’VE HAD TMJ PROBLEMS IN THE PAST: “I have had jaw problems in the past. Is Invisalign the best choice for me?”
  • YOU DON’T KNOW IF YOU CLENCH OR GRIND YOUR TEETH: “I don’t know if I clench or grind my teeth during the night. Can you check for signs before I decide to start Invisalign?”
  • YOU’RE ENTERING INTO A STRESSFUL PERIOD IN YOUR LIFE, such as moving or a divorce: “I’m going to be under a lot of stress in the near future. Should I wait until life is calmer to begin the Invisalign treatment?”
  •  YOU’RE ON A MEDICATION THAT COULD CAUSE MUSCLE TENSION such as Adderall. “I am currently taking Adderall. Could that impact my treatment?”

You may have your heart set on Invisalign, but it’s best to know for sure that it’s right for you before starting. If you are in the midst of treatment I recommend that you make great efforts to be as mindful as you can to keep your trays apart during the day. Report concerns about night clenching to your dentist immediately if you suspect you are doing it.

More than anything else: choose a dentist that you trust and who listens to you and addresses your concerns. It’s better to be safe than sorry.

Dr. Donald Tanenbaum is a dentist with offices in New York City and Long Island, NY. He is uniquely qualified to diagnose and treat problems associated with facial painTMJ and sleep apnea. To find an orofacial pain expert in your area, link to the American Academy of Orofacial Pain here:


6 Options For Sleep Apnea Treatment  
February 26, 2016 — by Dr. Donald Tanenbaum


sleep apnea treatment, donald tanenbaum, osa

In the United States it is estimated that 50-70 million adults experience insufficient sleep on a regular basis, with sleep apnea being one important cause. Depending on whom you ask (sleep physician, dentist, respiratory therapist, ENT surgeon, oral surgeon, dietician) you’ll get a wide variety of opinions on the best sleep apnea treatment options.

Regardless of which treatment is chosen to address apnea, attention to nasal breathing is the key. The oxygen that passes through your nose is filtered, warmed, humidified and combined with nitric acid, all of which increase the percentage of oxygen absorbed in your lungs. In my practice, we work hard to combine the best of multiple treatment strategies to result in outcomes that speak for themselves. We consistently hear commentary that indicates that the treatment strategies  employed are truly working. It is not uncommon for my patients to tell me how much better they sleep.

“For the first time in ten years I wake up refreshed and I no longer fall asleep at my desk at three in the afternoon.” 

With a focus on individual attention and quick responsiveness to a patient’s needs we, often treat these problems with multiple therapies; sometimes during the same night and/or week. The successful outcomes of this approach have become the foundation of our care. These are the 6 sleep apnea treatment options that my office relies upon. 

6 Options For Sleep Apnea Treatment

1. CPAP (Continuous Positive Airway Pressure)

CPAP continues to be first line therapy for most severe and some moderate apnea patients. The problem is that more than 50% of those who choose CPAP discontinue using it within 6-12 months. In most of these cases, it is because they can’t tolerate the facemask (or even partial mask) due to feelings of claustrophobia, the noise of the machine, or its interference with comfortable sleep positions.

For others, the airflow can be cold and feel dehydrating, which prompts them to remove the mask in the middle of the night. Although quieter machines with built-in humidifiers and heaters are now available, leakage of the masks often produces distressing drafts across the face and less than adequate efficiency.

For young patients, the CPAP sleep apnea treatment option often does not sit well, especially when dating and establishing new relationships. As a result, compliance suffers.

2. Oral Appliances

[Oral appliances] (or MRDs) are mouthpieces that move the jaw forward and subsequently move the tongue base forward. This is designed to keep the airway open. These devices are most effective when custom-made, adjusted, titrated and watched over by a dentist with expertise.

This sleep apnea treatment option has been shown to be extremely effective in patients with mild and moderate apnea and less problematic sleep-related breathing disorders, which are often associated with social snoring.

Approximately 25% of my patients who use an oral appliance will alternate with CPAP. Sometimes switching randomly during the week. It is also commonplace for some of my patients to go to sleep with CPAP then switch to the oral appliance in the early morning hours. This way they get the best of both worlds. In many cases a patient will use an oral appliance when traveling instead of transporting his or her CPAP machine.

These strategies help minimize the complications of full time oral appliance which can include as jaw discomfort, bite changes and moving teeth.

Note: It is essential that people who use oral appliances be monitored by their dentist. Monitoring by home pulse oximetry and home sleep studies ensure the effectiveness.

3.  Nasal Plugs

Some of my patients have had success with nasal plug therapy called Provent. Nasal plugs make it easy to breathe in, but hard to breathe out. This leaves some air chambered (like the air in a balloon) and supports the soft nasal tissues which can collapse and cause apnea.

When tolerated, nasal plugs are a worthwhile option, but require clear nasal pathways to work. In a patient who has nasal obstructions due to a deviated septum and/or enlarged turbinates (the shelves on the inside of the nose) the complaint “I was suffocating with the plugs in place” is not uncommon. 

Recently a patient developed jaw soreness wearing a night oral appliance, switched to this option with success, and is now splitting the week between these two options.

 4. Positional Apnea Aids

Many people experience breathing interruptions only when they are sleeping on their backs. To keep a patient from sleeping on his or her back, I recommend sewing two tennis balls into a tube sock and attaching it to the back of pajamas. The discomfort of the tennis balls forces the patient to stay on his or her side.

In one study, 38% of people who tested this method were still using it six months later.

Body positioners are also available and can be purchased online. This effort to promote side sleeping is essential and when used with oral appliances, can reduce the amount of jaw positioning required. This is what we strive to achieve.

5.  Weight Loss

A big risk factor in the development of obstructive apnea is obesity. Since stress often promotes overeating, I have begun to put into place programs that address stress-related behaviors. The challenge here is to build and maintain collaborative relationships with other health care providers, as well.


Sleep apnea treatments used in combinations seem to be the best way to address the problem at this juncture. The key to more successful outcomes in the future will require the integration of medical, dental and other health related practitioners. This still remains to be achieved, but we are getting closer.

In the meantime, I will continue to bring together the latest ideas and technologies available and will share them with you here.

Note: The Centers For Disease Control and Prevention has designated insufficient sleep as one of our most serious public health problems. To find out more: []

Dr. Donald Tanenbaum is a dentist with offices in New York City and Long Island, NY. He is uniquely qualified to diagnose and treat problems associated with facial painTMJ and sleep apnea