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Face, Jaw and Head Conditions

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Facial and Jaw Pain

What makes Renaissance unique as a head and neck TMJ specialty clinic?

Dr. Hobson has had the privilege to work directly with one of the most influential people in the field of head and neck TMJ, Dr. Mariano Rocabado.  He is a known expert in this field, recognized by many dentist, oral surgeons, and physical therapists as the most knowledge for the head and neck/TMJ mechanics and function.  Dr. Hobson started her training with Dr. Rocabado in 2001 and then began a yearly residency for the month of January in Santiago, Chile where he resides since 2004.  This yearly training keeps Dr. Hobson trained in all the newest researched based techniques that Dr. Rocabado teaches all over the world.  She works directly with him and his patients and also teaches his physical therapy staff in Chile all the new things she has learned in the previous year.  Dr. Hobson is the only physical therapist that has done such an extensive training program with Dr. Rocabado for the past 20 years that he has allowed her to teach his techniques to the physical therapists that are working towards Cranial-Facial Certification certified through the U of St. Augustine, FL.   Dr. Hobson spends her year learning from the best and teaching her own staff at Renaissance all that she knows.

The Importance of Treatment for TMJ, Headaches & Neck Pain

Many people are told that they have TMJ when they have jaw pain. An estimated 75% of the U.S. population have experienced signs or symptoms associated with disorders involving the Temporomandibular Joint (TMJ), also called Temporomandibular Disorder (TMD). It is somewhat misleading because the TMJ is the joint that is made up of the temporal bone of the skull and the mandibular bone. It is more appropriate to say that one has TMJ disorder or temporomandibular disorder also known as temporomandibular dysfunction (TMD).There are two types of TMJ disorders, including either pain caused by the muscles surrounding the TMJ or pain from changes in the TMJ joint. Many areas of the body affect the TMJ and one needs to evaluate all the areas to truly get to the root of the problem.

Many patients deal with day to day computer work and slowly lose their spinal alignment. The TMJ specialists at Renaissance understand how this can happen and also know how to reverse the effects of poor posture. For anyone that is dealing with a desk job and experiencing pain in the neck, TMJ or face, consider coming to our office for an evaluation. With very simple exercises to keep you aligned and out of pain, you can be feeling better in less than a month. If not treated properly, you can be left with one or all of the following physical issues: degenerative disc/joint disease of the cervical spine, poor posture, chronic clenching, tooth fractures (need for extensive dental work), TMJ arthritis, poor sleep, painful chewing and limited mouth range of motion, and poor breathing patterns.

What are typical symptoms of TMJ Disorders or TMJ Dysfunction (TMD)?

TMJ or TMD symptoms consist of pain in the ear, face, jaw joint, facial muscles and neck. This pain may be caused suddenly, i.e. when biting into something hard and straining the joint. The jaw and facial pain may fluctuate in intensity and frequency over months to sometimes years. There may be joint sounds, such as grinding, grating, clicking or popping of the joint when moving the jaw during daily activities, such as talking or eating. Locking may occur which may be an indicator that there is a temporomandibular disc displacement problem. At times, there may be a deflection or deviation to one side when opening the mouth. Headaches are also very common with TMJ disorders, along with difficulty eating due to pain or limited opening.

What does TMJ, headache and neck pain treatment consist of?

Dr. Hobson and her team of head and neck specialized therapists are all trained in the Rocabado approach to treating the head and neck for both children and adults. Dr. Mariano Rocabado is a head and neck world renowned physical therapist that has been teaching PTs and dentists his approach for years, which now Dr. Hobson is teaching herself. The Rocabado approach consists of an evaluation of your head, neck and TMJ joints to determine the cause of your jaw clicking, jaw pain, headaches, migraines, and ear and neck pain. At Renaissance, you will have a thorough examination of your spine, starting at the pelvis to make sure it is aligned all the way to your cranium and TMJ. The Rocabado approach consists of restoring the proper position of the head on the neck which is called the cranio-vertebral angle. Many of us slouch in front of the computer and end up losing our alignment and getting a “straight neck” or “inverted cervical lordosis”. Cervical lordosis is a very important curve to have in your neck to maintain good healthy neck joints and to use your neck when upright with the least amount of load or compression. Those of us that have compromised necks will eventually get lower cervical degenerative changes such as osteophytes, bone spurs, degenerative disc disease, herniated discs and more. There is a proper position of the head and neck that we are trained to restore in patients so that they return to improved neck range of motion, good lordotic curvature of the neck, proper cranio-vertebral angle, decreased facial and shoulder tension and more.

Should children be screened for TMJ head and neck problems?

Absolutely! Children that have poor posture are on their way to becoming adults with poor posture along with an array of alignment issues causing chronic tension and pain in the body. Children are undertreated and should be evaluated. Any child going through braces is recommended to have an evaluation by one of our therapists. All parents should consider bringing in their child if there is clicking and popping in a child’s jaw joints, if they have poor posture, or mouth breathe. We at Renaissance can identify the problem and in a short period of time, the child will be guided to improving their head and neck posture, breathing mechanics and mouth and tongue posture. Dr. Hobson is one of a few reviewers of the GOPex program which would allow you to work with her through a simple app on your phone through videos you send for her to critique and give the child guidance from the convenience of your own home. Dr. Hobson recommends that you don’t spend all the money on orthodontics without checking the child’s mouth/TMJ condition and posture as you may cause a problem to worsen if the child needs to continue going through a monthly treatment of wide opening when there is a TMJ problem already present. Dr. Hobson’s mentor, Dr. Mariano Rocabado in Santiago, Chile screens all children going through braces before they actually start to make sure that their joints are “ready” to undergo orthodontia. If a clicking of clenching problem is detected, it may take a month to resolve but it will be well worth the time and effort to avoid a degenerative problem in the future.

What should I expect during the head and neck evaluation?

Dr. Hobson or one of her licensed physical therapy associates evaluate the following:

MRI’s and X-rays of the neck and TMJ are reviewed or requested by the TMJ specialist to further investigate the joint.

A physical therapy diagnosis is given to the patient and a comprehensive assessment is explained to the patient. A home exercise program is developed in order to address all aspects of the problem with the goal to immediately reduce TMJ symptoms.

The TMJ specialist at Renaissance will also explain their hands on plan to correct the patients TMJ problem. If the patient has a muscular based problem, the TMJ specialist will teach them how to reduce facial and neck tension through exercise, posture and also manual therapy techniques to these areas. If the TMJ has an internal joint problem, the TMJ specialist will explain what techniques they have to alleviate the joint noise and pain.

  • During the TMJ evaluation, the TMJ specialists at Renaissance will take the patient’s history and ask about causes of jaw, neck and head pain. The patient will also be asked about the amount of dental work he/she has undergone.
  • Spinal alignment, starting from your pelvis to your cranium. Posture is evaluated from head to toe in order to examine the amount of muscle tension in the surrounding areas.
  • We assess your gait or walking pattern to see if your ankle, knees and hips are part of the problem affecting your head and neck and TMJ.
  • We evaluate your atlas (1st vertebra: C1) position as this affects the position of the jaw bone.
  • We will evaluate your joint mechanics of your spine, neck as the influence the proper functioning of the TMJ.  Joint mobility testing and mechanics of the neck, upper back and TMJ are performed to identify any abnormalities or asymmetries.
  • We assess the mechanics of TMJ and neck to determine the cause of clicking, jaw pain, headaches, and neck pain.
  • We use the Rocabado TMJ approach to treat TMJ disc displacements, locked jaw, clicking and popping, painful opening and painful chewing.
  • Full evaluation of the muscles and soft tissue testing is performed to examine the tenderness and activity level of the surrounding neck, shoulder and facial muscles.
  • Further examination of the cranium and facial bones for asymmetry

What should I expect during a treatment of the head, neck and TMJ?

Specialized manual therapy: To restore full range of motion, proper joint mechanics and decrease pain of the jaw, neck and upper back.
Soft tissue massage: We will perform and teach you these techniques so that you can decrease your facial swelling and pain.
Dry needling may be performed to eliminate active trigger points of the head and neck muscles for those that are open to that treatment.
Education: We will educate you on what to do to help yourself decrease chronic headache and jaw pain through exercises and postural corrections.  Many of us don’t realize that our daily habits are actually hurting us and keeping us in a state of over-loading our joints and soft tissues.
Postural screening and re-education: We will teach you what ideal posture is so that you experience less pressure in the jaw, face, neck and shoulders.
Facial exercises: These exercises will decrease the tension in your face, head, neck and upper quarter.
Breathing exercises: To restore proper nasal diaphragmatic breathing patterns to reduce neck tension and added stress to the body from chest or mouth breathing.
Gait training:  To improve and optimize our alignment during gait to reduce head and neck tension.
Myofunctional therapy:  All of our patients receive tongue training.  We train the tongue to rest up gently on the palate, strengthen the tongue when it is weak, and position it for optimal swallowing function.  This is critical to restore the proper support to our throat airway, and will reduce added stress to the head and neck if we are using our tongue properly.

How long is the PT session?

The first visit that is the Initial evaluation may take about 60 mins. And continued care with regular PT sessions usually take about 45-60 mins each visit.

What is the frequency of physical therapy ?

An average treatment plan consists of 2x per week for 1 month and then if you are improving and progressing appropriately, one can be decreased to 1x per week.  To change these automatic habits such as proper mouth and body posture, and breathing habits, it takes time. When this frequency of 2x per week for the first month is not possible, due to location and work, it may take longer to stabilize the condition.

How do I learn to manage my TMD or facial pain problem?

The TMJ patient needs to understand that when there is a TMJ problem, it normally means that the patient needs to learn how to manage the problem. There is no quick fix to this issue. It requires a good understanding of why symptoms are occurring and how to minimize the cause. Sometimes it just requires a few daily exercises to the neck and jaw in order to reduce tension in the area and to better align the neck and jaw. Another factor is reducing the amount of hard or crunchy foods in order to reduce the compressive forces of the joint. This is particularly important when there are degenerative changes of the joint or a disc displacement present in the jaw joint. At times, a psychologist visit may be necessary when feeling very stressed and overwhelmed with life or the facial pain. Our TMJ specialists work with other healthcare practitioners to address all aspects of the TMJ problem.

How does Renaissance work with dental appliances, night guards or splints?

Our TMJ specialists at Renaissance work closely with dentists that also provide night splints to patients to help reduce muscle tension at night. TMJ splints or appliances are thought to protect the teeth and help decompress the joint. At times, splints may initially cause more pain but with the help of our cranio-facial specialists and their hands on manual therapy techniques, much of the pain is relieved. It is always recommended that when dealing with pain while using a splint, the patient have a physical therapist that specializes in TMJ disorder or TMD to also work with the patient during that time.  Many appliances or splints cause a posterior rotation of the cranium on the first vertebrae which may cause headaches if you already have poor posture and limited space at the base of your skull. Therefore, one should know that if your dentist has given you an appliance that is causing more pain, that you could have the specialists at Renaissance also work with your dentist to optimize the ability for you to adapt to your new appliance. We have found that working on the posture and the alignment of the spine will give you enough wiggle room to be able to tolerate your appliance. The cranio-facial specialists at Renaissance know how to work the muscles and joints of the head and neck to help your body accept and tolerate the new dental appliance.

What happens when you lose your alignment due to a forward head posture? For example, while working at the computer and using our smart phones?

  • Our heads move forward which will depress our breast bone or sternum.
  • This causes a posterior rotation of our cranium on our first vertebrae C1.
  • This causes limited space at the base of our skulls and compression of the nerves and arteries that run through the upper neck which many times will eventually cause headaches.
  • As our heads go forward, our mandibles move slightly back causing a change in the TMJ articular disc position with the mandible/jaw bone.  
  • This starts the beginning of a TMJ disc displacement problem which will worsen over time, especially if one clenches while they were on the computer.
  • Our curve of our cervical spine/neck will no longer be lordotic (curved inward) but will change into a straight neck position which loads the neck joints and causes a slow progressive degenerative change to occur.  
  • People wonder why their lower cervical spine ends up wearing down, having degenerative changes such as osteophytes, degenerative disc disease, degenerative joint disease, narrowing between the joint spaces.  As we hang our head forward, the lower cervical spine gets the brunt of the weight and fulcrums off the C5C6 region causing for many a flexed lower cervical spine or a dowager’s hump.
  • As our heads are forward, the muscles that connect our shoulders to the back of the head (such as our upper trapezius muscles)  will take on the weight of the head and neck which starts the process of tension and trigger points which eventually can cause pain to run up and down the head and neck.
  • As our heads are forward the pull of the muscles between the jaw bone and our sternum/breast bone will create tension which leads to clenching.  Many of us are unaware of this and have facial tension all day long.
  • Forward head posture causes the tongue in the mouth to move into a lowered position which reduces our airway support and leads to a decreased amount of space in our throat for breathing and eventually causes snoring in patients during sleep.

What is the TMJ Anatomy?

The temporomandibular joint or TMJ is made up of the articular eminence or fossa of the skull’s temporal bone and the convex shaped condyle of the mandible. There is a bi-concave TMJ disc that is located between these two bones that acts as a shock absorber and a stabilizer between the two convex surfaces. Ligaments also play an important role in stabilizing the TMJ. The ear canal is situated very close to the TMJ which is one reason that patient complain of ear pain.

What are the proper TMJ mechanics?

On opening the mouth, the first part of opening should be a rotation in the joint. The second part of opening consists of a translation in the joint. The disc moves with the condyle as it translates in the joint between the condyle and the fossa of the TMJ.

What are the TMJ muscles of mastication?

The deep and superficial masseter, temporalis, and lateral pterygoid muscles are all chewing muscles that close the mouth. They often become hyperactive and cause excessive compression of the TMJ. Another term for this is bruxism, which can result in jaw pain, headaches and neck pain. The surrounding neck muscles help stabilize the skull during jaw use and function and can also be hyperactive due to poor head on neck posture.

What is bruxism or clenching?

Bad oral habits, such as nail biting, pen biting, biting the inside of the cheek, lip biting, daily clenching, or grinding can be contributing factors that aggravate the TMJ. Our TMJ specialists will teach the patient to reduce bruxism and decrease facial ad neck tension.

What are different causes of TMJ joint related pain?

TMJ disorder or TMD joint related pain may be caused by trauma such as a blow to the face, fall on the chin, or car accident. These types of trauma sometimes cause arthritis to set in. Clenching or bruxism and neck tension also are known to cause TMJ pain and compression, which will eventually aggravate the arthritis.

How does being hypermobile or loose jointed/double jointed affect my TMJ?

Many patients that are hypermobile throughout their body, are “double jointed” or loose jointed can develop pain in the TMJ due to over-stretching of the jaw. The connective tissue and ligaments surrounding the TMJ is looser than normal in patients that are hyper mobile and therefore this may cause problems with stability of the TMJ. These patients tend to have difficulty going to the dentist for dental work and can even have problems dislocating or subluxing the TMJ. If a patient is told that he/she has systemic hypermobility, it is very important to learn proper head on neck posture and exercises to the jaw in order to stay stabilized in the TMJ. This is where the TMJ specialists at Renaissance come in. It is critical to learn the limits of mouth opening when hypermobile so as not to overstretch the joint and cause instability. Over time, when a patient with hyper mobility continues to open past the stable position, this may cause a disc displacement. Our TMJ specialists have manual therapy techniques to reduce TMJ disc displacement to reduce joint noise and clicking.

Is stress management important in the treatment of TMJ dysfunction?

Learning how to reduce ones stress is very important during management of the TMJ. Meditation, yoga, guided imagery, relaxed or diaphragmatic breathing and exercise are effective was to reduce stress. Seeing a psychologist or psychiatrist may also help in reducing stress. The TMJ specialists approach at Renaissance is to work as a team with other healthcare practitioners to address all aspects of the patient’s problem.

What are the different headaches and how are they treated?

Headaches are a common problem for many people. They range in severity and may be minor for some and life altering for others. There are two categories of headaches consisting of primary and secondary headaches. Primary headaches are not a result of another disorder but a constellation of clinical symptoms. This category includes tension type headaches, migraine headaches, and cluster headaches. Secondary headaches are caused by an underlying medical condition, i.e. brain tumor, sinus disease, or stroke.

At Renaissance, the specialized headache PTs will used their manual therapy skills to improve joint mechanics of the upper cervical spine, thoracic spine, and pelvis to make sure that one is in good alignment and using your body appropriately.  THis will start the process of alleviating head and neck, shoulder tension. Dry needling, when appropriate has also been an effective treatment for headaches and has even helped many reduce or eliminate migraine and headache medication. Ultimately, proper breathing mechanics, when restored to normal help patients with reducing anxiety that headaches may cause and also tension of the upper quarter.

How do the Renaissance PTs evaluate Headache patients?

A detailed history is taken from the patient, including questions about work, work related positions, depression, anxiety, diet and family. The pattern of headache is discussed in detail.

Examination of the cranial nerves of the head, and neck is performed. Palpation and joint testing of the head, neck, and jaw muscles and joints are performed in detail.  A full assessment of the patients head on neck position, posture of the body and gait are also performed.

The breathing pattern of the headache patient is examined mechanically and with a capnometer to measure CO2 levels and breath rate.

Radiology tests such as MRI, CT scans, X-rays are requested to further investigate the head and neck.

All the objective findings are compiled and a diagnosis is given to the patient with a treatment plan.

Why does one begin to experience neck Pain?

  • Our heads move forward which will depress our breast bone or sternum.
  • This causes a posterior rotation of our cranium on our first vertebrae C1.
  • This causes limited space at the base of our skulls and compression of the nerves and arteries that run through the upper neck which many times will eventually cause neck pain and even headaches.
  • Our curve of our cervical spine/neck will no longer be lordotic (curved inward) but will change into a straight neck position which loads the neck joints and causes a slow progressive degenerative change to occur.  
  • People wonder why their lower cervical spine ends up wearing down, having degenerative changes such as osteophytes, degenerative disc disease, degenerative joint disease, narrowing between the joint spaces.  As we hang our head forward, the lower cervical spine gets the brunt of the weight and fulcrums off the C5C6 region causing for many a flexed lower cervical spine or a dowager’s hump. This leads to chronic neck pain.
  • As our heads are forward, the muscles that connect our shoulders to the back of the head (such as our upper trapezius muscles)  will take on the weight of the head and neck which starts the process of tension and trigger points which eventually can cause pain to run up and down the head and neck.
  • As our heads stay forward, the front of the neck gets very weak and the posterior neck muscles become very tight and tender.
  • As our heads are forward the pull of the muscles between the jaw bone and our sternum/breast bone will create tension which leads to clenching.  Many of us are unaware of this and have facial tension all day long.
  • Forward head posture causes the tongue in the mouth to move into a lowered position which reduces our airway support and leads to a decreased amount of space in our throat for breathing and eventually causes snoring in patients during sleep.

How do the therapists at Renaissance approach patients with neck pain?

At Renaissance, the specialized head and neck PTs will used their manual therapy skills to improve joint mechanics of the upper cervical spine, thoracic spine, and pelvis to make sure that one is in good alignment and using your body appropriately.  THis will start the process of alleviating head and neck, shoulder tension. Renaissance PTs have been trained in specifically restoring the normal lordotic curve of the neck which is what many patients have lost. Restoring the proper head on neck position along with the natural curve of the neck will reduce compression of the joints and alleviate muscle tension of the head and neck.  Dry needling, when appropriate has also been an effective treatment for neck pain and will be offered during the treatment. Treatment will also include a stabilization of the neck muscles to strengthen the connection of the head onto the neck improper alignment. Ultimately, proper breathing mechanics will be taught to reduce anterior neck tension which occurs with mouth of chest breathing.  We at Renaissance treat the neck pain but always incorporate whole body wellness as our necks are connect to our spine and we must address the whole body unit a successful outcome.

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