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

Postpartum TMJ Pain – What Causes It & How To Get Relief
February 13, 2016 — by Dr. Donald Tanenbaum

Postpartum TMJ Pain, Donald Tanenbaum

As a practitioner focused on treating patients who suffer from the impact of TMJ problems, I am confronted with new challenges every day. One particularly challenging group of patients is women who suffer from postpartum TMJ pain. Here are some of my thoughts on why this population of patients is so commonly seen in my office.

The 3 Big Causes of Postpartum TMJ Pain

1- Sleep Disruption
Everyone knows that the presence of a newborn is incredibly disruptive to sleep. A fragmented, diminished and unpredictable sleep schedule leads to poor quality sleep. When sleep deprivation continues over many months or even years, pain symptoms can develop throughout the body as endorphin levels drop. Joint and muscle symptoms are common throughout the body including the jaw muscles and TM joints

If headaches in the temples are a common morning symptom suspicion of sleep bruxism must be considered. In addition, if the new mom does not quickly shed her pregnancy weight, she may be predisposed to airway problems, which further fragment sleep quality. Sometimes lingering postpartum TMJ pain is so severe that new moms seek many medical evaluations, most of them unnecessary other than for piece of mind.

2- Neck & Shoulder Strain & Fatigue
Next is the act of carrying around small babies. It seems easy at first but gets more and more difficult as a child’s weight increases. Carrying around the baby can be a challenge for anyone, particularly for small women. A 20-pound baby can cause neck strain and fatigue, which can result in pain. These neck problems very often initiate jaw problems. And thus the cycle begins.

Carrying a baby isn’t the only cause of neck and shoulder strain. Car seat challenges, pushing and folding heavy strollers (especially while holding the child in one arm), talking on the phone or cooking while holding the baby, and time spent sitting on the floor all add up to the potential for muscle problems to arise.

3- Emotional Issues
Last, but not least, the emotional issues than often arise following childbirth can be a significant cause of postpartum TMJ pain. Yes, having a baby is one of the most cherished events in life. But life as we know it is forever changed. For women whose independence started with high school graduation, college, grad school, and then career, the sudden loss of control that the new baby brings can cause tremendous emotional upheaval.

Plus, it’s no easy chore to be on call 24/7, even for the most hardy. For working moms the stress is two-fold. The hours away from her baby can create anxiety and the feeling of “being out of control.” Many new moms also sense a tremendous amount of guilt for being away from the baby every day.

Attending to poor sleepers, colicky babies, picky eaters and constant crying requires skills that must be learned, and there’s no manual.

As the challenges of motherhood continue, the limbic system (the part of the brain where emotions are formed) ultimately stimulates the fight or flight response and that gives rise to increased muscle tone, shallow and fast breathing, and daytime behaviors such as raised shoulders, furrowed brows, lip tension and clenched teeth, just to name a few. The end result, of course, can be the emergence of jaw pain, jaw stiffness, and/or headaches.

Help Is Available
There are no easy solutions for all of these challenges. However, when a new mom arrives at my practice suffering from TMJ problems, I have an arsenal of ways to help her get relief. They include:

  • Diaphragmatic breathing techniques
  • Jaw and neck exercises
  • Help to improve sleep hygiene 
  • Strategies to address awake and sleep bruxism
  • Meditation recommendations (TM is extremely helpful)
  • Referrals to Alexander and/or Feldenkrais specialists

I also encourage new moms to ask for help from their parents, siblings or even their friends. Taking some breaks from the daily obligations of caring for a newborn can go a long way to feeling better.

If you have a new baby and are suffering from postpartum TMJ, help is available. To find a dentist in your area that focuses on these types of problems, visit The American Academy of Orofacial Pain at

Good luck!

(This is a follow-up to a previous post 3 Reasons Why TMJ Problems Get Worse During Pregnancy

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.

3 Reasons Why TMJ Problems Get Worse During Pregnancy
February 2, 2016 — by Dr. Donald Tanenbaum

tmj problems worse during pregnancy, tmj when pregnant, tmj, donald tanenbaum

I have a very unique dental practice in that most of the people who pass through my door have TMJ problems, and 80% of them are women. The reasons that women are more prone to TMJ problems are very complex (a subject that I cover elsewhere in my website). Happily, I can report that after a treatment period of approximately three to four months, most of my female patients experience diminished and sometimes even the complete elimination of their symptoms. It is not unusual, however, for some women that were symptom-free for a long period of time to find their way back to my office when they’re expecting a baby. That’s because TMJ problems get worse during pregnancy.

Why do TMJ problems get worse during pregnancy? There are 3 main reasons:

  1. Sleep Disruption
    Most women discover pretty early on in pregnancy that their favorite position is no longer comfortable. In many cases, she can’t even find one sleep position that’s comfortable. Add to being uncomfortable, the frequent need to get up to urinate during the night and you have a situation that wreaks havoc on the sleep cycle. Disrupted sleep and brain arousals during the night seem to increase the likelihood of tooth grinding and clenching. Therefore, the pregnant woman that experienced jaw problems in the past is certainly now at risk again. The result is the typical list of TMJ problems: pain, jaw stiffness, morning headaches and jaw clicking and/or locking.
  2. Morning Sickness
    For many women unrelenting nausea and frequent vomiting characterize the early stages of pregnancy. Vomiting itself puts extreme pressure on the shoulder and neck muscles and causes the jaw to be violently thrust forward. Frequent vomiting can cause the jaw ligaments to be sprained and the jaw muscles to be strained. A traumatized jaw joint can be painful, stiff, and mechanically challenged. Although morning sickness usually lasts only a short time, that can be just long enough for TMJ problems to start or to reoccur.
  3. The Relaxin Hormone
    Relaxin is a very helpful hormone. It helps ligaments in the pelvis stretchier to accommodate the delivery of a baby. The ligaments become more “lax”. During the later stages of pregnancy relaxin becomes more and more elevated in the bloodstream. While relaxin’s main job is to prepare the pelvis, it also can make the ligaments in other parts of the body more elastic, including the jaw.Here’s a frightening scenario that is experience by many pregnant women:A visit to the dentist for a routine cleaning becomes a nightmare when her jaw gets stuck in the open position. Hello relaxin! Relaxin has made the jaw ligaments unstable and allowed the joint to open wider than normal. Sometimes assistance is even needed to get the jaw closed and that can result in pain and soreness for days, or even weeks. The fear of this scary event happening again is very stressful. (In these cases I teach some simple exercises that are very helpful.)

If you’re pregnant, have had TMJ problems in the past, and suspect that they are beginning to resurface, see your dentist before it gets worse. A custom-fitted night guard, a routine of jaw exercises, and some general relaxation techniques may just be what you need to relieve the symptoms and allow you enjoy the rest of your pregnancy.

If you are experiencing postpartum TMJ problems, please link to Postpartum TMJ Pain – What Causes It & How To Get Relief.


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Dr. Donald Tanenbaum is a specialist with offices in New York City and Long Island, NY. He is uniquely qualified to diagnose and treat problems associated with TMJ, jaw problemsbruxism, and more.


Why It’s A Bad Idea To Use Whitening Trays For Bruxism
January 26, 2016 — by Dr. Donald Tanenbaum

whitening trays with x


I recently came across an online press release with this compelling title: Teeth Whitening Trays From ProDental Functions As A Night Guard Against Teeth Grinding. The press release goes on to state: These teeth whitening trays help to stop the condition of teeth grinding which happens drastically at night when persons sleep.” In my 30+ years in practice I’ve treated thousands of people who suffer from the effects of teeth grinding. And I will tell you right now: it is a very bad idea to use whitening trays for bruxism.

Teeth grinding and clenching (clinically known as sleep bruxism) are caused by brain arousal during sleep. What causes the brain to become aroused? There is no easy answer. It could be any number of things: daily stress, a crying baby, chronic pain, breathing problems, too much light, a snoring bed partner…and the list goes on.

Medical practitioners face a big challenge when attempting to identify the exact cause of nighttime brain arousal. In my practice, the goal is to reduce, or even stop, nightly grinding. But that can happen only once the exact cause has been identified. This takes time and determination.

In the interim, most of my patients wear custom-fitted bruxism devices (also called oral appliances) at night. These bruxism devices protect teeth from the destructive impact of constant grinding and clenching. They diminish the loading forces placed on the jaw joints and diminish the contracture force of the jaw muscles.

However, bruxism appliances must be custom-fitted to do their job!

If you’re considering the use of whitening trays to treat your teeth grinding, as the above press release suggests, please beware. You may actually make your condition worse. Here’s why:

3 Reasons Why It’s A Bad Idea To Use Whitening Trays For Bruxism

1. Whitening Trays Are Too Loose

Whitening trays will rarely fit your teeth perfectly. In fact, they are designed to fit somewhat loose and because of that fact, they flop around in your mouth. You must clench your teeth to keep them in place. And the last thing you need is more teeth clenching.

2. Whitening Trays Are Too Short

Whitening trays that are designed for mass utilization will never extend all the way back to your rear teeth. As a result, when you clench or grind your teeth with one of these trays in place, all the force is shifted forward. Though it sounds like a good idea to prevent the back teeth from being engaged when clenching and grinding, this pattern of contact actually puts more pressure on your TM joints. Over time this can cause additional jaw stiffness, pain and even joint clicking and locking (which may not have been present before starting to wear the trays). And not only that; trays which do not cover rear teeth may cause your bite to change over time, adding another difficult problem to fix.

3. Whitening Trays Are Too Soft

Whitening trays are made of a soft, pliable material which makes them encourage more grinding and clenching. Patients call them “chew toys” when describing how they feel. In addition, because these soft trays don’t hold your teeth in place they can cause spaces to develop in between your back teeth. If this happens to you, you’ll forever be fishing food out from between your teeth with your tongue, further aggravating your jaw.

The Takeaway:

If you wake up in the morning with jaw pain, muscle stiffness, jaw clicking or locking, or sore teeth, you likely have sleep bruxism. You may be tempted to try the teeth whitening tray solution. After all, it seems to be adequate and inexpensive. But that decision will most likely lead to more problems with your teeth and jaw.

Please, take my advice: don’t be the victim of a phony pitch that can come back to bite you with a hefty dental bill later. Seek help by an experienced practitioner.

To find a dentist in your area that concentrates on sleep bruxism problems, visit The American Academy of Orofacial Pain at

When Is TMJ Surgery Needed? What You Need To Know
January 14, 2016 — by Dr. Donald Tanenbaum

When Is TMJ Surgery Needed_ Art

TMJ surgery has received some bad press lately. You may have read horror stories on the Internet about TMJ surgery gone bad. But countless patients would still be living with acute jaw pain and limited jaw motion if surgery not been an option for them.

I have spent the past 30 years focused almost exclusively on treating patients with TMJ and facial pain problems. I’m often asked how do I determine when TMJ surgery is needed. Here is my answer:

First, it’s important to understand that TM joint problems are orthopedic problems just like tennis elbow, for example. And, like all orthopedic problems, there are times when non-surgical treatments can fail. In my practice we always try non-surgical treatments before surgery is ever considered.

Sometimes, however, tissue injury in the TM joints can be very severe and involve compromised ligaments, stubborn inflammation, displaced cartilage, and/or arthritic and erosive problems affecting the bones. We use MRI and/or CT scans to evaluate what is going on.

After all non-evasive therapies have been tried, and when TM joint pain is due to inflammation, our one last non-surgical effort is often injecting steroids into the “hot” joint. This option is considered even when MRI or CT scans reveal structural damage in the joint.

This procedure is no different than injecting a steroid in a painful tennis elbow or rotator cuff. And its success is dependent upon how long you’ve experienced pain, the origin of your problem, the condition of the underlying bone, ligaments and cartilage, and your ability to avoid new injury to the joint. If progress is made after the first injection a second is usually administered in about three months.

However, when no relief is experienced after the first injection, the steroid method is put aside.

What If Steroid Injections Don’t Work?

If steroid injections are unsuccessful, the next option is usually arthrocentesis. Arthrocentesis is a procedure whereby the injured TM joint is in essence, washed-out. The goal here is to remove irritating chemicals that accumulate when you have tissue injury.

In addition, injured TM joints sometimes don’t move easily to sticky adhesions. So, the second goal of arthrocentesis is to break down these adhesions, which allow the joint to move more easily. When movement is easier so are the prospects of healing. Arthrocentesis is usually performed under local anesthetic and light sedation.

As with steroid injections, supportive therapies are put in place afterward such as oral appliance use, home treatments and exercises, dietary caution, oral medications and physical therapy.

When Arthrocentesis Is Not Chosen Or Fails Is TMJ Surgery Next?

Arthroscopic surgery is usually the procedure of choice in this instance. Arthroscopic surgery allows the practitioner to visualize the damage in your TM joint and effectively remove adhesions, smooth irregular bone, and inject steroids right into areas that are inflamed. We can also take tissue biopsies at the same time.

When performed by experienced hands, arthroscopic surgery is extremely effective in starting the process of natural healing which results in profound pain reduction and increased ease of jaw motion. Although usually performed under general anesthesia arthroscopic surgery is as an outpatient procedure.

Home exercises and/or physical therapy are always required after arthroscopic surgery.

When All Else Fails

In cases where the MRI and CT scans reveal extreme tissue damage, extensive bone erosions, and/or degenerative arthritis, we may need to surgically open the joint. Opening the joint enable extensive repairs to be made, but it requires special surgical skills and experience. And, like all of the procedures in this article, long-term rehabilitation is put in place and is required.

The Takeaway About TMJ Surgery

A full regimen of non-surgical care must always be attempted before TMJ surgery is ever considered. TMJ surgery can repair injured tissues, relieve (or even eliminate) pain, and improve your jaw function. But it should be always considered the last resort.

If you do need surgery, ongoing collaboration between your dentist, your surgeon, and your physical therapist must exist in order for you to heal and experience long-lasting results.

To find a dentist in your area that is experienced with TMJ problems, visit The American Academy of Orofacial Pain at

Can Bruxism Change The Shape Of Your Face?
November 9, 2015 — by Dr. Donald Tanenbaum

can bruxism change the shape of your face, donald tanenbaum, bruxism, jaw problems, teeth grinding, masseter

Here’s a story about a young woman named Sarah who came into my office a couple of weeks ago with her mother. Sarah is a 17-year old, college-bound, high achiever who was convinced that the shape of her face had undergone a dramatic change during the past few years. She was particularly concerned about her jawline. She felt that her jaw muscles looked bigger and more pronounced than before.

When I work with a new patient the first thing we do is sit down, relax, and have a conversation. I usually learn more during this conversation than I do from the physical examination. During my conversation with Sarah I asked her a lot of questions about her life and carefully listened to her answers. It didn’t take long for me to begin to see where her problems started. The physical examination reinforced my hypothesis.

In order to understand what happened to Sarah’s face we must take a look at the master muscles; they are the muscles that control the movement of the jaw. Masseters are like all other skeletal muscles in your body in that they will maintain a baseline shape and size when used normally. And, like all other skeletal muscles in your body, they will change in size and shape when over-used. It’s the same as when you workout your biceps in order to change the size and shape of your arms.

Each time you close your jaw or even swallow, you are using your masseters. Normal chewing and swallowing will not cause them to change in shape or size. What makes masseter muscles change, is when they are contracted over and above what is considered normal, over a long period of time. Since the masseters define the shape of your jaw, over-use behavior can actually change the shape of your face.

By chewing gum, biting your nails, biting your cuticles, chewing on pens, or even holding your glasses between your teeth, you are using your masseter muscles way beyond what they were designed for. Some people hold and clench their upper and lower teeth together during the day without realizing it and over a period of time this causes their masseter muscles to bulk-up.

Also of concern is sleep bruxism. Hundreds of thousands of people grind or clench their teeth while they’re sleeping. This excessive teeth grinding, jaw movement side to side-to-side, and/or clenching in a static, braced position plays a huge factor in the enlargement of the masseters and consequently, the shape of the jaw. So, the answer is:

Can bruxism change the shape of your face? Yes…

To reduce the impact of bruxism on the masseter muscles, I normally provide my patients with a custom-fitted oral appliance (also referred to as a night guard). The oral appliance is a very effective tool in reducing the impact of grinding and clenching. But an oral appliance will not stop over-use behavior.

Although Sarah wasn’t complaining about pain, soreness and stiffness are also common effects of bruxism. Imagine how sore your hand would be if ityou kept it in a fist for most of the day and night. Jaw over-use is just like making a fist in your face, and it can create excruciating pain for many people.

Let’s go back to Sarah. Through our conversation I was able to identify the main reasons that her jawline had changed so dramatically. It turns out that she is a long-time gum chewer, a nail biter, and a nighttime clencher. Sarah has literally been working-out her masseter muscles every day and night for years.

An oral appliance strategy as been put into place that will reduce the impact of Sarah’s sleep bruxism. Next, The next step is for her to change her daytime over-use behaviors. Today, Sarah is wearing the oral appliance at night and working hard to correct her daytime over-use behaviors.

An additional approach that could work for Sarah is Botox. Botox is a popular cosmetic therapy that has the potential to diminish the forces of nighttime bruxism. It works by diminishing the capacity of the masseters to contract, with the result often being a reduction in the bulk of the over-used muscles.

Today, Sarah is wearing the oral appliance at night and working hard to correct her daytime over-use behaviors. But before I will go forward with Botox for Sarah, she must convince me that she understands that if she does not correct the daytime over-use behaviors, Botox is not an option.

Here’s The Takeaway: If you have noticed changes in the shape of your face or your jawline, it’s probably not your imagination. Find a dentist that has special training in bruxism as soon as possible.

I invite you to follow me on Facebook, Twitter or LinkedIn to keep up with all the new research and case studies in this field (and with Sarah’s progress).



Does The TMJNext Generation™ Device Work?
September 22, 2015 — by Dr. Donald Tanenbaum

TMJ device


Every now and then a new product will hit the market that’s designed to assist in the management of the chronic pain problems that impact the lives of millions of people every year. And when it comes to pain caused by TMJ/TMD problems, one such product is The TMJNext Generation™ Device.

Having been sold in Europe for the past few years, this device is now available in the U.S. It is being aggressively marketed not only to dentists, but to other healthcare practitioners, as well. As a result, many physical therapists, chiropractors, physicians and wellness clinics are advertising that they provide the device.

Does The TMJNext Generation™ Device Work?

The TMJNext Generation™ Device is an ear insert which has been designed to create awareness in the patient of his or her jaw position. Here’s how it works:

First, impressions of your ear canals must be made. Although your dentist may have recommended the TMJNext Generation™, you may be referred to an audiologist (or another type of health care professional) that is willing to assume the liability of making the impressions, which may be outside of the scope of practice.

The impressions are made while your jaw is in a relaxed posture with your teeth apart. In this posture your ear canal will assume certain dimensions in volume and shape. These dimensions get smaller when you bring your teeth together or clench them.

The ear canal impressions will be used to create the custom ear inserts for you. The inserts feel comfortable when your jaw is in a resting posture, but when you bring your teeth together you feel an unpleasant pressure on the devices. The theory is that the uncomfortable feeling will get your attention and you will immediately relax your jaw. It’s like having a pebble in your shoe that makes it uncomfortable to walk.

For some people the devices might serve as a sort of reminder to keep their jaw muscles loose. In this way TMJNext Generation™ is essentially a biofeedback device. Anything that can help you keep your jaw loose during the day can be part of overall TMJ/TMD therapy.

Here’s the rub: Countless people who suffer from TMJ/TMD problems have NO NEED for daytime awareness because their jaw is always in a restful position during the day. It is at night while they are asleep that their grinding and clenching happens. For them, these devices could represent an unjustified expense. If physicians, chiropractors, physical therapists, and dentists who have limited expertise in the management of jaw problems are making decisions about the use of The TMJNext Generation™ Device, I’m afraid that overutilization is a real concern.

As of today I have not found scientific articles that provide an understanding as to how these devices could stop or diminish the impact of sleep-related teeth grinding and clenching (bruxism) which is the way many patients get in trouble. Since the devices can apply unpleasant pressure on the jaw joints during a grind or clench, one would have to assume that the irritation would merely wake the wearer up, as opposed to helping him or her stop the activity altogether. I don’t think that would have a favorable long-term outcome.

My limited distribution of these devices at the present time precludes an endorsement or negative commentary. As always, I believe that a careful assessment must be done to adequately understand the type of jaw problem of each patient and what the initiating and perpetuating factors appear to be.

Only with that information can the treating professional guide the patient with sound advice.

Photo credit:


Dr. Donald Tanenbaum is a specialist 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.

Can TMJ Patients Get Better?
September 14, 2015 — by Dr. Donald Tanenbaum

sad woman black and white


Over the past several months, I’ve had the opportunity to host many dental residents in my practice as part of a formal training program. At the same time, I have also worked with a number of practicing dentists from around the country who want to broaden their pain education. From this experience, two things have become very apparent to me.

First, Id like to focus on the dental residents, who for the most part, are recent graduates. They all have very limited practical knowledge about TMD/TMJ problems and have apparently been told in dental school that never can TMJ patients get better.

There is no reason why recent dental graduates should think that TMD/TMJ patients can never get better and here is why: these problems, though at times attached to challenging patient personalities, are essentially orthopedic in nature. This means that they involve muscles, tendons and joints. When viewed this way the most common diagnoses include muscle strains, muscle fatigue, muscle soreness, joint sprains, inflammation, and ligament- and bone-related compromises (which can include arthritis of one form or another).

The key then is to determine the primary cause of the compromise and whether or not there are other factors responsible for perpetuating the problem. This is where the evaluation process becomes so important and is not accomplished by pen and paper questions, but rather by sitting down and having real conversations with real patients.

Time and listening are whats necessary to gather the information essential to making the right determinations. Once achieved, TMJ/TMD problems can be addressed with understandable and practical therapies that involve and require doctor and patient participation. The time and listening formula is what distinguishes one practice from another.

Whether the recommended treatment is medication, education, dietary caution, exercises, injections, oral appliances, physical therapy, meditation or surgery, the process of healing can be quick, or can span months.

In my experience I estimate that half of TMJ/TMD problems are straight forward and solved with education and home therapies, one quarter are moderately complicated (but can respond wonderfully to formal treatment), and one-quarter are challenging cases impacted by the nature of the patients tissue injuries and his or her medical, social, and/or behavioral profile. I suspect that common knee problems carry with them the same statistics.

After spending a day in my office dental residents often say I never knew these patients could be helped.or I was told in dental school that caring for these patients is unrewarding and endless.These comments indicate that TMJ/TMD problems are a mystery for our young graduates. Unless dental schools start getting out the right message, nothing will change. In the interim, however, it is encouraging to see how many patients can be helped despite being told somewhere in their travels that there is no answer to their problem.

Practicing dentists with an interest in this area are another story entirely. They often end up in continuing education programs where the instructors preach unscientific dogma about how fixing a patients teeth and bite will fix the problem. After they attempt this often-complicated approach a few times in their practices, they usually realize that it simply doesnt work. At this point, its very common for the dentist to stop treating TMJ/TMD problems entirely, leaving behind some very discontented patients.

Long ago I was fortunate to discover that the vast numbers of patients who get relief do so without their teeth being ground-down or built-up. Today I see the frustration on faces of dentists who have tried these seductive approaches and when their patients don’t get better, realized that they were missing something.

The bottom line is that these problems are not big mysteries but rather understandable by practitioners, like myself, who have spent the time to learn and embrace the fact that jaw-related problems are orthopedic problems in nature and the accompanying pain emerges for specific (and often common) reasons. My practice continues to listen to, guide and educate our patients so they can be part of their healing process. And I hope that the time I spend with new graduates and practicing dentists will help to expand their understanding, as well.

Dr. Donald Tanenbaum is a specialist 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.