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TMD and the Medical Food Chain

By: Dr. Louis Giordano and Shannon DeAngelo

So you’ve been experiencing head/face/ear pain. Maybe the pain just started, or maybe you’ve had it a while and it’s gotten worse. You’ve been to your medical doctor who referred you to the ENT who, in turn, referred you to the neurologist who referred you for an MRI of your head- all of this legwork and expense to tell you there is “nothing wrong.” Hmmm….so now you try the chiropractor, massage therapist, acupuncturist, physical therapist, and/or just about any profession that you think might help. And after all that, you still have the same head/face/ear pain you started out with. You’ve also probably amassed an interesting array of drugs that haven’t resolved your problem, but have likely caused more issues for you due to their side effects. Sound familiar? This is how about 80% of our TMD (Temporomandibular Joint Dysfunction/Disorders) patients present. They have been seeking a solution for months or longer to no avail. Their frustration is palpable; their hope is diminished; and their patience is spent. They come to our office desperately hoping that by some miracle we will be able to tell them what is wrong and that we will be able to fix it. As we do our initial work up and discuss how all of their symptoms are related to TMD (we call this connecting the dots), we begin to see the light of hope in our patients’ eyes. At the conclusion of the initial appointment, when they realize we have successfully helped countless others just like them, our patients’ relief is often evident by their tears. It breaks my heart to think these patients have been through so much and suffered so long for something we can treat and have been successfully treating for the last 25 years.

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Treating TMD is not always easy, but it is rarely impossible. TMJ disorders can be very complicated as no two people ever have the same exact condition. Patients who suffer from this disease often have multiple issues occurring simultaneously due to the nature of these disorders. For instance, there can be physical changes (often felt as neck, back, and/or hip etc. pain due to your body moving away from the pain) and/or chemical changes (elevation in your “wake up” hormone, cortisol, that affects your sleep, etc.) that happen as a result of a TMJ disorder. For these reasons, when necessary, we work with a team of professionals to help get you better. The key phrase is “when necessary.” Our goal is to do as little to patients as necessary to get them better. The body knows how to heal. Sometimes it just needs a little help.

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TM Disorders can be very complex by nature. It is critically important to understand all the nuances of the disorder that we are treating so that we can be successful. The key to successful treatment is an accurate diagnosis. TMJ disorders can be muscular or structural and often a combination of both. Sometimes the primary issue might not be your jaw at all. It might be that your TMD is a secondary issue. Improper diagnosis/treatment can make you worse. It’s why there is so much TMJ therapy failure. We have spent the last 25 years in more than 1500 hours of continuing education for treatment of both TMD and sleep disorders, and we still continue to learn from each patient we treat. We are doing our best to educate our local professional community to help patients avoid going through the medical food chain so that they can get treatment sooner! You can help, too, by helping us spread the word! For more information, visit our website: binghamtontmjandsleep.com

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Case #1

This patient came to see us after breaking his tooth while playing football. He brought the broken piece with him. I was able to use the combination of the broken piece and composite (tooth-colored) bonding to repair this tooth. If I didn’t show you the picture, would you have known which tooth broke?

There is a difference!

The inability to tell that the tooth was broken in the first place is the true sign of mastery. This repair was done in 45 minutes. The patient and his parents were both relieved and pleased with this great result.

Most offices would have done a root canal, post and crown. I used a very conservative approach which was the most appropriate choice for this young patient. Might this patient need a root canal, post or crown in the future? ….Yes, it is a possibility. But putting it off for as long as possible is better for the overall health of the tooth and ultimately the patient! And there is always the possibility that the tooth won’t need any further treatment!

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Case #2

This patient and her family had left the practice to go to a dentist who “took their insurance” in order to save money. When this young patient left, she was decay free and dentally healthy. In fact, she had only had one very small, single-surface filling in her life. Six months later she went to the “new” dentist. The “new” dentist found multiple areas of “deep” decay and treatment planned them for large fillings. The patient returned to their office and had 2 large composite (tooth-colored) fillings on the upper right. She immediately began to have pain. She returned multiple times to have them adjusted. The adjustments did not resolve the discomfort, so the dentist decided to remove the composite fillings and replace them with silver (amalgam) fillings. The pain still did not resolve. More than a year later, the patient was still having discomfort. Her dentist told her that she was “acting like a girl and to toughen up.” The parents and the patient had had it and called our office for help. Frustrated and still in pain, she returned to our office to have me evaluate the area.

The photo and x-ray on the left are how the patient presented to our office for her evaluation. The silver fillings were only a few months old and were chipping out and the contact was very tight, so much so that the patient couldn’t get floss between them. Plus, the teeth were sensitive to cold and biting. She also reported sensitivity to the gums on the left side because she hadn’t been able to chew on the right side for more than a year. In addition, the teeth were mobile because she was hitting heavily on them. It should be noted that this patient has excellent dental hygiene. The photo and x-ray on your right represent the final fillings I did for this patient. She now reports that “her teeth have never felt better.”

There is a difference!

First of all, a dentist should only do what actually needs to be done. Second, the work should be done well with the intention of it lasting and not failing. A dentist should never being doing unnecessary or poor treatment based on the production they need to make for signing on with a PPO. Third, it is not normal for pain and discomfort to continue after having a filling. Finally, telling any patient: “you’re acting like a girl and toughen up” is deeply inappropriate and as uncaring as you can get. I listen to my patients, recommend only what the patient needs, and take all the time I need to do the work well. That is a big difference!

The Testimonial:

“A couple of years ago, I was overwhelmed with the rising cost of college tuition and all other things. I decided to take my family to a dentist who was a participating provider in my insurance plan. We went to another local dentist. Biggest mistake of my life! While most of us just got cleanings, my daughter was told she needed two fillings. She had nothing but problems once they were drilled and filled. The dentist told her that she was acting like a girl and to “toughen up”. She went back to Dr. Giordano and after a few visits, her teeth are fine again. She suffered for two years. We all went back to Dr. Giordano!! He is a great dentist.”

E.S.

Endwell, N.Y.

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Case #3

The proverbial hockey player: This patient got hit in the mouth with a hockey puck. He wasn’t wearing a mouthguard. You can see that he had a combination of lost teeth, as well as injured teeth. This wasn’t a quick fix. The patient wore a temporary partial to replace his missing upper tooth during the process so that he could smile. The upper tooth that was knocked out was replaced with an implant. The tooth next to it was repaired with composite (tooth-colored) bonding, as were the lower teeth. Orthodontics were used to close the lower space and correct the tooth crowding of the lower teeth. In-office whitening was done prior to restoring any teeth.

There is a difference!

While there may have been other quicker options for treatment (such as removable partials), taking the time to do what was best for the patient and to do it well resulted in a beautiful, healthy smile that doesn’t have to be removed and left in a cup overnight! It also resulted in a well-balanced bite that will keep his smile and surrounding structures healthy for many years to come. Oh, by the way, I also made the patient a custom mouthguard that he wears every time he plays hockey!

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Case #4

This patient wanted her spaces on the top and bottom closed. She was embarking on a new career and wanted a smile that could make her feel confident. I used a combination of in- office whitening and composite (tooth-colored) bonding. I then free-hand sculpted filling material on four of the front teeth to achieve the beautiful smile you see on your right.

There is a difference!

It takes a great deal of artistic skill to sculpt well. It’s necessary to have abundant patience, as well as skill when performing dental work. My abilities and attention to detail are clearly represented here. Note the perfect shade matching, shaping of the teeth, the closure of the spaces, smooth edges and balanced bite. All of this attention to detail ensures not only that the teeth look beautiful the day that they are done, but that they remain beautiful for many years to come. The patient has been able to keep her smile healthy because she has been able to floss and brush well. The result: A smile that was completed more than 12 years ago that has required no additional maintenance in order to remain beautiful.

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Case #5

This patient presented to our office with the smile on your left. She was very unhappy with her smile. Combining whitening, crowns, composite (tooth-colored) fillings, and artistic skill, I was able to give her the beautiful smile on your right.

There is a difference!

I understand how much a beautiful and healthy smile can mean to someone. It’s what people will notice first. It’s hard to feel good about yourself when you are embarrassed to smile. Giving someone the ability to smile is like giving a gift. Their whole face just lights up! I also feel that it is important that dental work be done well so it can last for many years. This smile was created more than 11 years ago and is still just as beautiful today.

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July 16th, 2015: My first retie!

Here I am, six weeks out. The pain has lessened considerably. My teeth have already started to shift, which is awesome. I can eat regular food (though I still have baby food for snacks, just in case!). And my braces now seem normal—to me, at least.

A number of our patients have stopped to comment on my braces, wondering who my orthodontist is. Yes, Dr. Giordano does braces! And I’m glad he does. As I started to say two posts ago, I had some potentially major issues with my mouth—ones that I didn’t realize were there until I became Dr. Giordano’s patient.

When I started working at Dr. Giordano’s office, he advised me that my bite was off. Basically, that means that my teeth don’t come together properly when I chew. Over time, this has resulted in some of my gum tissue pulling away from my teeth—not a dire issue, but not a good one to have either. Left unaddressed, gum recession can worsen, which could result in more serious problems down the line. Hence the need for braces.
More updates to come soon!

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June 8, 2015: My first bracket comes off

Five days in and my first bracket (i.e. one of my braces) popped off. Full disclosure: This particular bracket had a hook that was digging into my inner cheek. I had asked Dr. Giordano to try bending back the offensive hook. In his effort to do so, the little bugger came off. I didn’t relish having it put back on. The process of putting braces on the teeth is not glamorous: you have to etch the surface of each tooth with acid (read: a solution that tastes like bile) to help adhere the metal to your tooth enamel. You also have to have your mouth opened absurdly wide so that the dentist and his assistant can do their work. It’s a bit like eating your veggies as a kid: you really don’t like doing it, but you know it’s for a good cause. And, truly lucky me, I have the best people doing the job. But yes, it’s not pleasant. I won’t sugar coat it.

In fact, being an adult with braces comes with some additional not-so-fun add-ons. For instance, since I’m that much older than the teenagers who are the usual candidates for orthodontic work, my bones are that much harder and less inclined to move. Hence, the pain I experienced after my June 3rd appointment (when I got my braces put on), was at a higher level that most. I could barely eat. Not fun. I still can’t really eat normal food. But it’s not all bad. I rediscovered the joys of baby food. Seriously. There’s some high end, quality purees out there like purple carrot, apple, and spinach. So at least vegetables will taste good! ;o)

Also, I can already feel my mouth changing. More to come on that soon!

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June 3, 2015: I officially become a teenager

Today was the big day. Metal braces. The kind that shine when you smile. The kind that prompt your younger brother to gleefully call you: Brace Face. Yes, that’s me, good ol’ Metal Mouth. Except I’m not a teenager. I’m 31. And I have braces.

This sounds like a confession, something that I’d rather hide, but, honestly, I was excited for today. I’ll admit, it’s a bit painful. My mouth is not too pleased at having to make room for all this extra “stuff,” but I’m happy. It’s a step in the right direction on my journey to better oral and overall health.

Before coming to work for Dr. Giordano, I always thought I had a relatively “healthy” mouth: no cavities, good oral hygiene, and always on time for my 6 month cleaning. And I had been told as a teen that I “didn’t need braces.” However, working in a dental office makes you keenly aware that what you might perceive as “normal and healthy” is not necessarily so. The body is very good at adapting to situations that are not ideal. It’s a good trait to have. Our adaptability has allowed our species to both thrive and survive. However, just because something is, does not mean that it should be. Such was the case with my mouth…

To Be Continued…

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Lynn Acton Testimonial

Dr. Giordano’s method of treating TMJ is in a class by itself. I discovered this after 40 years of pain, treatment attempts by four other dentists, and more consultations than I can count.
Headaches and neck pain were a permanent part of my life for decades. Every day was a balancing act between how much pain I could tolerate and how much ibuprofen I dared take. I have a drawer full of useless appliances, a few of which actually provided temporary relief, especially if I didn’t need to eat or talk. I have a sleep disorder which was finally diagnosed, after 3 sleep studies, as “alpha intrusions”. I never went into a deep sleep because I had to monitor my sleeping position to avoid waking up with an excruciating headache.

The dental specialists I was referred to recommended jaw-breaking (literally) surgical solutions that sounded like they could create even more painful problems. My family dentist discouraged me from seeing Dr. Giordano, saying he was just a “regular dentist”, not a specialist. I understand now that is only because treating TMJ problems is not considered a specialty.
Then I went to another dentist who promised relief without surgery, and who delivered, almost immediately, a temporary devise. But that devise needed to be replaced almost weekly. The temporary period of waiting for my TMJ position to stabilize stretched into many months, then 2 years, with regular treatments and payments. When it became apparent that a long term solution was not forthcoming, I renewed my search for help.

Sometimes I didn’t get past the initial phone call. “Your back teeth don’t meet? Oh no, we don’t treat problems that serious.” One refused to see me without a referral from the dentist currently “treating” me, the one with the permanently temporary plan. The dentists I did see indicated that my bite was amongst the worst they had ever seen, and declined to treat me for fear of undoing the progress I had made.

I was referred to Strong Memorial hospital in Rochester, to a dentist who was billed as a highly respected expert in TMJ problems. He recommended that since my pain level was now tolerable, I should just continue to wear the appliance I had. Meanwhile, his students lined up the assortment of appliances I’d brought to show him what didn’t work, and took pictures.
When I met Dr. Giordano, I asked my usual question, “Is this the worst bite you’ve ever seen?” He was the first dentist to say, “Not even close”. (His assistant assured me that her bite had the dubious honor.) His exam was also unique. In addition to taking x-rays, he touched every muscle in my head, neck and shoulders, finding sore spots I had ignored for years. He wiggled each tooth, finding too many loose.

Dr. Giordano suggested that I needn’t settle for just keeping pain to a tolerable level; I might live without pain. He was right. My ibuprofen consumption has dropped from 4-6 tablets a day to 1 or 2 a month, usually for something other than my TMJ. My chiropractic visits for neck adjustments have dwindled to zero. I can sleep on my left side for the first time in 40 years.­
There were blips in my progress, as one might expect in addressing a long term problem. Many patient, meticulous adjustments were required before my orthotic consistently relieved my pain. More adjustments were needed over time. Sometimes an adjustment would feel “wrong” at first, triggering pain and the panicked feeling that all my progress would be lost. Usually within a few days my jaw would settle to a new and more comfortable position. If not, Dr. Giordano “adjusted the adjustment”.

I am still comfortably wearing the first orthotic that Dr. Giordano made for me 3 years ago, and I am confident that when it wears out he will produce another successful one. My only complaint is that he has not yet promised me that he will never retire!”

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