Thursday, April 11, 2013

My TMJ Odyssey

    Around the age of 20, my jaw started clicking occasionally when I opened it or ate something hard to chew. It wasn't terribly bothersome at first but over the course of several years it degraded to me being unable to open my mouth without feeling like I was breaking my jaw. I couldn't eat ANYTHING without my jaw popping. I couldn't even kiss my husband or talk without pain. While my jaw was disintegrating, I also had headaches everyday, constant pain in my jaw, painful and stuffy feeling ears and pain in my neck and shoulders. I did do some research on the internet about TMJ (Temporomandibular joint) disorders to see what the options were. I had my only two wisdom teeth removed when I was 23, hoping that it would help. It didn't. Everything I found said surgery or tooth remodeling were the only options and that it was expensive with no guarantee that it would work. After 6 years the pain and inability to function normally finally got to the point where I had to do something about it. I was living in Nashville, TN at the time and I went to my regular dentist who had some familiarity with TMJ disorders but she did not treat it. She evaluated me and immediately wrote me a referral to Dr. H Clifton Simmons DDS a TMJ specialist in Nashville.

    Dr. Simmons has a busy practice and it took three months before I could get in for an evaluation. At the evaluation, I filled out a questionnaire with all kinds of questions about pain and symptoms of TMJ. At this point, I did not know that nearly all of my pain was actually linked to the problem with my jaw. In a two hour  appointment Dr. Simmons explained what had happened to my TMJ, how all of my symptoms were related to my TMJ, what I could expect with treatment and how much it would cost to treat it. 

In a person with a healthy TMJ, the jaw works like this:

The head of the mandible sits in the socket with a disk of cartilage on top, cushioning it and preventing bone from rubbing on bone. When you open your jaw that disk slides forward smoothly with the head of the mandible. Dr. Simmons told me that at some point I had suffered an injury to my TMJ and caused the head of the mandible to press against the back of the socket, compressing all of the nerves and blood vessels in the joint and causing pain. My jaw functioned like this:

So every time I opened and closed my mouth, the cartilage pad slipped over the head of my mandible, making an audible pop. Then when I closed my mouth again, the disc slipped back over the head of the mandible, again making an audible pop. Each time the disc got squeezed out of place, I was basically dislocating my jaw. If you've ever dislocated a joint (an elbow, shoulder, etc), you know that you can't move that joint without pain until it is reduced (put back in place) and that the reduction itself is also very painful. Dr. Simmons' theory is that because there are only two joints in the head (the mandible and neck), when one of those joints is injured, all of the muscles in the head and neck go in to spasm and it results in headaches. He said that it was very likely that with treatment, I wouldn't need my morning aspirin just to dull the constant ache in my head. He also said that the ear canal is located just behind the mandible head and when it is compressing the nerves in the joint, it also compresses the ear canal and can cause pain and a "stuffy" feeling in your ears. So basically, he told me that all the pain that I had been suffering through for 6 years stemmed from my TMJ disorder. 

So then we talked about how he treated TMJ disorders. His approach is to reposition the lower jaw forward to relieve the pressure on the nerves and blood vessels using first splints and then braces. Phase 1 was splints. First, they make a splint that sat over my bottom teeth to adjust my bite forward (I previously had a small overbite). It looked something like this:

I wore this splint whenever I was awake. It works because about 3 times a minute, everyone gently clenches then unclenches their teeth when they swallow their saliva. The top of the splint was formed to match my top teeth in the desired bite position. So every time I swallowed my jaw moved in to the corrected position and then came back to rest. I also had another splint for sleeping. This splint was all one solid chunk of acrylic that locked all of my teeth in the desired position. When you sleep your jaw slips back (because you are relaxed and laying on your back) and back is the opposite of what we were going for. 

I noticed improvement in almost everything almost immediately. It took about 2 months for the popping to stop but it was instantly lessened. My daily headache stopped, my ears felt normal and the pain in my neck lessened. I still get headaches and neckaches from time to time, but I'm pretty sure that everyone does on occasion. Once my symptoms were stabilized (Dr. Simmons calls it "as good as it's going to get" because not every one gets to 100% symptom free) for six months we were ready to move on to Phase 2: moving the teeth to fill in the repositioned gaps. 

At this point in my treatment, I moved to back home to Ohio. When I told Dr. Simmons I was moving I found out that there is nothing standardized about TMJ treatment and that if I wanted to continue my treatment, I had to keep coming back to Nashville every three months. Obviously I didn't want to go back to being in pain every day so I moved on to Phase 2. 

Phase 2 began by cutting off the backs of my splints and putting brackets on them similar to this:

I had to keep rubber bands on them (of varying strength) all the time to close the gap that moving my jaw forward created. This was the longest part of the process because they did one tooth at a time. So every three months they cut of more of my splints and put more brackets on my teeth. Complicating things for me were my two crowns on my left side molars (from cracking my teeth on a tongue ring in my intemperate youth, just say no to mouth jewelry). Dental adhesives do not stick well to crowns so they put metal bands around them, but they still have to be cemented in place and it just never worked well for me. I was constantly pulling the bands off my crowns and because I was not in Nashville and couldn't afford to travel there more than every three months, treatment got set back a lot because I couldn't keep tension on the teeth on the left side of my mouth. Eventually though, my teeth had filled in the gaps in the back. It was finally time to finish up with the front teeth as I had developed an "open bite" that had to be corrected if I wanted to be able to bite things with my front teeth. So they put brackets on all of my teeth and strung them up. Lord, it was painful when they tightened them. I had metal brackets in the back and tooth colored ceramic in the front. The ceramics did much less damage to the inside of my lips but they also got broken much more easily.  I never needed braces due to crooked teeth or anything like that, so this was my first experience with braces and I hated every minute of it. It took twice as long to clean my braces after eating as it did to eat. I couldn't eat the things I wanted because I broke brackets off so often. I'm still convinced I have some sort of adaptation in the enamel of my teeth that makes them more slippery than every one else's because I had at least one bracket off (and the bands on my crowns) every time I went to Dr. Simmons. Over the next year and a half, my teeth were moved to their final positions. Last week, they removed my braces, put in permanent retaining wires and made me a new sleep splint that I will have to wear for the rest of my life. My teeth look great, they are beautiful and straight but really I don't care about that, they were pretty straight before treatment, I'm just thrilled that I can eat a bagel, kiss my husband and talk to people without dislocating my jaw. It has most definitely been worth it.

As far as how much this shit cost- a lot. I don't actually remember the exact prices but Phase 1 was around 2,000.00 and Phase 2 was around 4,500.00. Insurance covered nothing. Dental insurance doesn't cover it because it's a joint disorder and my medical insurance at the time would not cover Dr. Simmons as he was not on their preferred list of providers (the two on their list that treated TMJ both treated TMJ by surgical breaking of the jaw, something I did not want to do). That also does not include my travel costs from Cleveland to Nashville every three months. There is really no comparison between my quality of life before and after treatment though. It's like night and day and 100% worth it.