Is it TMJ?

Temporomandibular joint pain and dysfunction affects some 10 million people in the U.S. and is a frequent concern of people posting on the WebMD ENT Message Board. One researcher estimated that 75% of the U.S. population will experience one or more symptoms associated with this common joint and connective tissue disorder sometime in their lives. Ninety percent of people who seek a diagnosis or treatment for TMJ are women, mostly of childbearing age.

Although this condition is common, it is not well understood by many primary care clinicians and misdiagnosis is common. Furthermore, TMJ is often blamed for a variety of ear-related disorders without a valid medical investigation. Although an x-ray, CT scan, or MRI are often helpful, the diagnosis of this disorder is often made solely on the patient’s report of symptoms. Consequently, this diagnosis is often wrong.

The most common complaint is pain in the area directly in front of the ear, sometimes radiating to the temples or neck. This pain is triggered by movements in the jaw, such as chewing or speaking, or the psychogenic grinding of the teeth at night (bruxism). Many people experience clicking, snapping, or popping in the temporomandibular joint when the mouth is opened or closed. The jaw can even lock due to muscle spasms.

Because of the nerve pathways, TMJ disorders can cause a plethora of symptoms in other anatomical areas, such as headaches and ear pain. Dizziness, neck pain, shoulder pain, tinnitus (ringing of the ears), swallowing difficulties, and sleep disturbances may also be related to TMJ problems. Since many of these symptoms can also have hundreds of other causes, it is often medically difficult to attribute TMJ as the sole cause of symptoms such as dizziness or tinnitus.

The first step for any person that believes that have a TMJ disorder is to be properly diagnosed. This usually requires the intervention of a specialist, either a dentist or oral surgeon that specializes in TMJ disorders, or a good ENT. Since various forms of arthritis can be involved in TMJ, your primary care medical provider should be intimately involved in your collaborative care. Other than laboratory tests for arthritis, there are no specific lab tests that would determine if you have TMJ or not. X-rays are important, but have their diagnostic limitations. Many specialists will order an MRI or CT scan of the TMJ area. In some cases, a bone scan is helpful.

The next step involves management, with a goal to reduce pain and improve jaw function. A comprehensive approach that may include medications, physical therapy, and possibly intraoral appliances is optimum. Certain lifestyle modifications are often necessary, such as avoiding "chewy" foods, gum chewing, nail-biting, and excessive talking. People who are prone to teeth--clenching and grinding (bruxism) may need a custom mouth guard at night.

Pain and inflammation is often controlled by the use of NSAIDs (non-steroidal anti-inflammatory drugs), such as ibuprofen. In severe cases, short-term steroids are used, as well as muscle relaxants and antianxiety medications. Physical therapy, such as hot/cold compresses, jaw exercises, muscle-stretching, and massage can be very helpful in all cases. If anxiety and stress are underlying issues, this must be addressed, either by relaxation therapy or psychological intervention.

Alternative treatments such as acupuncture, chiropractic, or naturopathic methods have not been shown to be effective and there are few, if any, scientific studies to show they are curative.

Surgery is usually the last resort when conservative treatments fail. Surgery purports a high success rate. Every person and every case of TMJ is different, so surgery is highly individualized. Before undertaking a surgical approach, I often recommend second opinions.

TMJ disorders remain a frustrating problem for the patient and the treating clinician. The best hope appears to be a combination of therapies, coupled by a good attitude. Many things in medicine cannot be cured, but they can be effectively treated.

Related Topics:

• WebMD Video: Dental Health Reveals Overall Health
• Oral Health: The Mouth-Body Connection

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Is It ALLERGIES?

Anytime a runny nose seems to last longer than a week or so, people start to be concerned about allergies as a cause. Sometimes they are right. More and more people are being diagnosed with environmental allergies every year. Compared to the 1900's, we are now exposed to more chemicals and more foreign substances than ever before. No longer is just "weeds, grasses, and trees," there are thousands of potential allergens lurking about.

Making the diagnosis of an allergic disorder is relatively easy compared to identifying the specific allergen that may be causing your symptoms. For instance, when a person develops hives (urticaria), they want to know what caused it. I tell them it could be anything they ingested, touched, or breathed. Even changes in temperature, medications, molds, animals, cigarette smoke, invisible insects/mites, certain illnesses, and emotional states can trigger hives. You name it and someone may have an allergic reaction to it.

Allergies can be seasonal or year-round. They can also occur randomly and without warning. Even without allergy testing, many people have identified allergic triggers in their environment. I am absolutely amazed by the number of children allergic to peanuts and peanut butter. During my entire childhood, I can't recall one friend that was allergic to peanuts, unless he was the stinky kid that always ate tuna fish sandwiches.

Over the years, I have discovered that I am allergic to two things (just two): bees and Levaquin (an antibiotic). I discovered that I was allergic to bees when I was a teenager. While working on a farm, I was initially stung a few times up my pant legs. This resulted in immediate hives all over my body. A week or so later, I was stung again. This time, it caused me to have some serious breathing difficulties. A few years ago, I took a new antibiotic for a sinus infection. After the first dose, it was Hive City once again. Like most humans, I am probably allergic to other things, too. Now that I think about it, I am also highly allergic to poison oak, but then again, most people are.

The most common symptoms experienced by allergy patients would be an itchy, runny nose and watery, itchy eyes. The key symptom here is itching. Unlike colds, allergies tend to cause itching. In children, a common observation is the constant, up-wiping of the nose with the hand, affectionately termed the allergic salute. In children, upward nose wiping can cause a horizontal, white crease occur across the bridge of the nose. Children also wipe their noses on sleeves, fingers, furniture, and unwary pets. They can also develop a repetitive sniff that drives adults crazy.

Asthma is considered the most serious form of allergy. Almost all children with asthma have been sensitized by an inhaled allergen, such as pollen, mold spores, animal dander, or insect proteins. Uncontrolled, asthma can be a killer. Sadly, several of my patients have died from asthmatic attacks over the years. The mortality rate among African Americans is three to four times higher than the white population; boys get asthma twice as often as girls. Exposure to cigarette smoke is a significant factor for asthma.

The most common symptom in asthma is wheezing - the air goes in but has a whistling time getting back out. Dry cough, chest tightness, chest pain, and shortness of breath with exertion are also seen. Mysterious, persistent nighttime coughing in children could also be a sign of asthma. Asthmatics also have the plethora of allergy symptoms, too, such as runny nose, dry/itchy skin (eczema), itchy/watery eyes, and sneezing.

The key to allergy and asthma management starts with the proper medical assessment and education. Many primary care medical professionals are quite experienced in allergy management. The more severe cases may need the involvement of an allergist or pulmonologist. If known allergens can be identified, they should be avoided. There are many great allergy and asthma medications, but they do not work very well when they remain in their containers. Failure to comply with prescribed treatment regimes is a major obstacle in allergy management. A mainstay of asthma management is the use of anti-inflammatory medications, namely steroids. Because people are afraid of steroids or confuse them with body--building and abused steroids, they often are reluctant to use them. Big mistake. When it comes to asthma and allergy management, it is often best to allow your medical provider to do the driving.

Related Topics:

• WebMD Video: Environmental Allergens and Immune System
• WebMD Video: Allergy Shots for Asthma

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The Fine Art of Lying to Your Medical Provider

Not everyone is honest, at least 100% of the time. Whether it is human nature to stretch the truth, exaggerate, or just downright lie is up for debate. In the medical world, it happens all of the time.

"What was his temperature this morning?" "Oh, it was 103.6. " "What kind of thermometer did you use?" "My thermometer is broken, so I just felt his forehead and "guessed" that it was about 103.6."

Now, I have felt hot and feverish people throughout my entire medical career, and there is no way that I could guess a fever to that level of accuracy.

Parents are so afraid that their child's fever will be normal when they finally get to the office that they often withhold giving acetaminophen or ibuprofen so that I will take the fever more seriously. The child unnecessarily suffers for hours by this decision. While fever is absolutely harmless, the profound discomfort associated with illness should be promptly addressed. At this stage in my career, a high fever does not impress me. Basically, unless I see smoke or flames coming out of some body orifice, I don't really care how high a fever is. Other symptoms and physical findings are much more important.

Did you complete all of the medications I gave you? Yes, I took them all, but the pharmacist must have given me too many pills. They lasted 14 days instead of ten. Guess what? The pharmacist probably counted them out corrected; you just "missed" a few."

I often have patients under my care bring the medications they are taking with them to every visit. Not only can I make sure that the pharmacist did NOT make a mistake (It happens), but I can check on compliancy. For instance, if a person is supposed to take two pills a day for a month (sixty pills) and I see them in two weeks, they should have about half a bottle left. I am not shy about dumping out their pills on a piece of paper and counting them out. If I find about 20-25 in there, I am going to need an explanation. As basic as this advice sounds, pills are totally ineffective from inside the bottle.

Are you staying on your diet? Yes, I am eating less than 800 calories a day. So, what do you attribute to your 12 pound weight gain since your last visit a month ago? No, I don't think you are retaining that much water. Unless you have a camel hump on your back, there needs to be another reason. I often ask patients to write down EVERYTHING they eat for a week so that I can review their diet. When I see "one Krispy Kreme donut" written down, I know they are lying. NO ONE can just eat one Krispy Kreme. Who are they trying to fool? That's like writing down one potato chip. Unless it was stale or had a fly sitting on it, that is lie, too.

Lying about salt use, caloric intake, or the amount of exercise is universal. I could easily lie about that myself. I love to eat. I love salt. I hate to exercise. When my own doctor asked those questions, I am tempted to stretch the truth, but why? He will know I am lying. I will know I am lying, so I just try to be honest.

I was listening to Jeff Foxworthy the other day talking about his dentist visit:

"Do you floss your teeth every day?"

"Well, not every day. I guess the last time they were flossed was when YOU did it!"

When a patient consciously fails to provide vital medical information, this is the same as lying. This is a very dangerous practice. For instance, if you have a heart murmur, you have to let your medical provider know about it. This is not the time to see if "your doctor is smart enough to catch it." Medical care is not a game.

Accurate information about a person's sexual history is very difficult to obtain, especially from teenagers. Teenagers often lie as the first line of defense. They even lie about stuff that is not important. An accurate sexual history IS very important in order for your medical provider to assess health risks.

I stopped asking if a person was "sexually-active" since that statement can be misunderstood. The word "active" is vague and can mean different things to different people. I once had a teenager respond to that question by saying, "What to you mean? Do I like, move around a lot during sex?" So now, I simply ask teenagers if they have EVER had sex...in any form. I don't want any of those Bill Clinton answers. When a teenager tells me they have never had sex and I find out they are three months pregnant, we need to have a long talk. Unless a star rose in the East, or someone is a very heavy sleeper, that someone is not telling the truth.

People always lie about the number of sexual partners. Some men are proud of their life score, so I always cut that exaggerated number in half. On another sexual issue, I once read that said that "Ninety percent of all men masturbate. The other ten percent lie." Whether someone masturbates or not, is really not an important sexual question. If your doctor asked you about it, he is just "weird," so it's okay to lie. If you are asked if you masturbate, just proudly say, "You bet! Every chance that I get. I was doing just before you came in."

Women tend count only significant sexual relationships; one-night stands don't make the list. They are probably afraid to tell me that they have had some God-awful number of partners for fear that I will think poorly of them. They always throw out a small number to throw me off track. Besides, what if someone read their chart? People may be whispering and grinning at them the next time the come in. For sensitive information like this, I tend not to write this stuff down in their chart.

I once took care of a 75 year old mother of a PA colleague. She was concerned that I would call her son and share her private medical history so she decided to test me. She told me that she was thinking about leaving her husband and having an affair with the bus driver. We discussed this at great detail. When that MIS-information never made it to her son (I would NEVER reveal confidential information like this), she eventually told me the affair story was just "a lie." She was just testing my level of confidentiality. Rather than be amused by this act, I dismissed her as a patient. Personally, I think she was hitting on that bus driver.

Related Topics:

• WebMD Video: Keeping Family Medical Records
• WebMD Video: Medicine Cabinet Makeover

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Sex Seminar at Disneyland

During the early days of my profession, it was important for us to form a cohesive organization. I am very proud to be the founding father of the California Academy of Physician Assistants, a very strong and viable professional organization that thrives to this day. We started with a handful of PAs and a few hundred dollars, and now have an organization with thousands of dues-paying members, thanks in part to our early, innovative, fund-raising efforts.

Forming an organization takes money. One way to get this money is to have medical seminars. It takes a year to plan a good one. You have to pick interesting topics, find the best speakers, and find the perfect venue. I had planned a few seminars in the past that had mediocre attendance for whatever reason. The one I planned a year in advance that ended up to be Super Bowl Sunday was bust. The one in Fresno, although centrally located, was also poorly attended. Apparently, no one goes to Fresno. I tried the seashore which increased attendance, but also decreased the number of people who sat in the conference room while others were goofing off at the beach. I needed the "perfect" seminar to fill the organization's coffers.

The topic? Sex. Everyone loves to learn about sex. The place? The Happiest Place on Earth. Disneyland. I will plan a sex seminar and hold it as Disneyland! So, I did. The attendance was the highest yet. We even had negotiated for discount coupons for a private night at Disneyland, along with another group - the Far West Ski Association. I need to add that Disneyland was not involved in this conference whatsoever. It was held at a hotel adjacent to Disneyland.

I hired two well-known experts on human sexuality. One was a physician who specialized in this area. His teaching partner was a woman who worked as a sexual surrogate (hands-on instructor, so to speak). She was completing her doctorate in human sexuality and writing her thesis - an illustrated book on the penis (I am NOT lying about this!).

The four-hour afternoon sex seminar was standing-room only. We had invited spouses and significant others as guests. We had the hotel crew bring in as many chairs at the room would hold. The sexual experts were previewing their videos for the session. Suddenly, the sound of chairs being moved stopped. When we turned on the lights, all of the hotel personnel were sitting in them, watching the movies!

Now, I am not a prude or a shy person when it comes to discussing sexual matters, but this seminar would have made a sailor blush. The first job of the sex experts (sexperts?) was to desensitize the audience. Not all patients will understand medical language when it comes to sexual matters. In other words, if you ask a person how often they have coitus, they may just stare at you. If you ask how often "he and the ol' lady get it on," he will understand. So, the audience was assigned to write down as many terms for the sexual act that we could come up with in fifteen minutes. We were encouraged to work in groups. The audience literally exploded with enthusiasm. The laughter was deafening. After fifteen minutes, our responses were passed up to the front were they were tallied. Duplicates were eliminated.

I have never been so proud of my profession, as I was at that moment. Our humble group of medical professionals came up with over TWO HUNDRED different names for the sexual act! Even the sexperts were impressed. Then someone (not me) asked them to read them out loud. They did. It was all I could do not to pee in my pants. Because I don't want my blog to be linked with a porno site, I won't list them here, but I can say that I was educated.

During the break, we discovered that a large portion of our audience had "accidentally" wandered in from the Far West Ski Association, and decided to stay. Apparently, our lectures were more interesting than skiing down moguls.

The group was then asked to review a variety of movies that showed people with physical disabilities, different sexual orientations, etc. doing the dirty deed. If you added some cheesy harmonica music and a sticky floor, this dignified medical seminar went downhill from there.

The final lecture was the sexual surrogate's slide show of penises. The purpose of her book was made clear. She states that she has female clients that have only seen a few penises in their entire life. This book was to demonstrate to the naive that penises come in all shapes, sizes, and colors (as if we didn't know that). She even asked if there were any volunteers that would like to include a picture of their penis in the book. Yes, there were volunteers. And, yes, there were jokes about fold out pages, etc. I have no idea if she subsequently published this book or not. I just can't see myself going into Borders and asking for it.

This year, I am one of the many speakers at the annual conference held in Palm Springs. My topic this year will be "Teenology - Issues in Adolescent Medicine." Hmmm...I wonder if I asked teenagers to list all of the names for the sexual act, if they could beat the record still held by California PAs. I think not.

Related Topics:

• WebMD Video: Exercise for Better Sex
• WebMD Video: Adolescent Specialists

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