Case Histories

The following are the stories of some of my patients. These case histories illustrate different aspects of how TMJ disorder affects your health. Enjoy!

Case History #256

Patient: Female, age 20, college student

Principal Complaints: GC, a very nice, healthy, athletic young woman, was advised by her dentist to seek treatment for her TMJ disorder. Her chief complaints were: frequent headaches; migraines; and popping on the right TM joint accompanied by pain.

Medical History: Since high school she had been suffering these symptoms and they had gotten progressively worse. She reported that she had been an active child, free of headaches and migraines. She noted one injury, hit in the forehead with a golf club at age 12. She wore braces for 1 ½ years, in 2000-2001, and the symptoms started when the braces were taken off. When she had her wisdom teeth removed at age 18, she was told by the oral surgeon that her TMJ symptoms might improve, but they did not.

Oral condition: All teeth were present except wisdom teeth, and in good shape. Orthodontic result showed a pleasing and pleasant smile; however, the left side premolar area was in a crossbite, the midline was off 1.5 mm, the vertical dimension was overclosed, and the lower molars were lingually inclined. Her radiographs showed arthritic breakdown of both TM joints with more severe breakdown on the left side. Both condyles were posteriorly superiorly displaced when the mouth was in a closed position.

Symptomatology: Crepitation was present in both TM joints, both exhibited opening and closing click. Maximum opening was 45 mm. Lateral excursion was 10 mm right and 12 mm left. Popping of her jaw on right side caused pain. Her headaches and migraines lasted a few hours, 2 – 3 times per week, usually in the afternoon and evening. She experienced shoulder pain on the right side; yawning and chewing caused jaw pain, as did brushing the teeth; she also reported muscle fatigue from chewing; she had difficulty opening her mouth wide.

Medications: Imitrex, Differin, Minocycline, Ibuprofen

Treatment record: At her second diagnostic visit (a day after her first visit), she was fitted with temporary occlusal guards to open the vertical dimension. She returned 2 weeks later for fitting of the Gelb MORA (mandibular oral orthotic repositioning appliance) to be worn 24/7 and while eating. She returned 2 weeks after that for her adjustment appointment (typically 4 weeks later but she was leaving for college). Her bite was adjusted, the premolar prematurities were removed, and clasps tightened. The patient tested strong with an applied kinesiology deltoid press, which indicates that the jaw was in its correct Gelb 4/7 position, nature’s preferred position. She reported that her treatment was going really well; no more popping, clicking or jaw pain; and no more headaches or migraines! She returned 2 months later with a cracked and worn down appliance. It was relined and she again tested strong. She reported having had 1 – 2 headaches in the past 2 months, and had slight shoulder pain on the right side. When she returned six weeks later to have the saddles relined and the frame unbent, she reported that all symptoms were better. She was then seen by me every 1 – 2 months, whenever she could come home from Baylor University, to adjust and resurface the appliance to account for wear & tear.
After 13 months, her TM joints had healed, she was asymptomatic, and her jaw was staying automatically in the Gelb 4/7 position. At this point she was ready for arch expansion to correct her crossbite and to increase the vertical dimension. She is currently in the expansion phase, which will take about 9 months, wearing both upper and lower removable expanders 24/7.
GC has been very compliant with her treatment and is back to normal and healthy. She reports being calmer, sleeping better, having more energy, and doing better in school.
She will start her final phase of treatment this summer, using the Elastodontic silicone aligner (tooth positioner) to guide her teeth to the correct position while maintaining her jaw in its correct Gelb 4/7 position. This aligner is worn at night, approximately 10 hours per day, for about six months. At the conclusion of this phase she will have completed her treatment.

Case History #144

Patient: Female, age 32, personal trainer/fencer

Principal Complaints: CV, a very nice, very fit, very athletic young woman, sought a second opinion for her preliminary diagnosis of multiple sclerosis. Her chief complaints were facial numbness and pain on the right side of six months duration, numbness in her right arm, especially during exercise, for the last month, tremors, muscle spasms in her right arm and muscle twitching in her whole body for the last two months. Her neurologist had recently prescribed an MRI.

Medical History: The patient reported suffering from frequent headaches lasting 24 hours since her teen years, pressure around the eyes since adolescence, hypersensitivity to light since childhood, pain in neck and shoulder on right side for the last 10 years, jaw tenderness in the TMJ area on the right side for years, poor circulation and slow healing in her right arm for the last six months, short term memory loss for the last 5 years, digestive problems for the last month, hyperactivity since childhood, inability to relax or sit still, poor sleep, always fatigued in the morning, itchy and bloodshot eyes since her teens, and chronically tired all the time.

Oral condition: Very healthy mouth with all teeth present. Jaw relationship was very retrognathic with a very deep bite. Her radiographs showed normal joint anatomy on the left, arthritic breakdown of bone of right joint and flattening of right socket. Both condyles were posteriorly displaced when the mouth was in closed position.

Symptomalology: Crepitation was present in both TM joints, the disc was locked out in closed position. The patient reported pain when turning her head or moving her neck. Her teeth were painful on the U/L right. She clenched and ground her teeth at night. Other symptoms were frequent dizziness and fainting, stuffiness in her right ear.

Medications: None.

Treatment record: At her second diagnostic visit (three days after the first one), she was fitted with temporary occlusal guards to open the vertical dimension. She reported immediate relief of her pain, felt like the blood vessels were opening on the right side of her head. She went home and slept four hours, so soundly that when she awoke she didn’t know where she was. She said she hadn’t experienced a sleep like that in ages.
When she returned 3 weeks later for placement of the Gelb MORA (mandibular oral repositioning appliance) she reported that all of her symptoms had either greatly improved or disappeared and she had decided not to have the MRI. She responded extremely well to treatment and very shortly all of her symptoms were history. She reported she could now sit down and relax and enjoy a whole movie. She came in for appointments every four weeks to have the orthotic adjusted. Occasionally it would wear down, and the patient could always tell right away that her bite was off, because her symptoms would gradually return and she would notice she was not fencing as well.
Six months later her maximum opening had increased from 42 mm to 50 mm. She was extremely pleased with the results of her TMD therapy and the overall improvement in her health and decided to bring in her two sons to be evaluated for TMD because of their health problems. They were successfully treated, too, but that’s another case history!

Case History #196

Patient: Female, age 33, Pharmacist

Principal Complaints: OH, a very nice young woman, was referred to me by her neurologist for her bilateral TMJ pain. He considered it medically necessary that she be treated for her TMD, which was aggravating her chronic migraine headaches.

Medical History: One year ago her jaw pain, neck pain on the left side, left shoulder pain and headaches started to get worse and more frequent. The jaw was still clicking and rubbing. She reported suffering from migraines weekly for the past five years. The only accident she recalled was falling off parallel bars at age 10, hitting her nose, face and mouth.

Oral condition: All teeth were present, except her wisdom teeth, and in good shape. She had orthodontic treatment at age 11 through 14. Her occlusion was Class I left side, Class II right side. Her lower molars were lingually inclined and the midline was off 1.5 mm to the left. Her radiographs showed arthritic breakdown of both TM joints. Both condyles were posteriorly displaced when the mouth was in closed position. Cervical spine showed excessive lordosis. Forward head posture was evident. Her lower jaw was three dimensionally off; the left side was 2mm higher and 1 mm further back than the right side. She had wear facets on her posterior teeth, a scalloped tongue, and internally rotated temporal bone on the left side.

Symptomalology: Crepitation was present in both TM joints, the right TMJ exhibited an intermediate opening and closing click. Maximum opening was 41 mm. Lateral excursion was 12 mm right and 7 mm left (normal range of motion is 50 –60 mm opening, lateral motion 12 mm). She reported that the pain travels up her left scapula and turns into a migraine usually once a week. She would get headaches that turned into migraines if she didn’t take ibuprofen and Imitrex twice weekly. Other symptoms were jaw pain on the right side, teeth pain on the left side, chronic fatigue, poor sleep, stress, depression, a ‘short fuse’, weight gain, and neck pain that travels to the back of the eye on the right side. She reported clenching and grinding her teeth 24/7. Her neck and muscles of mastication were full of trigger points and very spasmodic.

Medications: Inderal, Flexeril, Imitrex, Ibuprofen

Treatment record: She was initially fitted with temporary occlusal guards which she wore for 3 weeks, which gave her some relief of her symptoms. She was then fitted with the Gelb MORA (mandibular oral repositioning appliance) and at her first adjustment appointment four weeks later she reported that she was doing very well and had not had a single migraine, had no TMJ pain, but still had neck and shoulder pain. At her next appointment, four weeks later, she reported having had 2 migraines. Her maximum opening had increased to 46 mm, and her lateral excursions were now both normal at 12 mm. The orthotic was adjusted, the premolar prematurities were removed. At her next monthly visit, she reported only one migraine and no regular headaches. Left scapular and right neck pain persisted. At the following monthly visit, she reported having one migraine and some eye pain and felt that intense exercise had triggered it. Her scapular pain had moved to the right side. Some adjustments were performed. At her next monthly visit, she reported that all of her symptoms were gone. The same was true at her next two monthly visits. The patient remarked that it was wonderful to have no migraines, she also had no more popping in the TM joints. She did still have tension in the splenius capitus and the right masseter
One month later her maximum opening was 50 mm, her lateral excursions right and left were 12 mm, all back to normal. The patient has been seen monthly to maintain orthotic at current level by relining the occlusion to maintain the correct Gelb 4/7 jaw position. She no longer needs to take her medication for vertigo, no longer takes the Certuss and Flonase, occasionally takes the Allegra as needed. She went on a short vacation and her appliance cracked, immediately the headaches started again and she had to start Nexium for the acid reflux, which recurred but went away again as soon as her appliance was repaired and her normal molar occlusion was restored.
The patient now feels like she is back to normal and ready to start Phase II treatment to expand and align her upper and lower jaws and open her vertical dimension so that she doesn’t have to wear an orthotic the rest of her life.
This case shows how dependent the patient is on the appliance keeping her jaw in the correct position 24/7. In Phase II, we will work toward adjusting her occlusion to permanently maintain the correct position without an appliance.

Case History #145

Patient: Male, age 8, student

Principal Complaints: IV, a very well behaved young boy, was brought in for a consultation by his mother (case history #145) to see if his health problems were perhaps related to TMD. His chief complaints were seizures, headaches, migraines and chronic, continuous pain.

Medical History: The patient has been on Trileptal anti-seizure medication for several years which controlled his seizures but did not improve his other symptoms. He started seizure medication at age 4.

Oral condition: Healthy mouth with all teeth present, good oral hygiene. X-rays revealed osteoarthritic breakdown of both condyles and sockets of the TMJ. Very deep bite with retrognathic jaw, accompanied by forward head posture. Insufficient eruption of molars.

Symptomatology: Seizures, speech problems, lack of coordination, headaches, migraine headaches, nausea, dizzy spells, ringing in ears, poor balance, fatigue, nightmares, car sickness, jaw pain on both sides, constant painful teeth, clenching and grinding 24/7, slow speech, cloudy thinking, ear stuffiness.

Medications: Anti-seizure medication.

Treatment record: IV was a very good patient and was very careful with his oral orthotic. He was initially provided with occlusal guards to increase his vertical dimension and immediately reported no more headaches, nightmares, dizziness or car sickness. All of his other symptoms cleared up shortly after he started treatment with the Gelb MORA (mandibular oral repositioning appliance). His mother reported that, since treatment for TMD, all of his symptoms have disappeared or dramatically improved. He is now medication free and his EEG readings are normal.

Case History #146

Patient: Male, age 11, student

Principal Complaints: JV, a shy, quiet young boy, was brought in for a consultation by his mother (case history #144) to see if his health problems were perhaps related to TMD. His chief complaints were frequent headaches, mental confusion, petit mal seizures.

Oral condition: Healthy mouth with all teeth present, good oral hygiene. Very deep bite with retrognathic jaw, accompanied by forward head posture. Osteoarthritic breakdown of left TM joint.

Symptomatology: Frequent tension headaches, inability to focus attention for long periods of time, confusion, hyperactivity, petit mal seizures (10 – 12 per day), fatigue, loss of appetite, insomnia, frequent nightmares, limited range of motion in head, neck and shoulders, clenching and grinding of teeth, dizziness, ringing in ears.

Medications: None.

Treatment record: He responded very well to treatment with the Gelb MORA (mandibular oral repositioning appliance) and within four months was back to normal. Then he lost his appliance and suffered a small relapse until he received a replacement a few weeks later. His mother reported that since receiving treatment all of his symptoms have disappeared or improved. His has not had a single petit mal seizure since he got his oral appliance. Before treatment, his mother planned to take him to a neurologist, but now he is healthy and strong. Before treatment, he was a ‘scaredy cat’, now he is full of confidence. His appetite is back, he eats like a horse and is hungry all the time. He sleeps well and has no more nightmares. Six months later his maximum opening had increased from 44 mm to 50 mm.

Case History #64

Patient: Female, age 54, self-employed

Principal Complaints: TP, a very nice, healthy, middle-aged woman, woke up one morning in August, 2005, with a sore left TM joint and difficulty opening her mouth. While eating breakfast, her parotid gland swelled up.

Medical History: For the last 2 years, she had been seeing her ENT for dizziness and a previous parotid gland flare-up. She’d been diagnosed with too much fluid in her middle ear as the cause of dizziness and been prescribed Dyazide and a low salt diet.

Oral condition: All teeth were present except wisdom teeth, and in good condition. She had crowns on teeth #2, #9, #10, #15, #30 and #31, and root canals on teeth #2, #9 and #10. Her teeth were in Class II, Div. I malocclusion, the midline was off the left by 1.5 mm, the vertical dimension was overclosed, more so on the left side. Her radiographs showed arthritic breakdown of both TM joints, more so on the left side. Both condyles were posteriorly superiorly displaced when the mouth was in a closed position.

Symptomatology: Crepitation was present in both TM joints. Maximum opening was 23 mm (normal is 45-60 mm). Lateral excursion was 4 mm right and 7 mm left (normal is 10-12 mm right and left). She qualified as ‘closed lock’, in which the disc is anteriorly displaced and unable to reduce. She had constant pain in her left TM joint, more severe at night. It was painful to open her mouth, yawn, brush her teeth or eat crunchy food. She saw her dentist for a regular cleaning and exam in September, 2005, but could not open her mouth to have it done. He advised rest and warm compresses. Next she saw her ENT for the parotid gland swelling and the dizziness, which usually lasted 2-3 days and was so severe she would vomit and be unable to get out of bed. She also experienced ringing in both ears, ear stuffiness, eustachian tube pressure and pain. Florescent lights and ceiling fans aggravated her dizziness. She also suffered from tension headaches, and headaches above and behind her left ear, and pressure and pain behind her left eye. Her left eye watered frequently. Her teeth were painful and sensitive to hot and cold on the upper and lower left side. An excessive and lengthy opening of her mouth during RCT of #2 exacerbated her symptoms. She also clenched her teeth and her jaw muscles tired frequently. She had a high right eye, internally rotated right temporal bone, and excessive freeway space on the left side. All of her muscles of mastication were in spasm, as well as several neck muscles.

Treatment record: She felt only minor improvement with temporary occlusal guards due to her hard clenching. However, she responded positively to the Gelb MORA (mandibular oral orthotic repositioning appliance) and reported that all of her symptoms were better after wearing it for 10 days. She was seen monthly for adjustment and reline. The MORA wears down over 14 - 21 days and needs to be periodically relined to maintain the correct jaw position, otherwise symptoms will return. After 4 months, her interincisal opening increased from 23 mm to 37 mm. She was still off the disc but improving. After 5 months, her opening had increased to 43 mm, lateral excursions to 12 mm right and 9 mm left, and all symptoms were better. 7 months later she was fitted with the maxillary ALF (alternative lightwire appliance) to expand the maxilla and correct cranial distortion, and a mandibular expansion appliance. She progressed steadily, with a few small flare-ups whenever her appliance was off-balance.
10 months later, she was fitted with the Elastodontic silicone aligner (tooth positioner) to align and straighten her teeth. She wore this aligner at night, for approximately 1.5 years, and did well. However, she was still clenching, and finally chewed through the aligner causing her ear stuffiness to return. To cut down on her grinding, I fabricated a MAPA (Maxillary Active Passive appliance) for daytime use and a FARRAR (Maxillary Anterior Positioning Appliance) to be worn at night. Both appliances reduce clenching by up to 80%. Grinding had also caused restorations on teeth #18 and #19 to wear down. I refilled them with occlusal composites to restore left TM joint support. These restorations lasted only 10 months due to cracking and excessive wear. The ear stuffiness returned within days after the cracking took place. At this point I advised her that she probably would need crowns in the future. She was still clenching! She was then treated with soft tissue laser to relax the masseter, temporalis and pterygoid muscles. An ETPS 100 electroacupuncture unit was prescribed for home muscle care. She was also placed on a myofunctional tongue exercise program to counteract the clenching. You can’t clench while you’re exercising your tongue!
As you can see from this case, it can be relatively easy to place the jaw in its correct position, but hard to maintain it there 24/7!

Case History #242

Patient: Female, age 57, school teacher

Principal Complaints: VF, a very nice woman in her 50’s, was referred to me by her oral surgeon for an evaluation. Her chief complaint was severe left facial pain of eight months duration and, recently, right facial pain. When asked to point to the area of pain, she pointed to the left mandibular angle.

Medical History: One year ago, while the patient was eating a corn chip, her jaw popped very loudly and the pain started. The jaw was still clicking and rubbing. She had previously suffered from migraines continuously for years which stopped suddenly in 1989 after back alignment and wisdom tooth extractions. For the past year, she had regular headaches and other TMJ symptoms. Her history is significant for hypothyroidism, vertigo, allergic rhinitis, osteoporosis, osteoarthritis, scoliosis, carpal tunnel syndrome, 6 screws in her lower back for a slipped disc that was pinching a nerve to her leg, and acid reflux.

Oral condition: All teeth were present and WNL, with some bone loss on lower second molars. Lower molars were lingually inclined and upper molars had a mesial tilt. The patient had braces on three occasions; in 1967, the upper only; in 1980, upper and lower; in 1993, upper and lower. Her mouth was slightly retrognathic and exhibited loss of vertical dimension. Her radiographs showed normal joint anatomy, however the condyles were posteriorly displaced when the mouth was in closed position.

Symptomalology: Crepitation was present in TM joints, left TMJ had opening and closing click. Maximum opening was 45 mm. Lateral excursion was 7 mm right and 10 mm left. Jaw pain on left side was constant. Her headaches lasted all day, they usually started upon awakening, sometimes later. Her neck pain was also constant. She had ear pain on both sides, worse on the left. She was experiencing sharp pricks of pain all over her body, especially her right knee, causing her to stumble. Other symptoms were; vertigo, facial pain in sinus area, poor sleep, chronic fatigue, eye twitching, postnasal drainage, and memory problems.

Medications: Lexapro, Sprinolac, Forteo, Synthroid, Flonase, Allegra, Certuss, Nexium.

Treatment record: At her second diagnostic visit (three days after the first one), she was fitted with temporary occlusal guards to open the vertical dimension. She returned 3 weeks later for placement of the Gelb MORA (mandibular oral repositioning appliance) and commented that most of her symptoms had improved. She left feeling very optimistic. At her next appointment, four weeks later, the orthotic was adjusted, the premolar prematurities were removed, clasps tightened, and lingual bulk was removed to help her speech. The patient tested kinesiologically strong with a deltoid press while wearing the appliance, indicating that the jaw was in its correct position. She was anxious to report that she no longer suffered from headaches and she was sleeping better and had more energy. Also earaches were gone, as was jaw pain, neck pain and facial sinus pain. Stabbing, pinching pains had stopped and her stumbling was better. She felt less anxious and stressed out. Her eyes stopped twitching and postnasal drainage was less.
One month later her maximum opening was 50 mm, her lateral excursions right and left were 12 mm, all back to normal. The patient has been seen monthly to maintain orthotic at current level by relining the occlusion to maintain the correct Gelb 4/7 jaw position. She no longer needs to take her medication for vertigo, no longer takes the Certuss and Flonase, occasionally takes the Allegra as needed. She went on a short vacation and her appliance cracked, immediately the headaches started again and she had to start Nexium for the acid reflux, which recurred but went away again as soon as her appliance was repaired and her normal molar occlusion was restored.
The patient now feels like she is back to normal and ready to start Phase II treatment to expand and align her upper and lower jaws and open her vertical dimension so that she doesn’t have to wear an orthotic the rest of her life. It is interesting to note that after 8 months of treatment, she brought her 88 year old mother in, who also suffered from TMJ disorder, and has also seen much improvement since treatment began.
This case shows how dependent the patient is on the appliance keeping her jaw in the correct position 24/7. In Phase II, we will work toward adjusting her occlusion to permanently maintain the correct position without an appliance.