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After TMJ Treatment

I appreciate life more than most people I know. l didn't have a life before
—a 34-year-old musician

It's like starting all over again. But it's exciting
—a 40-year-old psychotherapist

Many patients enter TMJ therapy doubting that they will ever be pain-free. One patient had been through two surgeries, a year of orthodontia, a year of wearing a splint, and physical therapy. "Whatever you do, it will only last two weeks," she said. However, she did agree to start TMJ therapy again, even though she was convinced that it would benefit her for only two weeks. After about eight weeks of Phase I treatment, she was symptom-free for about sixteen consecutive days; after that, her progress was rapid. When she was finally convinced that her life could be pain- free, she said, "I think I'll make plans for three weeks from now."

In a nutshell, the biggest change many TMJ patients experience is being able to plan life more than one day ahead. Many have become used to thinking about work and play in terms of the pain they are in, or may be in. When they no longer have to consider the pain in their plans, an enormous burden is lifted. Many are so accustomed to that burden that they have forgotten what it was like to live in freedom from constant pain.

Patients who are beginning recovery in Phase I often complain about having to come in for weekly visits. Some will comment on the difference in their attitude. "I was so glad to get here when we first started," one patient said. "But now it's such a bother. I'm too busy catching up with my life."

REFUTING STEREOTYPES

Many stereotypes exist about people in pain—they are hypochondriacs, they use pain to control people, they are in pain because they are depressed, they need the pain as a way to avoid responsibility. Certainly these stereotypes may apply to some people. A minute number of patients have had some kind of need to have the pain. But in the eighteen years I have been treating TMJ these people have been so few that I can barely remember them.

Remember Sandy Gilbert? Her husband carried a beeper so that she could reach him. She often had to call him to come and rescue her when a headache struck. Most of the people who knew her, except her husband, believed she was trying to control her husband with pain.

About two months into treatment, Ms. Gilbert told her husband to throw the beeper away. "It was the happiest day of my life," she said. "I hated the beeper, and I hated what people were saying about me." For Ms. Gilbert, a new life opened up when she was pain-free. She began spending time with her daughters and grandchildren. "We went shopping for a whole day, and I didn't think about pain once," she said. "I haven't done that for years. Even holidays were planned around 'mother's condition,' and the family got tired of it."

Sarah Johnson started looking for a teaching job as soon as her treatment was over. "Imagine. I was worried that I really was depressed. Now I know that it was truly the pain that finally got me down," she said. Ms. Johnson had been through so much that it would have been normal for her to have a long re-entry period. However, that was not the case. She typifies many patients who have lived in agonizing pain. When the pain is over, they jump back into life— usually with both feet.

REBUILDING MARRIAGES AND LIVES

Some patients have experienced destroyed marriages. In a sense they have a double tragedy. They have lived in physical pain, and also had a spouse who either couldn't understand what they were going through or couldn't live with the problems. This is perfectly understandable. Living with a person in chronic pain means living a "handicapped" life as well.

Ray Foreman had to rebuild almost everything in his life. He'd lost his wife, his social life, and a successful business. Mr. Foreman began psychotherapy during treatment. "I think I am in a depression," he said. "I've lost a lot, and I want help getting some of it back." He felt an enormous amount of anger toward his ex-wife, and while he couldn't recapture that relationship, he was able to be on friendly terms with her after he had some help.

A patient like Mr. Foreman literally has to rebuild everything. Often a patient like this can benefit from some kind of psychological counselling. He knew the depression wasn't causing his pain, because his pain was gone by the time he began to get help for the depression. It took him almost two years to rebuild a social life, start another business, and, in short, live normally. "I was so isolated that I felt like I had to become a 'social animal' all over again. I was uncomfortable with people for quite a while," he said.

Another patient had given custody of her child to her ex-husband. After treatment was complete, she was able to negotiate joint custody of their son, an arrangement agreeable to the father. "He wasn't being vindictive when he took custody," she explained. "I was unable to take care of him. He's relieved too that I'm well enough to take care of our child." The kind of relief and joy a patient like this feels is almost impossible to describe.

SMALLER CHANGES

Most patients' recovery isn't that dramatic. Many patients notice smaller things—an ability to sleep well is a common one. If sleep has been disturbed by pain, the patient often adjusts to the disturbance and may not even mention it during the initial evaluation. But a month or two into treatment, the patient may say, "I can sleep so much better than I used to. I just noticed this."

Sometimes patients begin doing things they couldn't do before treatment. Joy Rubin, the patient with restricted neck motion, had at one time been an avid tennis player. One of the first things she did was dust off her racket and get back to the courts. Former runners go back to the track, and weight lifters go back to the gym. The patients are asked to resume these activities slowly in case symptoms are retriggered. It's important always to treat the jaw mechanism carefully, because we know that these muscles are vulnerable to spasm.

Sometimes patients have to be cautioned against trying to do too many things at once. Some patients want to take up two or three physical activities immediately, when they really should add activities one at a time. If for some reason symptoms are re-triggered by weight lifting, jogging, or scuba diving, it's better to be able to isolate the activity. The chances of re-triggering TMJ symptoms are slim, but muscles that have been in spasm should be treated with some caution. This is especially true during attempts to solve the problem permanently in Phase II. During Phase II, spasms may be triggered inadvertently either by physical activity or by stressing the jaw during the dental treatment itself.

FUTURE DENTAL AND MEDICAL CARE

Once a TMJ patient has had treatment, any future dental work needs to be carried out according to the concepts underlying the Phase II definitive work. Dentists need to be aware of the delicate gearing scheme created and that it was done with special care to avoid stressing the jaw. Dental work can re-trigger TMJ symptoms.

In patients with combination headaches, once the TMJ component has been taken care of, the patient can go on to have further diagnostic evaluations and treatment. In the case of a patient who is being treated for allergies, the search for "forbidden" food becomes much easier. A patient who suspected an allergy to dairy products found out that she truly was sensitive to that family of foods. The coming and going of TMJ symptoms had stopped, and gradually it became possible to test more foods. Some were removed and others reintroduced into her diet.

Many patients suffering from true migraines notice having fewer of them after TMJ treatment. Although it's unclear why TMJ headaches trigger other kinds, this phenomenon occurs over and over. Patients who are sensitive to chemicals commonly found in foods—MSG or preservatives, for example—can see patterns, and cause and effect, in their headaches. Before the TMJ component was removed, isolating causes was often much too confusing.

Patients who have used many self-help techniques often continue them or discontinue them based on how much the techniques have enhanced their lives overall. People who have taken up yoga, meditation, massage, or exercise programs often keep them up because they find them enjoyable and beneficial in other ways. Sometimes they find they get more pleasure from the activities when they view these measures as optional rather than mandatory. "I was down on myself if I missed a relaxation class," one woman said. "I felt so responsible for my own pain."

We also warn patients about surgical treatment after TMJ treatment. Sometimes surgery can trigger TMJ in the first place because of the tube that is passed into the windpipe when the patient is under general anaesthesia. This tube takes over the patient's breathing during the surgery. However, for the tube to be passed down the patient's throat, his or her mouth must be opened very wide. The patient is unconscious and can't tell the physicians that his or her jaw is being stretched too wide and is being stressed.

Generally the same function can be served by using a nasal-tracheal tube. This involves passing the tube down the patient's nose, into the throat, and on to the windpipe. The anaesthesiologist opens the patient's mouth briefly to see where the tube is going, but the stress is for a much shorter period of time.

When a patient who has had TMJ treatment is going to have surgery, a nasal tube should be used rather than an oral tube. Most physicians are co-operative once they understand the reason for the request. The problem is seldom insurmountable. However, the patient should remember to discuss this with the physician. Sometimes people want to put their experience with TMJ so far behind them that they forget to consider their past vulnerability to muscle spasm.

RENEWED LIFE

Some routine observations about post-TMJ patients haven't been scientifically documented. More research may make it possible to quantify some effects of pain and its removal. Many patients have reported an overall improvement in their well-being. They sleep better and have fewer colds, many report eating better, and some say they have less indigestion or other digestive disturbances.

Nearly every person who sought treatment because of debilitating pain reports having more energy after treatment. Pain can be exhausting, and patients seldom realize how exhausting until it's gone and they feel their normal energy return. Patients have said they have tried new things—sports, night classes, new careers, or having babies they had put off having because they didn't feel they could handle parental responsibility while in pain. And some patients establish relationships and marriages they felt they couldn't handle because of incapacitating pain.

Even patients whose symptoms and life losses were less severe report having increased energy and ability to live fully. Their new lease on life may be less dramatic, but they still mention them throughout treatment and after. Patients with less severe symptoms often say that they had become used to living at an unnecessarily slow pace.

Patients who are lucky enough to have supportive family members, spouses, and friends report a kind of renewal. They routinely say things like, "My sense of humor is back. We joke more now in our house. People aren't so careful not to disturb me for fear of being snapped at." Others will say that their sexual lives are more normal, too. "It was a relief to know that I really did a have a normal sex drive—it was just pain that got in the way," one man said. The "not tonight, dear" joke has often been attributed to women, but anyone who treats TMJ knows that men, too, are unable to enjoy normal sex lives when pain takes over.

Some patients are able to take care of other health concerns now that the pain is out of the way. For instance, I've seen patients deal with weight problems they couldn't handle before. Other patients take up much-needed exercise programs for the first time. Pain had prevented them from doing almost any physical activity, even though they had been advised to start an exercise program as part of a treatment for high blood pressure or heart disease.

In general the life of the ex-TMJ patient is pleasant indeed. For a few people who were long-term TMJ sufferers, it seems as if they are beginning life for the first time. These people, as well as some shorter-term sufferers, even look different. Their faces are more relaxed, they smile more, and their eyes are brighter.