The December 8th meeting of the East Bay Headache Support Group was held in the Ball Auditorium at John Muir Medical Center with 30 people in attendance. William R. Danzig, D.D.S., a dentist with a practice limited to orofacial pain and temporomandibular (commonly known as "TMJ") disorders, was our featured speaker. There were about seven new people in the audience who came as a result of our recent paid advertisement in the Contra Costa Times.

Dr. Danzig began by saying there are over 300 causes of headache, and there is no one person who has a magic pill to get rid of the problem. After many years in dentistry, Dr. Danzig now is a limited specialist who only treats patients with TMJ problems. He prefers a team approach to helping his patients. He has them see a biofeedback therapist and a physical therapist as well as himself, as they bring an understanding of physiology to the table. It helps to have an understanding of how the body works. He introduced two biofeedback therapists, Shirley May and Ellen Place, both R.N.’s, and a physical therapist, Arlyn Van Dyke.

Dr. Danzig presented a video on TMJ anatomy and pathology. The video was made in Sweden in 1985, and displayed a number of different temporomandibular joint problems. It was very useful in helping us understand the anatomy of the temporomandibular joint and surrounding muscles, and the changes that can occur to cause pain.

Dr. Danzig explained that the difference between experiencing pain in your head and pain in your knee is that pain in your head is a lot more threatening.

Years ago, Dr. Danzig injected his TMJ patients with xylocaine. He said a lot of pain caused by problems with the temporomandibular joint and muscles behind it can refer pain to the area of your eyes. It can even make you photosensitive (sensitive to light). This pain may even play a role in the "mixed" headache.

In 1992 Dr. Danzig wrote a paper with Shirley May on the "Effect of an Anesthetic Injected into the Temporomandibular Joint Space in Patients with TMD," which is attached for your review. He discovered that he could give an injection on one side and the patient might tell him that the pain on the other side of her head was improved. One can get a lot of referred pain, from the TMJ, from muscles, etc.

When doctors first starting using MRI’s (magnetic resonance imaging), replacement surgery was very popular. And then arthroscopy was developed. Dr. Danzig said he used to operate on ten to fifteen patients a year, but as the practice of treating TMJ problems has evolved, in the past five years he has not performed a single surgery.

He stated that 33% of the population has TMJ problems, but apparently without pain. Some problems may be caused by displaced disks.

When Dr. Danzig first began practicing dentistry thirty-five years ago, the general rule was that dentists just worked at changing their patient’s bites. Years ago dentists treated TMJ problems in a very mechanical way by realigning the teeth. He noted that some of his patients got better when the teeth were ground and realigned, while some others did not.

Now TMJ problems are treated as a physical phenomena, using biofeedback and other disciplines.

The capsule can thicken and stiffen and get painful, but appliances can be used between teeth until the disk becomes fibrous. Dr. Danzig mentioned that sometimes whiplash patients will compain of pain in their temporomandibular joint. He mentioned four types of arthridities, and also the supporting tissues (muscles) can produce pain and headache. It is important to make a differential diagnosis as to what is wrong. It can be a vascular, muscular (myofascial), or joint problem.

If a person experiences chronic pain for six or more months, it will change his personality. He may become angry, irritable, depressed.

Dr. Danzig said that dentists are paying less attention to a TMJ patient’s teeth and occlusion then they did years ago. Today, if the patient is pain free, Dr. Danzig won’t touch the TMJ patient’s teeth (if they use an appliance).

Biofeedback therapists observe the way we hold our bodies, whether we are tense or relaxed, and teach the patient to relax to reduce pain. The only time your teeth should touch is when you chew and swallow. If your tongue appears scalloped along the edges, it means that you’ve been bracing it against the roof of your mouth, and if a muscle is contracted for a long time it can trigger a headache—maybe even a vascular headache.

If you experience injury in the cervical region (neck), it can refer pain to the head, and vice versa.

At the end of Dr. Danzig’s presentation he asked for questions from the audience. One person asked about Trigeminal Neuralgia, a condition of severe facial pain where the sheath normally covering the cerebral artery is lost. Dr. Danzig said that doctors have discovered that surgically adding a sponge helps the situation.

Another told us about her experience in learning to relax her tongue. Dr. Danzig said your tongue should go up when you swallow (once a minute), but that you need to relax the tongue the rest of the time.

He was asked to discuss nutritional aspects of treating TMJ problems. If a patient has a painful displaced disk, he/she must be put on a liquid diet. But females especially tend to get constipated on liquid diets, so careful attention must be paid to getting proper nutrition while trying to rest the temporomandibular joint. Dr. Danzig asks his patients to refrain from eating difficult chewy foods.

When you have a painful joint, whatever the joint function is, then that’s the activity that needs to be limited. If your knee joint hurts, stop skiing. If your jaw hurts, then eat foods that don’t need a lot of chewing.

Dr. Danzig was asked about the xylocaine injections he used to give frequently. He initially injected xylocaine into the temporomandibular joint, and the pain that was eliminated he assumed was referred pain.

In the last five years, a new procedure called arthrocentesis has been used for patients with TMJ problems. The joint is lavaged with cortisone and adhesions are broken up. Before that, arthroscopy was performed, where a tube was inserted to clean up the adhesions.

If you’re not in pain, what should you do? Dr. Danzig answered that you should leave it alone—and don’t chew gum. He reiterated that 33% of the population has displaced disks without symptoms. "Leave well enough alone."

One member of the audience asked Dr. Danzig if chewing gum can cause TMJ? He answered by first stating that "TMJ" stands for "temporomandibular joint," and is only part of the name. She could call it TMJ disease or a TMJ problem, not just TMJ. Chewing gum doesn’t cause the problem, but it will certainly aggravate it. Dr. Danzig’s record teenage gum chewing patient admitted to chewing gum fourteen hours per day. Even chewing gum one to two hours per day can give you a headache. When the gum is taken away from someone who overuses his jaw, his headache will likely go away.

Dr. Danzig has noted over the years that 80% of his patients are female and only 20% are male. It may be that the size of the TMJ is larger and the muscles that protect it are larger in the male. There also may be tissue changes (chemical changes) in the female during the premenstrual period which may weaken the muscle. Males and females do tend to recover the same after surgery, though.

He has always wondered why he doesn’t see more male athletes as patients. A trauma or blow to the joint (perhaps incurred in an auto accident) can make the ligament hyperextend, the blood supply may be compromised, and some arthridities can arise.

As we learned from the video Dr. Danzig presented, when you lose cushion, there’s a change in the distribution of forces to the condyle. He was asked when a person with a TMJ disorder needed to have surgery. Dr. Danzig responded that the normal opening of a person’s mouth is forty to fifty millimeters (about three fingers), but if the joint gets so painful that you can’t get a spoon in your mouth, then it’s time for surgery on the joint.

What do they use to replace cartilage? Dr. Danzig explained that silastic used to be inserted in patients to replace cartilage, but it turned out to be a horrible solution, as it invaded the bone. Dentists have found that putting nothing in works as well as putting something in. There is now less surgery performed on patients with TMJ problems—generally throughout the country.

The referred pain phenomenon is how Dr. Danzig got started in this field. A trigger point may be the muscles in your shoulders which refer pain to the head. He found that if you inject that spot with xylocaine generally some of the pain will go away.

One member of the audience said that she couldn’t tolerate anesthetics because of the vasoconstrictor properties in them, but Dr. Danzig they could be left out if necessary. Just tell your doctor.

What do you tell your patients about exercise? Dr. Danzig said that he and his team tell all of their patients to exercise (walk 45 minutes per day, etc.), but they’re instructed to rest the affected joint.

Are TMJ problems more accepted in the medical profession now? Do insurance companies pay for treatment? Dr. Danzig said it used to be a mechanical problem, and dentists would just say that you needed $22,000 of dental work to take care of all your problems with your TMJ. But we’re treating it as more of a biological problem now.

Many things we don’t do anymore. When CAT scans and MRI’s were developed, it opened the eyes of the medical community. For example, how many backs are operated on now, as compared with years ago? A lot of positive changes have taken place.

One man said he was given a splint to wear at night and Dr. Danzig asked if he was given a diagnosis. 100% of the population grinds its teeth at night. He said that any joint can be injured, any muscle can cramp. It’s very difficult for him to make a diagnosis of a cramping of the muscle or a problem with his TMJ. Dr. Danzig told us in making a diagnosis the medical professional needs to determine if the problem is intra-articular (inside the joint) or extra-articular (outside the joint).

There are about ten TMJ specialists, highly trained, in Contra Costa County.

Dr. Danzig doesn’t use the needle at first. He has his patients work with the biofeedback and physical therapists first, which he calls Phase I.

He mentioned the fascia, the tissue that surrounds the body (under the skin—it contains the internal organs). Fascia pain and muscle pain are hard to differentiate.

Phase II is when Dr. Danzig gets involved and becomes more aggressive in treating his patient’s TMJ disorder. He stressed that it’s important to get a good night’s sleep. He sometimes will prescribe 10 mg of amitriptyline (an anti-depressant) to help the patient sleep.

There is a lot to patient management—it’s not any one thing you do. It is important to get the person moving—getting a person to walk for 45 minutes a day does wonders for muscles.

If you are a stomach sleeper, the teeth grinding tends to be worse. Use a thin pillow—it allows you to sleep better and have better posture for your neck. We don’t know why people grind their teeth at night. People can be taught not to tighten their jaws while awake. Dr. Danzig then demonstrated a face-relaxing technique where you slide your hands down both sides of your face to manually relax your facial muscles.

Mind/body awareness is a form of biofeedback. Get in touch with your body and know what it’s doing. If you can take control of the muscles, you can relax the joint. But you have to be receptive to things like that to be helped. Some people are not receptive at all to biofeedback therapy.

A member of the audience said that he was told to wear a night guard, or "splint," to keep him from grinding his teeth at night; and asked how long he should wear it. Dr. Danzig said that the name of the game is making a diagnosis as to what’s going on before you treat. A splint is a therapeutic device—it’s not a diagnosis. Dr. Steven Goldman in Pleasant Hill was mentioned by Dr. Danzig as a good dentist to see if you are having problems with your temporomandibular joint.

How do you work the insurance system? Dr. Danzig said you have to go through your physician to be referred to a dentist who specializes in TMJ problems. He said he works with his patients’ physicians to try to get their treatment approved by their insurance companies.