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Old 06-19-2008, 04:14 PM   #1
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Advice Needed from TMJ Patients with Success Stories

I am badly in need of advice. My sister is suffering from severe TMJ pain to the point where she can hardly function. She has asked me to seek out advice from individuals who have had severe cases of TMJ (not minor) and have been able to at least manage the pain in order to function.

Specifically, to the extent you can share any forms of treatment that have or have not worked (e.g. acupuncture, massage, etc.) and details (duration, frequency) and any other advice you can offer would be greatly appreciated. Please feel free to go into as much detail with your history (the more info the better) as you feel necessary to help provide an accurate picture.

Thank you in advance for your thoughts.

 
Old 06-19-2008, 06:09 PM   #2
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Re: Advice Needed from TMJ Patients with Success Stories

Well - I am not an expert on tmj but I have an extreme / complicated case as do some other members here. I have had it for 4 years now and have not been able to work let alone function normally as a result and am currently out on disability. So guess I qualify - LOL - just one of the lucky few so I have been told.

What has your sister done in terms of seeking any formal or professional treatment for her tmj? Have any dx tests been done to determine what is wrong or causing it? Does she have any problems with her neck, body pain, muscle twitching or spasms in arms or legs, back or hip pain, trouble walking, etc or is it limited to face and head pain? Is she having trouble with her tongue or moving her jaw or is it basically muscular in nature?

Most alternative therapies and pain mgmt meds will help but they alone are not a permanent solution - although they can help ease the severity of the symptoms.

If pain seems to be the primary symptom you may want to seek out a Pain Mgmt clinic in hospitals or teaching universities and /or dental schools or search under myofacial or orofacial pain syndrome for the nat'l web sites or the sticky post at the top of this forum may list them - it may help you locate a dr or pain mgmt center in your area. Most pain mgmt drug therapies include a anti-spasm and/or muscle relaxant and an anti-depressant - not necessarily to treat depression but some also affect or dull the pain signals received by the brain which can reduce the body's response to pain. Most people go through a trial and error period until the right combination and doseage of drugs is determined that provide some relief, minimal side affects and still allow for a somewhat normal functioning.

In terms of alternatives therapies like PT, accupuncture, chiropractors, cranial sacral therapy, to name a few - most will help reduce the pain and some other symptoms - but not all therapists and drs are trained the same and get the same results so individual responses to treatment may vary - again a person may have to go from one dr to another before they see some positive improvement. The nature of your sister's symptoms and/or root cause of her problem would also dictate what form of therapy might help her best.

Can you provide more info in terms of your sister's symptoms and dental history, how long she has had it, what has she done to in the past to treat it - it might help me as well as others provide you with more specific info or advice. Thanks.

Last edited by Thelma-Louise; 06-19-2008 at 06:15 PM.

 
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Old 06-19-2008, 09:39 PM   #3
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Re: Advice Needed from TMJ Patients with Success Stories

Thelma-Louise

First, thank you so much for taking the time out with such a thoughtful reply. I really appreciate (as I am sure others do on the website) you sharing your experience and hope that you are able to get better soon. With selfless people like you it may guide others to get appropriate help sooner, understand their condition better and mitigate their situation. Also, I apologize for the length of my response but wanted to give you as much info as I could.

I know some but not all of my sister's symptoms and/or history so will do the best I can with what I know. I am going to pose your questions to her and hope to get more comprehensive answers (she is on heavy pain meds right now so sleeps a lot).

My understanding is that it started when she was about 11 shortly after she had orthodontic work which removed a tooth from her lower jaw. It has steadily been growing in pain but had not become severe enough to prove incapacitating until the past couple of years. Throughout this time she saw doctors/dentists but did not have any specific treatment done. Most recently she went to a couple of TMJ dentists (also do cosmetic and orthodontic work) and it was determined after exams and dental X-Rays (is that what you mean by dx) that her jaw is misaligned and her disc is not correctly positioned. The symptoms that she is experiencing/experienced recently:

- eye pain above, below, behind
- pressure behind the eyes

Head Pain, Headache Problems, Facial Pain:
- forehead pain
- temporal pain
- sinus headache under the eyes
- posterior headaches, back of head, with or without shooting pains
- hair and/or scalp painful to touch

Mouth, Face, Cheek, and Chin Problems:
- discomfort or pain to any of these areas
- limited opening
- inability to open the jaw smoothly or evenly
- jaw deviates to one side when opening
- inability to "find bite" with teeth

Teeth and Gum Problems:
- clenching or grinding at night
- looseness and or soreness of back teeth
- tooth pain

Jaw and Jaw Joint Problems:
- clicking, popping jaw joints
- grating sounds
- pain in cheek muscles

Ear Pain, Ear Problems, and Postural Imbalances:
- ringing sounds
- diminished hearing
- ear pain - without infection

Neck and Shoulder Problems:
- stiffness
- neck pain
- tired, sore neck muscles
- shoulder aches
- back pain upper and lower
- arm and finger tingling, numbness

She experienced severe hip and lower back pain (S/I joint) for a long time (3-4 years) several years ago which now has not bothered her thankfully for a while (never correctly diagnosed) but now we are wondering whether this was related to her current TMJ status.

Very recently she has been trying to manage the pain with massages from my mother and seeing an acupuncturist. She has only been to 3 sessions and although the last session helped initially it was somewhat short lived possibly due to a stressful non-recurring situation. She is hoping to try again and see if the effects are more long term if there is no stressful situations involved afterwards. She is also planning on getting evaluated by a physical therapist.

Any additional insight you can provide based on the above would be very helpful!

Again, I can’t thank you enough for your willingness to help and I will write back some more after getting additional info from my sister and pursuing some of the research you suggested. You gave me some stuff to follow up on. It is sometimes tricky to find out the real info on doctors and separate those who have had extensive experience with TMJ and ones that deal with minor situations on a cursory basis. I have been told that some reviews can be suspect as to the source and validity- any suggestions or resources on how to sift through this and get authentic opinions on doctors we are looking at? Phew…that was a long one- please respond at your leisure.

Best,
Bgreene

 
Old 06-19-2008, 10:01 PM   #4
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Re: Advice Needed from TMJ Patients with Success Stories

I have been on Augmentin (antibiotics) for the past 2 weeks and my nerve pain has almost gone. I was diagnosed with TMJ. The ENT I saw for inner ear pain and loss of balance, nausea etc said it was TMJ. A CT scan showed some arthritis in that area (early stage apparently).
After the augmentin settled the pain in cincentrated on a tooth and jaw above it. I went to an endodontist. He found 3 dark areas, presumably at least one source of infection, in my jaw above that hurting tooth..who knows maybe moreinfection about. It still hurts a little behind my right ear.SI joint also affected as is stiff neck and it felt like nonstop trigeminal neuraliagia.. not on -off,. I've been told by the endodontist that my problems were not caused by the jaw infection. This infection didnt show up in a CT scan or OPG and I'd been 5 times to 3 different dentists, and an oral-maxilofacial surgeon who said my TMJ did not need operating on as mild... no holes etc.found.
Maybe worth checking if even only by trialling some broad based penicillin type antibiotoic for 5 days? I know its difficult to get. It took me 3 weeks of begging at docs, but it was worth it. ..I noticed improvement within 2 days and every day has been better, so if it is an infection that reposnds to Augmentin and it is fairly broad, then you'd know it within 4 days. If no improvement that is not your answer:-)
only a suggestion of course.
I found that half the transplant deaths are from undiagnosed infection in teeth and relating to teeth.
mY need to clench and grind has dimishedand the ability to relax my facial muscles has , my ability to concentrate and recall is improving, my anxiety is still there but lifting
Hoe this may help you or someone out there
jan

Last edited by jandi; 06-19-2008 at 10:17 PM.

 
Old 06-20-2008, 08:46 PM   #5
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Re: Advice Needed from TMJ Patients with Success Stories

Sadly - prior orthodontic treatment in which teeth were removed (primarily bicuspids) is one of the main causes of tmj in later years. What's worse is most people believe or are told they need to have it done or are doing the right thing in having orthodontic treatment (and there are those like myself who just wanted the perfect smile) not knowing that there is a chance they may develop tmj or problems down the road - I for one wish I had my old crooked teeth back.

If your sister was diagnosed with an incorrectly positoned disc and mis-aligned jaw, what were the options recommended by the tmj dentist or orthodontists she did see - chances are it involved splint therapy followed by braces again or did any of them suggest orthognathic surgery to re-align her jaw and then braces to move the teeth to a better position which would prevent this from recurring.

You are right - it is very hard finding a knowledgeable tmj dentist - some are really cosmetic dentists in drag or just egomaniacs that really are not qualified to treat tmj but think they can since they attended a one day seminar on it and have a plaque to hang on their wall to prove it. I have found sometimes the good ones do not advertise themselves that much.

Have you checked the Great TMJ Dr sticky post at the top of this forum - members who have been helped by their drs can post their drs name there so others might benefit from them as well - however sometimes a dr may be able to help one person but not another - as no 2 individuals or problems are exactly the same - but its worth a shot.

Has she seen a holistic dentist or neuromuscular dentist or one that deals in bio-aethestics? These types of drs each take a different approach in treating tmj in terms of the appliances used to reposition the jaw and disc and tend to consider the entire body in treating tmj and not just the mouth.

You may want to search under FJO (functional jaw orthotics) - dentists that are trained in FJO - usually have a better understanding of the musculo-skeletal and structural components of the body and are more familiar with the widespread symptoms that can result. The types of dentist mentioned above should have FJO qulaifications listed within their credentials.

Try and search for a chiro under ICAK - applied kinesiology - they are very good in addressing torquing and derangement (distortion or or mis-alignment, there can be many terms for it depending on the dr) caused by tmj. The adjustments are not painful - no manual cracking or anything like that - its more based on simple step by step movements that guide the body back to being balanced and aligned. Once the jaw deviates it generally pushes against the c-spine and knocks the spine out of alignment which accounts for most of the widepread body symptoms. Getting the c-spine, spine and pelvis back to where they belong will partly help bring this back to just "a disc" issue. A good tmj dentist generally refers their patients to a chiro while undergoing tmj treatment as well since it is very important that the neck and pelvis be aligned while the jaw is being repositioned - there is no reason to wait until a dentist is found or chosen however - also a good cranial chiro (as ICAK drs are oftened called) may also know of a really good tmj dentist.

Have your sister ask her regular dr for a referral for Physical Therapy (PT) - it is usually covered by most medical insurances. Look for a therapist trained in tmj or sports medicine. A good therapy session usually is an hour long and may include heat packs, ultra sound, back, neck and head massage, and use of tens unit - my insurance covered 2 sets of 8 week (2x weekly) rounds. They will not help with the disc issue but will help the affected muscles (and overall musculo-skeletal structure) to relax and help her deal better with the chronic pain.

Criteria for selecting the right dr - well that's a hard one since I have met drs that met the criteria but still were not able to help me - I am on my 5th dr currently and always keep a pending list of other drs just in case this "one" doesn't work out - LOL - but based on my experience here are some things to look for:

There is s stickly post at the top of this forum that lists some nat'l orgs for TMJ, Cranial or Myofacial Pain Syndrome, etc - a dentist should belong to several of these orgs - I believe there are 4 main ones although I can't recall their actual names or the title of the sticky post right now (took my night time meds a little while ago).

A thorough examination - this includes in no specific order: a tomogram or MRI or ICAT, muscle response or pressure point testing of the arms or legs, postural examination, a lengthy questionairre that includes asking the patient about their dental and medical history and to map their body pain on a body chart, an oral examination to check for jaw mobility (forward, back and lateral), listening for joint noises (crepitus, cracking, popping) upon opening and closing - which may require the dr to put his fingers in the ears or use a stethis scope, and overall examination of the facial and jaw msucles for tightness, spasm, tenderness, etc.

Don't fall for glitz or glamor - don't be fooled by a drs reputation as a miracle healer even if his web site seems awesome- most should tell you there is no guarantee to successful treatment - a good dr that is honest will not promise anything or falsely mislead the patient to think they alone can fix their problem and their office should be well run and professional. If they offer plasma tvs and hand waxing ,etc. while these amenities are nice, you pay for it and personally I feel it undermines the seriousness of tmj - let's face it, if you have tmj do you really enjoy watching tv or having someone rub hot wax on your hands when all you can think about is when your pain is going to stop?

A good dr will or may be terse - straight to the point and doesn't pooh pooh his patients - he should be available either to speak with by phone or for emergency visits - if he's only in the office 2-3 times a week it can be frustrating. Also, he himself should be providing the treatment - not his assistants.

Of course fincances will come into play - they always do - but don't be fooled into thinking a high priced dentist is better than someone who's fees are modest. Some of the dental treatments - primarliy splints or orthotics - may be covered by medical insurance (dental insurance may cover some of it but its usually limited) - so a well run office should be able to either submit claims on your behalf or provide you with a claim you can submit yourself. If a dentist uses accupuncture or the tens unit during a visit, they may be able to submit these for you for reimbursement which helps offset their fees that are not covered.

Lastly - you may find in your search very different recommendations from drs in terms of treatments - there is no way, as far as I know of a full proof approach of deciding which dr is correct and which treatment will work - we are afterall relying an "experts" to advise us. Obviously the treatment should make sense, have some logic and facts behind it - most people will opt for conservative and non-surgical approaches first which makes the most sense - the other more invasive (and riskier) treatments will always be an option down the road should the less invasive or conservative approaches not work.

Ok - now I wrote a book - hopefully that gives you some more to think about - if it didn't put you to sleep by now. Keep in mind - obviously this is based on my personal experience - hopefully others will add to what I may have left out or have overlooked and provide some advice based on what they have gone through.

Last edited by Thelma-Louise; 06-20-2008 at 08:53 PM.

 
The Following User Says Thank You to Thelma-Louise For This Useful Post:
jeanharlow (04-26-2012)
Old 05-27-2009, 09:13 AM   #6
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Re: Advice Needed from TMJ Patients with Success Stories

Quote:
Originally Posted by bgreene View Post
Thelma-Louise

First, thank you so much for taking the time out with such a thoughtful reply. I really appreciate (as I am sure others do on the website) you sharing your experience and hope that you are able to get better soon. With selfless people like you it may guide others to get appropriate help sooner, understand their condition better and mitigate their situation. Also, I apologize for the length of my response but wanted to give you as much info as I could.

I know some but not all of my sister's symptoms and/or history so will do the best I can with what I know. I am going to pose your questions to her and hope to get more comprehensive answers (she is on heavy pain meds right now so sleeps a lot).

My understanding is that it started when she was about 11 shortly after she had orthodontic work which removed a tooth from her lower jaw. It has steadily been growing in pain but had not become severe enough to prove incapacitating until the past couple of years. Throughout this time she saw doctors/dentists but did not have any specific treatment done. Most recently she went to a couple of TMJ dentists (also do cosmetic and orthodontic work) and it was determined after exams and dental X-Rays (is that what you mean by dx) that her jaw is misaligned and her disc is not correctly positioned. The symptoms that she is experiencing/experienced recently:

- eye pain above, below, behind
- pressure behind the eyes

Head Pain, Headache Problems, Facial Pain:
- forehead pain
- temporal pain
- sinus headache under the eyes
- posterior headaches, back of head, with or without shooting pains
- hair and/or scalp painful to touch

Mouth, Face, Cheek, and Chin Problems:
- discomfort or pain to any of these areas
- limited opening
- inability to open the jaw smoothly or evenly
- jaw deviates to one side when opening
- inability to "find bite" with teeth

Teeth and Gum Problems:
- clenching or grinding at night
- looseness and or soreness of back teeth
- tooth pain

Jaw and Jaw Joint Problems:
- clicking, popping jaw joints
- grating sounds
- pain in cheek muscles

Ear Pain, Ear Problems, and Postural Imbalances:
- ringing sounds
- diminished hearing
- ear pain - without infection

Neck and Shoulder Problems:
- stiffness
- neck pain
- tired, sore neck muscles
- shoulder aches
- back pain upper and lower
- arm and finger tingling, numbness

She experienced severe hip and lower back pain (S/I joint) for a long time (3-4 years) several years ago which now has not bothered her thankfully for a while (never correctly diagnosed) but now we are wondering whether this was related to her current TMJ status.

Very recently she has been trying to manage the pain with massages from my mother and seeing an acupuncturist. She has only been to 3 sessions and although the last session helped initially it was somewhat short lived possibly due to a stressful non-recurring situation. She is hoping to try again and see if the effects are more long term if there is no stressful situations involved afterwards. She is also planning on getting evaluated by a physical therapist.

Any additional insight you can provide based on the above would be very helpful!

Again, I can’t thank you enough for your willingness to help and I will write back some more after getting additional info from my sister and pursuing some of the research you suggested. You gave me some stuff to follow up on. It is sometimes tricky to find out the real info on doctors and separate those who have had extensive experience with TMJ and ones that deal with minor situations on a cursory basis. I have been told that some reviews can be suspect as to the source and validity- any suggestions or resources on how to sift through this and get authentic opinions on doctors we are looking at? Phew…that was a long one- please respond at your leisure.

Best,
Bgreene
Hi there--I know your post is from 2yrs. ago, but I wanted to get in touch with you about how your sister is doing, and who she started to see for treatment. Her list of symptoms is almost identical to mine since this past Feb. Please let me know info on her treatment, and I hope she has gotten better since 08'. Thanks!! J.

 
Old 05-27-2009, 09:37 PM   #7
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Re: Advice Needed from TMJ Patients with Success Stories

Hi jmitchell,
I am glad you pointed out that the chain of posts was from 2008!! I was almost about to comment and help that sister with what I know.

Well, in her case I am almost 99% what the cause was.
Even if your case is similar I can't just give any suggestions until I'll know some more.
Interestingly as I thought about it my suggestions in some sense will be the same but might not be the same and this is why if you can share more of what is your tmj story and symptoms I'll try to share what I learned in 9 1/2years.

 
Old 05-28-2009, 07:02 AM   #8
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Re: Advice Needed from TMJ Patients with Success Stories

HI--Thanks for responding so quick. i'm at my wits end. Here goes with my story. I had braces done in highschool, I had impacted wisdom teeth removed first, and then braces for almost 2 yrs. My teeth really weren't that crooked, I just wanted the top teeth straightened a bit. Big mistake. Half way through started the muscle spasms around my joints. The doctor basically shooshed me and said use a heating pad. He was of no help. I had the braces removed, and at the time, I didnt' really notice it, but I definitely do now that when I smile , I'm all gums, and he brought my bite into a very narrow bite. Every doc. that I see now says the vertical dimension of my face is remarkably wrong, and with the high cheekbones I have, I should have a really wide smile. (I used to.) Anyways, then came 2 episodes of locking closed, major muscle spasms over the years, grating sounds in my left joint. I tried splint therapy, and did very well with it, being able to only use one @ night for the past 9 yrs. or so. Which leads me to this past Feb. I went in to my tmj doc. and I wanted to have him check the splint, and possibly make me a new one for nighttime because this one was so old. He did a couple of adjustments on it, and I went home. That night, when I laid down to sleep, I could feel that the adjustment made it feel not equal and comfortable , but I had no choice to sleep with it because I'm always afraid I'm going to lock again. Sure enough, that morning I woke up in total spasms in my head especially around the joints, and the right joint which was my good side ever since has had sounds of grating, popping when I chew, or lay down, or bend over a certain way, and my left side which has had grating sounds for ever is much much worse. It's like wearing the damn thing for one night caused major damage to my joints. I'm trying to get back into splint therapy day/night, but we are having a heck of a time getting me comfortable. I'm in tremendous muscular pain, with headaches I've never had in my life, also sometimes my balance is off, pain behind eyes, pain in temples, light sensitivity, extreme fatigue and some dizziness. I have 2 little girls too that need my attention, and I'm scared to death that this won't be resolved any time soon. I'm looking for a new doc. in the Northern IL. area to help. Sorry this is so long. Any suggestions would be greatly apprec.!!!! Take care--Jill.

 
Old 05-28-2009, 03:14 PM   #9
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Re: Advice Needed from TMJ Patients with Success Stories

First of all I know all how it feels!
Yah, you too lost the VDO and moreover at the same time your jaw was pushed to the back (thus closed lock) limiting all your muscles with the space and freedom they need.

What to do?
First, learn to relax your jaw and the whole body. Seems like you have a good awareness of your muscles (which most of dentists hate!!!); try to increase it even more. In your case probably placing the tongue on the inside of the front teeth is not a solution (I mean temp solution) b/c your fronts are likely too close for that. But you can try.
Anything that will stop your jaw from closing at the height that you have is good.

So focus on letting your jaw drop down. Try to bite on smth like a "pad" from a paper towel or ask for dental cotton rolls and so on.
B/c it's not hard as a splint it will allow your jaw to balance in left and right.
Oh, for you an aquilizer might be a good idea. And it's cheap to try compared to dental treatments. I think I ordered some for about $25 each or so. It's like biting on two tiny plastic "bags" filled with water.

They are not recommended for sleeping. When I was abandoned in an emergency situation created by a well-respected dentist from Dawson's Center in Florida without ANY usable temps and with the ruined temps in which I came in I just could not sleep w/o choking and suffocating. So I tried to sleep with the aquilizer. In a few nights I chewed it through and the liquid was gone. I also got a blister under my lip. But at least it helped to regain some consciousness and control and not to kill myself right there.

You might also benefit from anything that relaxes the body and the neck muscles, like heat pads and so on. I found a good shiatsu massage being of a great help.
It is also essential to focus on keeping the correct posture. Imagine growing taller from your neck and dropping the shoulders at the same time. I bet your shoulders are up and the head is into them. Is that so?

Breathe and think about elongating the spine and being more relaxed everywhere while dropping the jaw down.
This is what we can do to survive. It's not a solution of course,

You will need a good comfy splint that's for sure and then restore your VDO somehow. It all depends on your dental situation.
Just keep in mind that it's not good to allow dentists to make any irreversible changes unless they are "backed up" in some way!!
Hope that helps.

 
Old 05-29-2009, 07:30 AM   #10
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Re: Advice Needed from TMJ Patients with Success Stories

Quote:
Originally Posted by StillHope View Post
First of all I know all how it feels!
Yah, you too lost the VDO and moreover at the same time your jaw was pushed to the back (thus closed lock) limiting all your muscles with the space and freedom they need.

What to do?
First, learn to relax your jaw and the whole body. Seems like you have a good awareness of your muscles (which most of dentists hate!!!); try to increase it even more. In your case probably placing the tongue on the inside of the front teeth is not a solution (I mean temp solution) b/c your fronts are likely too close for that. But you can try.
Anything that will stop your jaw from closing at the height that you have is good.

So focus on letting your jaw drop down. Try to bite on smth like a "pad" from a paper towel or ask for dental cotton rolls and so on.
B/c it's not hard as a splint it will allow your jaw to balance in left and right.
Oh, for you an aquilizer might be a good idea. And it's cheap to try compared to dental treatments. I think I ordered some for about $25 each or so. It's like biting on two tiny plastic "bags" filled with water.

They are not recommended for sleeping. When I was abandoned in an emergency situation created by a well-respected dentist from Dawson's Center in Florida without ANY usable temps and with the ruined temps in which I came in I just could not sleep w/o choking and suffocating. So I tried to sleep with the aquilizer. In a few nights I chewed it through and the liquid was gone. I also got a blister under my lip. But at least it helped to regain some consciousness and control and not to kill myself right there.

You might also benefit from anything that relaxes the body and the neck muscles, like heat pads and so on. I found a good shiatsu massage being of a great help.
It is also essential to focus on keeping the correct posture. Imagine growing taller from your neck and dropping the shoulders at the same time. I bet your shoulders are up and the head is into them. Is that so?

Breathe and think about elongating the spine and being more relaxed everywhere while dropping the jaw down.
This is what we can do to survive. It's not a solution of course,

You will need a good comfy splint that's for sure and then restore your VDO somehow. It all depends on your dental situation.
Just keep in mind that it's not good to allow dentists to make any irreversible changes unless they are "backed up" in some way!!
Hope that helps.
Thanks for the info!! I did actually try the aqualizer temp. , but it was of no help to me. Right now I really need to find someone who understands what's going on with my joints, muscles, and exactly how to stabalize my bite, and get me out of this constant pain. If I have to wear a splint 24/7 again, that's ok, but I would like to get to a specialist to see if I actually can get this fixed , not just bandaid my symptoms. I'm about to travel to Chicago if I have to to see Dr, Goldman, who Maxwell recommended to me. Anyone know of anybody whose been treated by him?? please let me know.. Thanks! J.

 
Old 05-31-2009, 10:44 AM   #11
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Re: Advice Needed from TMJ Patients with Success Stories

A splint helped me when I wore it while sleeping, now I don't have one cause my yorkie chewed it up, but medications so far have failed to work including strong pain medications, anti-inflammatory meds, & Flexeril, but I am going to try Soma, a corticosteriod, & migrane medication to see if that works. I've also noticed 2 things that make it worse, dental work + antidepressants. Will let you know how it goes.

 
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