A few months ago I had the great privilege of meeting TMJ Specialist, Dr. Gary Demerjian, who spoke to me of a new frontier in non-invasive neuro-muscular medicine and dentistry. With a thorough understanding of the TemporoMandibular joint and the surrounding nerves, Dr. Demerjian and his colleagues are able to treat many chronic, painful, and debilitating conditions, thought to be incurable, with a device called an oral orthotic. I have personally gone through the assessment for this device, and had a very positive experience. With that in mind, this article will be the first of a three part series, and will provide all the necessary background information about the TemporoMandibular joint, information on the screening process, and a bit about the device. The second installment (coming shortly, will explain my experience with the assessment process). The third installment will be written after I receive the orthotic, to inform how an oral orthotic impacts the day to day pain and quality of life for a RSD/CRPS patient. After watching countless videos of this treatment process, getting to know fellow chronic pain sufferers who have used this device, personally viewing the look of relief and excitement when patients have had an initial screening, and having undergone said screening myself, it is safe to say that I am a believer and advocate for the use of oral orthotics and their future in neurological medicine. That is, with the right doctor at the healm-
As he stated in our initial interview, Dr Demerjian treats TMJ symptoms. Working from his Los Angeles based practice, what he tends to find in relation to many neurological conditions is that a great deal of pain patients he examines have an underlying TMJ condition that has never been explored. When the jaw is placed into a better anatomical position, a great deal of the painful TMJ symptoms are alleviated. Upon examination of the jaw joint under x-ray, they find an irritation or compression of a nerve that plays a crucial role to the nervous system. The aforementioned is known as the trigeminal nerve, and is the fifth cranial nerve. It is the largest nerve that comes out of the brain stem (For context, this means that other than the spinal cord, the trigeminal is the body’s biggest nerve!). Its path goes all over the head area: the face, the eyes, the cheek, the lower jaw, and one of the branches goes inside into the jaw joint. A painful condition that stems from irritation of this nerve is known as trigeminal neuralgia, formally called tic douloureux which causes sharp shooting pain in the face.
A very important feature to the understanding of the inner workings of the TemporoMandibular joint, the trigeminal nerve, and this revolution in medicine is a nearby large nerve bundle called the Trigeminal nucleus. As is pictured (right) the Trigeminal nucleus acts as a chief network or relay system in the brain stem. This is significant because cranial nerves run so closely together that they may be accessed at this large bundle or relay point. In our discussions, Dr. Demerjian made reference to several specific nerves passing very close to this area, such as the tenth cranial nerve, or the vagus nerve, which plays many roles in the body including breathing regulation, control of muscle movement, regulation of the digestive system, and many other key functions of the body. The proximity by which these important nerves run in the cranial space, allows them to be positively impacted by proper alignment of the TMJ. Dr. Demerjian also explained how he was able to help cervical dystonia patients who had symptoms such as being pulled by the muscles of the neck towards one side of their body. Due to the fact that the Trigeminal Nucleus extends down to the C-3 level of the cervical spine, use of an oral orthotic to align the TMJ can have a significant impact in relieving symptoms for dystonia patients.
Potential causes of TemporoMandibular joint injury
The right and left TemporoMandibular joint articulate the mandible (also known as the lower jaw) against the maxilla (the upper jaw). TMJ disorders refer to a dysfunction in either one or both joints. The causes of TMJ disorders can be chronic or acute inflammation, and can include micro trauma such as grinding the teeth, or macro trauma in the form of a major accident. There can be myofascial causes such as trigger points, where spasming muscles in the neck or temple area can refer pain to teeth. Developmental anomalies can also play a role in TMJ disorders. TemporoMandibular joint disorders manifest as signs and symptoms that involve the surrounding muscles, ligaments, bone, connective tissue, teeth, and nerve innervation to the joint. They can cause proximal (near) or distal (Far), dull or intense, acute or chronic pain. Many patients report a clicking or popping of the jaw. This is caused by the cartilaginous discs of the TMJ. Dr. Demerjian compared this popping to that which is sometimes observed in kneecaps. In reference to the knees, he joked that, despite the greatest of intentions, one will only be able to run so far with such an action taking place. As for the TMJ, he informed me that each time this clicking and popping sensation occurs, a negative input is sent to the nervous system
Im my discussion with Dr. Demerjian, we spoke of a few cases in which patients had significant neurological difficulties, but had numerous neurological traumas in the past. He offered a theory for what might cause someone in similar circumstances to have significant neurological injury or illness. He gave a few examples of potential recurring injuries that he has observed, such as numerous falls on the spine, head trauma, or car accidents and explains that all of these injuries can have an accumulative effect over time. To illustrate this point he uses the analogy of a cup of liquid. Every injury adds a little bit of liquid to the cup (where liquid represents trauma) until eventually one injury takes the cup too high. When this happens the cup overflows, causing the nervous system to go haywire. He has been able to help return quality of life to a number of people in situations such as these with a specially made oral orthotic. Dr. Demerjian states that he has seen this same phenomenon in a number of neurological conditions including RSD/CRPS. Having had several neurological injuries and surgeries in the past, I was very excited to meet him in early November 2012. With this being said, I feel it is important to again highlight at this point that it is not a prerequisite to have had significant neurological injury to be a candidate for this noninvasive treatment. There are many other factors that may lead to the misalignment the TMJ and potentially cause nerve irritation. Some such causes include: intubation tube from anesthesia, having the mouth open for extended periods during long dental procedures, extraction of wisdom teeth, clenching of the jaw, and grinding of teeth.
The Screening Process
In the initial TMJ screening, Dr. Demerjian uses tongue suppressors to align the jaw joint and take pressure off the nerve ( If you are unfamiliar with a tongue suppressor, it is essentially a large popsicle stick). One at a time, a tongue suppressor is added and maneuvered until it reaches as Dr. Demerjian candidly calls it, “the sweet spot.” When the jaw becomes properly aligned the nerve becomes decompressed. The moment this point is achieved pain truly does melt away. In RSD/CRPS patients, a temperature change can be quickly detected. For the pain sufferer, the change is clearly noticeable, but it can be monitored with the use of thermography as well. Some might ask how it is possible that one could have been suffering for months to years with such severe pain and it have it subside so quickly. The answer, as Dr. Demerjian eloquently states it is quite simple. Pinch yourself-notice how quickly you are able to feel that flash of pain. Recognize the instantaneous response that your brain gives to the stimulus, and the corresponding messages that it sent to the body. When the jaw is properly aligned, pressure is taken off the compressed and irritated nerve, allowing the pain gates that have not been able to close for such a long time, that have been continually sending pain signals body, to finally close, allowing no-pain messages to be sent and relief to set in. Having personally experienced this phenomenon, I can tell you that it is it an extremely moving, powerful, and emotional moment. (I will elaborate on my personal TMJ screening experience with Dr. Demerjian in part two of this article).
While reading this, one might ask why not just use tongue suppressors for pain relief? While this technique will work to a degree in the short term, the life of tongue suppressors is short-lived. The blades lose their effectiveness after bite marks accrue, and it is overwhelmingly uncomfortable to have a large amount of tongue suppressors in one’s mouth for an extended period of time. With that said it is nowhere near as uncomfortable as the extreme pain that comes along with a significant flare-up, and I have many times used this technique to battle pain on my worst days. Be forewarned however, as I was, using tongue suppressors for short-term relief will provide that to an extent, but it is somewhat of a taunting tease. As soon as the tongue blades are removed from your mouth, the pain comes back with vengeance. A tip that I was given is to remove one blade at a time so that the pain comes back slowly, almost to ease back into it. This helps me bridge over a bad flare, and get through the hardest times. When an oral orthotic is made for you it should be worn most of the time except eating. This allows the body to recover and inflammation to reduce overtime.
Along with his counterpart, Dr. Anthony Sims (Columbia, MD), Dr. Demerjian continues to work to drastically improve the quality of life for patients suffering from debilitating neurological conditions such as Parkinson’s, Tourettes, CRPS/RSD, blepharospasm, spasmodic torticolis, dystonia, and more. In his ongoing desire to help fight these conditions, he has taken courses from the cranial academy, in chiropractics, and has become a diplomate from the American Academy of pain management.
Dr. Demerjian and Dr. Sims have pushed and promoted this practice for about 3 years, along with the research of the University of Washington’s Dr. Mark Cooper and expertise of fellow TMJ specialist Dr. Brendan Stack (Vienna, Va). They continue to advance the clinical applications for the oral orthotic and the effectiveness of said device. Dr. Sims and Dr. Demerjian have partnered with the Academy of cranial facial pain are setting out to fully understand this science, and create a standardized protocol to be able to teach other dentists and doctors to make these oral orthotics. Dr Demerjian cautions about dentists and oral surgeons jumping into what is sure to be a booming field in the near future without proper knowledge, training, or understanding of how to create the oral orthotic. These mouth pieces must be specially titrated and adjusted to precise specifications. If you have tried a similar treatment years ago, it may be worth investigating how an oral orthotic can impact your life.
There are some things that simply cannot be put into words. I encourage any and all who read this article explore Dr. Demerjian’s website and his YouTube channel to view some of the ‘Jaw-Dropping’ videos. Links to both are below. There are truly no words for some of the amazing images you will find.
You can visit the Power of Pain Website at http://www.powerofpain.org