Latest / The Driven Athlete / TMJ Dysfunction And How Physical Therapy Helps with Dr. Gianna | Ep 131

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TMJ Dysfunction And How Physical Therapy Helps with Dr. Gianna | Ep 131 · The Driven Athlete

• 0:00
  SPEAKER_02: If you're a driven, active person who wants to reach and pursue a higher quality life with some ambition, then guess what?
• 0:06
  SPEAKER_02: This podcast is for you.
• 0:08
  SPEAKER_02: This is the Driven Athlete Podcast.
• 0:12
  SPEAKER_02: What's up, y'all?
• 0:12
  SPEAKER_02: It's your man, Dr.
• 0:13
  SPEAKER_02: Kyle.
• 0:14
  SPEAKER_02: Welcome back to the Driven Athlete Podcast.
• 0:15
  SPEAKER_02: We got our very own Dr.
• 0:17
  SPEAKER_02: Gianna Morton with us, the um the legend.
• 0:22
  SPEAKER_02: So I I know you're busy, so thank you for taking the time to share some insights with us.
• 0:27
  SPEAKER_02: Specifically about the TMJ, right?
• 0:29
  SPEAKER_02: The temporal men do with their joint.
• 0:30
  SPEAKER_02: We had done some podcasts in the past, and other guests saw about like TMJ dysfunction and TMJ anatomy, TMJ pain and stuff, how it presents, but I wanted to bring you on too and like have you share the patients that you see specifically with TMJ dysfunction, TMJ pain, what they look like, what they come in with, pain, all that stuff.
• 0:48
  SPEAKER_01: Yeah, how to treat them.
• 0:49
  SPEAKER_02: Right.
• 0:50
  SPEAKER_02: And we've you've done some presentations locally at other dental offices, orthodontist offices, um about this, about like and honestly, but like well thought of as like not really commonly known that TMJ can be the TMJ joint, the temporal mandibular joint, can be rehabbed, like there's could be physical therapy interventions for it because it's a joint, and so it can be intervened upon with physical therapy related uh interventions.
• 1:17
  SPEAKER_02: Yeah.
• 1:17
  SPEAKER_02: Um, and then like how, like, okay, what do you do for it?
• 1:20
  SPEAKER_02: Right.
• 1:21
  SPEAKER_02: Um, but anyway, so tell us like um what when somebody has jaw pain, right?
• 1:28
  SPEAKER_02: Um, what are some of the most common signs and symptoms?
• 1:31
  SPEAKER_02: Like, what do they have?
• 1:33
  SPEAKER_01: So the biggest or the most common thing you'll hear is I feel like a tightness in my jaw, I feel a clicking in my jaw.
• 1:42
  SPEAKER_01: Um a common symptom associated with it is headaches.
• 1:46
  SPEAKER_01: So um I feel headaches, whether they're at the back of the head, that Ramsworm headache that comes around.
• 1:52
  SPEAKER_01: Um, and then limitation-wise, just I have difficulty like opening my mouth fully.
• 1:59
  SPEAKER_01: So like eating.
• 2:00
  SPEAKER_01: Um, I can eat small bites of food, but like I go to eat a sandwich and my jaw clicks, or sometimes my jaw won't even open that much.
• 2:10
  SPEAKER_01: Um, talking, yawning, sleeping, um, all those like physical impairments will be kind of what people come in with.
• 2:19
  SPEAKER_01: Um, but anything from you can even get ringing in your ears.
• 2:23
  SPEAKER_01: Um, but mostly it's like that kind of tenderness, kind of right where you're you feel your jaw like opening and closing that hinge point.
• 2:31
  SPEAKER_01: And then the clicking, the popping, like a crepitous um sensation is what people come in and come, those are the biggest complaints.
• 2:40
  SPEAKER_02: Gotcha.
• 2:41
  SPEAKER_02: Um, explain.
• 2:42
  SPEAKER_02: Um, let's go over like some of the, you know, we nerd out on this stuff.
• 2:45
  SPEAKER_02: This is cool.
• 2:46
  SPEAKER_02: If you if you think this is interesting, you can nerd out with us.
• 2:48
  SPEAKER_02: But the like the anatomy, like what is the joint?
• 2:51
  SPEAKER_02: Where where is it at?
• 2:52
  SPEAKER_02: Explain like the anatomy behind like the joint structures and stuff.
• 2:54
  SPEAKER_01: Yeah.
• 2:55
  SPEAKER_01: So your TMJ, your temporal mandibular joint, your temporal bone and your mandible, and it creates a um hinge joint there.
• 3:05
  SPEAKER_01: Um in between, I I don't want to describe it as a ball and socket because it's a very complex joint, um, just with how it the different movements that occur.
• 3:15
  SPEAKER_01: Um, but if you think of it as like there's like a bony round surface and then a curved surface, and that's kind of how the joint um will move, especially with opening and closing.
• 3:26
  SPEAKER_01: Um, and then in between that surface is a disc.
• 3:30
  SPEAKER_01: And the disc is where we do get a lot of um that clicking, those issues that people come in complaining about.
• 3:37
  SPEAKER_01: Um, so the disc itself um has no neural innervation.
• 3:42
  SPEAKER_01: So the important part with that is looking at where the disc attaches anteriorly in the front and then posteriorly in the back.
• 3:50
  SPEAKER_01: Um, so anteriorly it does connect um to your lateral pterygoid, um, which is one of the muscles that help control um the motion of your TMJ.
• 4:02
  SPEAKER_01: And then posteriorly to the back, um, it connects to the retro-discal tissue.
• 4:08
  SPEAKER_01: And that's where a lot of the neural um sensation, those nerve endings are.
• 4:14
  SPEAKER_01: So when people are complaining of disc clicking, popping, um, issues with their TMJ, and it's associated with pain, then that's when we take a look there to say, well, my disc doesn't have any neural innervation.
• 4:26
  SPEAKER_01: How is this causing pain?
• 4:28
  SPEAKER_01: So we look at those surrounding structures, and just like any other joint, there's ligaments that help keep it together.
• 4:33
  SPEAKER_01: There's a capsule around the TMJ joint, um, and then the associated um muscles as well.
• 4:40
  SPEAKER_01: So your masseter, your temporalis, your mediolateral pterygoids.
• 4:44
  SPEAKER_01: Um, you can even look at your subocipital muscles of your neck, your upper trap, your SCM, um, the muscles here, your hyoids, your digastric.
• 4:56
  SPEAKER_01: Um, so there's a lot of muscles that kind of play a role.
• 5:00
  SPEAKER_01: Um, but a lot of symptoms kind of start right.
• 5:04
  SPEAKER_01: I'm gonna say if you go right in front of your ear and you put your fingers right there, open and close, that's your TMJ.
• 5:10
  SPEAKER_01: Um, that's the joint itself.
• 5:12
  SPEAKER_01: Um, but like any joint, you have to take a step back and look at the bigger picture to really get a full analysis of what's going on.
• 5:20
  SPEAKER_02: Right.
• 5:21
  SPEAKER_02: Because if you just treat symptoms, just like what we do for like other joints, like just the shoulder, the knee, the back, like the hip, like whatever, just treating the actual site doesn't comprehensively fix the problem.
• 5:32
  SPEAKER_02: And a lens that we look at for other joints as well, the same thing with TMJ, is like, why did it happen in the first place?
• 5:38
  SPEAKER_02: We have to fix those little microcompensation patterns that all kind of work collectively that then generated this symptom that you're having now.
• 5:47
  SPEAKER_02: Um, a little bit deeper look, where unfortunately it's like, we're gonna get into this later, but like like um only doing bite guards, right?
• 5:55
  SPEAKER_02: Night splints or whatever alone doesn't really comprehensively solve the actual underlying reason and why it happened in the first place.
• 6:02
  SPEAKER_02: Yeah.
• 6:03
  SPEAKER_02: If it's like an instability issue, a serve neck cervical involvement, whatever.
• 6:07
  SPEAKER_02: So the disc is kind of like the meniscus of the knee.
• 6:09
  SPEAKER_02: Yeah.
• 6:10
  SPEAKER_02: And it it helps to make the joint more congruent and move and glide and slide better.
• 6:16
  SPEAKER_02: But it's not innervated by nerves, meaning that it doesn't have any sensation for it.
• 6:20
  SPEAKER_02: So if the jaw is painful, the pain isn't coming from the disc.
• 6:23
  SPEAKER_02: But the disc can be involved and just create joint dysfunction, clicking, popping, getting stuck, whatever.
• 6:29
  SPEAKER_00: Yeah.
• 6:30
  SPEAKER_02: Um, I think it's also interesting, like, well, I mean, this is what you do, like you're, you know, super knowledgeable on this stuff, but all the muscles and that pull and tug on the bony structures around the joint are all kind of working in concert together and they tug in different directions all simultaneously.
• 6:49
  SPEAKER_02: And if some of those muscles are guarded or tight and tense, usually in protection mode, yeah, it's gonna alter the joint mechanics and then make other things get lit up and irritated.
• 6:58
  SPEAKER_01: Yeah.
• 6:59
  SPEAKER_01: I think that's why the lateral pterygoid's such a big muscle, too, that you'll look at with um disc involvement, disc issues, um, just because of the way that if that's in a guarded state and it's pulling, it's I mean, it's attached to the disc.
• 7:15
  SPEAKER_01: So if it's guarded, if it's pulling in that one direction, um, then it would not you'd have to to do justice, you have to address the the guarding and the control.
• 7:26
  SPEAKER_01: Can we get back that neuromuscular control of how that muscle should work properly, um, which could play a big role in helping with the pain, the clicking, the popping, um, when it comes to disc issues with the TMJ.
• 7:39
  SPEAKER_02: Good point.
• 7:40
  SPEAKER_02: Um, and the lateral pterygoid and the medial pterygoid, they work, they mean they all work together.
• 7:45
  SPEAKER_00: Yeah.
• 7:45
  SPEAKER_02: Um, the lateral pterygoid moves the mandible, right?
• 7:49
  SPEAKER_02: The jaw, and it helps to open the jaw.
• 7:52
  SPEAKER_02: So if you were to like resist under your chin and open against it, the lateral pterygoid is like op opening your jaw against resistance.
• 7:59
  SPEAKER_01: Yeah, the lateral pterygoid um plays a role with the opening.
• 8:04
  SPEAKER_01: It also helps with some protrusion, lateral deviation.
• 8:06
  SPEAKER_01: Um, so they all kind of have a role together.
• 8:10
  SPEAKER_01: It's kind of hard to isolate one over the other just because there's multiple muscles helping with opening um protrusion, which is like bringing the jaw forward, retraction, bringing it backwards, like an underbite.
• 8:23
  SPEAKER_01: Yeah.
• 8:23
  SPEAKER_02: Underbite with like protrusion.
• 8:25
  SPEAKER_02: And then lateral deviation side to side.
• 8:27
  SPEAKER_01: Side to side.
• 8:28
  SPEAKER_01: Um, I'd say it's hard to isolate um just because a lot of the muscles are working together, like you said, in conjunction with one over the other.
• 8:37
  SPEAKER_01: Um, but yeah, they all play a role with helping open the jaw, close the side to side, um, the protrusion, retraction.
• 8:46
  SPEAKER_02: Um and part of the evaluation that you do is you would evaluate all those movements and then assess like where the limitations and movement range of motion is, and then also pain.
• 8:56
  SPEAKER_01: Yeah.
• 8:56
  SPEAKER_01: Uh looking at how someone opens and closes their mouth um can tell you a lot about the joint.
• 9:02
  SPEAKER_01: I mean, you look one, you could just palpate.
• 9:05
  SPEAKER_01: Are you feeling a notable click?
• 9:07
  SPEAKER_01: Are you feeling a pop as they're opening and closing?
• 9:10
  SPEAKER_01: Um, is it symmetrical?
• 9:11
  SPEAKER_01: Is a big thing with TMJ because each joint is moving, should be moving simultaneously the same amount.
• 9:20
  SPEAKER_01: So are you having that left side open?
• 9:22
  SPEAKER_01: Is there a deviation to the side?
• 9:24
  SPEAKER_01: Um, it can give us a kind of sense of okay, maybe one side's overcompensating, it's opening more, that other side's not opening at all.
• 9:32
  SPEAKER_01: Um, or you know what, it does open, but we have to deviate to the side first before it opens.
• 9:37
  SPEAKER_01: Um, so you could look at things we saw like a C curve, an S curve, um, just to kind of see the the pattern of how it's opening and closing, and that could tell us a lot.
• 9:49
  SPEAKER_01: Um, I mean, just like any other joint, too, there is a normative value for how much a joint should open and close.
• 9:57
  SPEAKER_01: Um, not as concrete as like your shoulder or your knee, like you need this mount, but it's a a range, and then you can compare that to the other motions too.
• 10:06
  SPEAKER_01: Whereas like someone can open their mouth like 60 millimeters.
• 10:11
  SPEAKER_01: Um, but when they move it side to side, you're at like that eight millimeter range.
• 10:16
  SPEAKER_01: So it doesn't add up.
• 10:18
  SPEAKER_01: Um, there should be like a one to four relationship between your opening and deviation.
• 10:23
  SPEAKER_01: So it's helpful if you just say, oh, they're both in normal range, like we're good.
• 10:28
  SPEAKER_01: But just diving into more of like the pattern of how they're moving, just like you would do with if someone did a squat, like, yeah, they're squatting, they could do it the right way, but how is their movement pattern?
• 10:38
  SPEAKER_01: How is the um co-contraction of like the muscles?
• 10:42
  SPEAKER_01: Are they favoring one side over the other?
• 10:43
  SPEAKER_01: So similarly with like opening and closing um with your TMJ.
• 10:47
  SPEAKER_02: Yeah, explain like so the S curve.
• 10:50
  SPEAKER_02: Explain S curve and C curve.
• 10:52
  SPEAKER_02: C curve.
• 10:53
  SPEAKER_01: So an S curve would be where you are opening your mouth, everything's symmetrical, and then you have a deviation where your jaw will deviate, it deviates towards the side of less motion, um, which makes sense if you have more motion on one side, less on the other, it's gonna help compensate um by going towards that side, and then it returns back to normal at the end of opening.
• 11:15
  SPEAKER_01: So you kind of have normal deviates to the side and then comes back.
• 11:20
  SPEAKER_01: Kind of makes like an S shape.
• 11:23
  SPEAKER_01: Um, with a C curve in that sense, is that you have the deviation, it will kind of start a little bit normal and then it starts to deviate to the side, but we don't get that um return to midline in that sense.
• 11:37
  SPEAKER_02: So what would that indicate?
• 11:38
  SPEAKER_01: So that would indicate more like if you're having a hypo or like a joint restriction on the one side and we can't get it open.
• 11:46
  SPEAKER_01: So with an S curve, um, you deviate towards that side until it kind of gets over the hump.
• 11:51
  SPEAKER_00: So then it opens.
• 11:52
  SPEAKER_01: Then it opens.
• 11:53
  SPEAKER_01: So if you think of uh an issue with a disc, that would be an S curve.
• 11:57
  SPEAKER_01: That would be like a sign that there's some disc involvement that it's having difficulty kind of getting over that TMJ joint.
• 12:04
  SPEAKER_01: So we have to deviate to the side, help it out a little bit, and then we can open fully.
• 12:09
  SPEAKER_01: And it's usually associated with a click versus like the C curve.
• 12:12
  SPEAKER_01: Um, it's like you are working, you're trying to help, it's deviating in that direction, but we never return back to midline.
• 12:20
  SPEAKER_01: Um, so that there's some like limitation in the joint.
• 12:23
  SPEAKER_02: So it's not opening fully at all.
• 12:25
  SPEAKER_01: Yeah, you'll see usually a limitation with how much um the jaw opens.
• 12:30
  SPEAKER_02: So the S curve um it deviates over and then goes back to midline.
• 12:34
  SPEAKER_02: That it means it represents the disc issue, usually more clicking and popping with that type of pattern.
• 12:39
  SPEAKER_02: A C curve is it just doesn't open really enough at all.
• 12:42
  SPEAKER_02: Yeah.
• 12:42
  SPEAKER_02: And it never returns open.
• 12:44
  SPEAKER_01: Which is gonna get confusing, but a disc, there's a lot of ways to classify discs.
• 12:50
  SPEAKER_01: So you can have a disc um like disc involvement without reduction or with reduction.
• 12:55
  SPEAKER_01: So the with reduction would be where it kind of gets stuck.
• 12:59
  SPEAKER_01: We get over that hump and it returns back.
• 13:01
  SPEAKER_01: But people can also have that occur where there's a reduction.
• 13:05
  SPEAKER_01: Um, that's when people are like, my jaw feels like it's like kind of locked or it's stuck, um, where there's some disc involvement and you actually have a loss of a limited opening um with a disc not reducing.
• 13:18
  SPEAKER_01: Um, so I don't want people to think just because my mouth doesn't open all the way, it's not a disc.
• 13:23
  SPEAKER_01: You can have some disc um involvement.
• 13:25
  SPEAKER_01: There's just different ways to classify it.
• 13:27
  SPEAKER_02: Um that'd be more of like a disc with without reduction.
• 13:30
  SPEAKER_01: Yeah, disc without reduction with um limited opening.
• 13:34
  SPEAKER_02: Yeah, gotcha.
• 13:35
  SPEAKER_01: So it's there's a lot of ways to classify discs.
• 13:38
  SPEAKER_01: And then you can even have a um without reduction, without a limitation with opening where the people have a functional opening, um, but maybe that's that end range.
• 13:51
  SPEAKER_01: They're like, I can't get to the end, I can't get that my mouth open as wide as I would like.
• 13:55
  SPEAKER_01: Um, so there's some interpretation to it as well.
• 13:59
  SPEAKER_02: Gotcha.
• 14:00
  SPEAKER_02: Um then with like so what what else, what other kind of presentations would people have?
• 14:06
  SPEAKER_02: Like S curve, C curve, disc involvement with reduction, disc involvement without reduction, and that's a different movement pattern that you notice.
• 14:14
  SPEAKER_02: That's gonna change the treatment disc you know protocol a little bit.
• 14:17
  SPEAKER_01: Yeah, someone who has a if their joint isn't fully opening, obviously you want to work on re achieving that full range of motion.
• 14:25
  SPEAKER_01: So focusing on joint mobes, I mean there's still some soft tissue involvement in there versus someone who has a full opening, but they're having that um reducing happening.
• 14:39
  SPEAKER_01: Um, it'd be well still you can pr do some joint mobes, some soft tissue work, but like the neuromuscular control behind it.
• 14:46
  SPEAKER_01: And it would be like, okay, well, the disc is my motion is still limited on that right side because I am deviating towards it, can't get over that hump.
• 14:56
  SPEAKER_01: So my joint mobes would kind of focus more on like that portion of it.
• 15:00
  SPEAKER_01: Um, and then like what soft tissue could be causing that that guarding to limit that.
• 15:06
  SPEAKER_01: Um, but then the control behind it would be kind of focused on that.
• 15:10
  SPEAKER_01: But even discs aside, like other um issues that I've had patients come in where they don't even have like an audible click or they don't even feel um like a popping, but they'll just come in and say, like, my jaw's super tender, it's super um, like it feels tight, it feels guarded, and then they open their mouth and it's not that it's necessarily limited in motion, um, but just more of that, like everything feels tight, um, more from the muscle being just like guarded and in that like heightened state.
• 15:41
  SPEAKER_01: Um, so a lot of people too will just have like hypermobility.
• 15:44
  SPEAKER_01: Um, like you can have jaw hypermobility where they are opening their mouth um and it it's a functional, like check the box for range of motion.
• 15:54
  SPEAKER_01: Um, but it's more that they don't have good control over the joint.
• 15:58
  SPEAKER_01: So we're kind of slamming into that end range, like it opens so much, but it's putting extra stress on the muscle.
• 16:04
  SPEAKER_01: Um, so it's in working on like more soft tissue.
• 16:07
  SPEAKER_01: Can we, or those are kind of classified as more like myofascial muscle um type, like if you were to bucket TMJ issues into three separate buckets, um, that would be more of like that masculatory muscle dysfunction.
• 16:23
  SPEAKER_01: Um, and it would just be working on like getting those muscles firing properly so that they have better control of their opening, they're closing.
• 16:31
  SPEAKER_01: Um a big symptom with that is people will come in um and they're big clenchers.
• 16:38
  SPEAKER_01: So those muscles are just constantly in like a state of like tension, like I'm sleeping and I'm biting and I'm clenching, I'm driving and I'm clenching.
• 16:48
  SPEAKER_01: Um, so they'll come in with not necessarily a range of motion limitation, but more of a like subjective report of okay, I'm feeling so much tension, I'm feeling so much tightness.
• 16:58
  SPEAKER_01: Um, whether it's here, sometimes it will refer to the neck, which I know we will talk about later as well.
• 17:06
  SPEAKER_01: Um, and then I would say that third kind of bucket of way to classify issues would be um like people who have joint like arthralgia type pain.
• 17:16
  SPEAKER_01: Um, and you can just like any other joint, you can have some degenerative changes happening in there.
• 17:21
  SPEAKER_01: So is there loss of motion happening um because it's a disc issue that's not reducing?
• 17:27
  SPEAKER_01: Or is there actual like degeneration happening in the joint where maybe someone has like an OA of their TMJ joint?
• 17:34
  SPEAKER_01: Um, even RA can be seen um in your TMJ.
• 17:39
  SPEAKER_01: Um and then that would be just the way you treat it would be a little differently.
• 17:43
  SPEAKER_02: Yeah.
• 17:44
  SPEAKER_02: To clarify, you mean uh RA being rheumatoid arthritis.
• 17:46
  SPEAKER_01: Rheumatoid arthritis, yes.
• 17:47
  SPEAKER_02: And osteoarthritis.
• 17:48
  SPEAKER_02: It is in people at listeners, I'm sure.
• 17:50
  SPEAKER_02: Sorry.
• 17:51
  SPEAKER_02: Um cool.
• 17:52
  SPEAKER_02: That's what I mean.
• 17:53
  SPEAKER_02: Super interesting.
• 17:54
  SPEAKER_02: Um let's also, well, the um the nerves that innervate the TMJ, right?
• 18:01
  SPEAKER_02: So like explain like um you have nerves that come from your brain that don't go through your spinal cord that innervate your face, right?
• 18:08
  SPEAKER_02: Your neck.
• 18:08
  SPEAKER_02: And then you have nerves that come from your spinal cord that innervate the rest of your muscles and stuff, like on your arms and your legs and everything.
• 18:13
  SPEAKER_02: But explain like uh the muscles in the face, the muscles, the chewing muscles, the mastication muscles, like where they're innervated from.
• 18:20
  SPEAKER_02: Because I could we'll talk a little bit next to like how the interplay and where they can refer from.
• 18:26
  SPEAKER_02: Yeah, what's what are those?
• 18:27
  SPEAKER_01: So the you have your trigeminal nerve that plays a big role.
• 18:31
  SPEAKER_01: It's cranial nerve five, um, that will play a big role because it has sensory and also motor control.
• 18:39
  SPEAKER_01: So it has the motor control over your muscles of mastication.
• 18:42
  SPEAKER_01: Um, so masseter, temporalis, pterygoids, all the ones that play a role um in chewing, but also what we see commonly dysfunctional with TMJ.
• 18:52
  SPEAKER_01: Um, and there's also a sensory component of the trigeminal nerve as well.
• 18:57
  SPEAKER_01: Um, so it sends signals um that kind of innervate the sensation of um areas up from like your eye down towards um your jaw, your mandible, your um like maxillary area.
• 19:11
  SPEAKER_01: Um, so there could be referred pain there.
• 19:14
  SPEAKER_01: And then also in referring to nerves, your upper cervical spine um also share a similar pathway with the nerves that provide the sensation to your face.
• 19:26
  SPEAKER_01: Um, so specifically cranial nerve one, cranial nerve, or not cranial nerve, C one, C2, um, the spinal nuclei there, they follow the same pathway.
• 19:36
  SPEAKER_01: So people who are having upper cervical dysfunction can get referred pain um to that TMJ area.
• 19:44
  SPEAKER_01: Um, and that's why it's super important to kind of also look at the cervical spine when talking about TMJ.
• 19:50
  SPEAKER_01: Um, and then when dealing with TMJ issues to also investigate the cervical spine is the neck causing symptoms to the jaw or vice versa.
• 19:59
  SPEAKER_01: Um, and a lot of the times it's both.
• 20:01
  SPEAKER_01: It's that they're having some cervical dysfunction, whether it's a hypermobility where there's too much motion or a hypomobility, a lack of motion, um, and there's some compensations going on.
• 20:13
  SPEAKER_01: Um, and then those muscles in your neck of your um jaw, um, are they also involved?
• 20:20
  SPEAKER_01: Um, so that's why I've taken a step back looking at everything.
• 20:24
  SPEAKER_01: Um, you want to investigate both because of the neural pathway that they share.
• 20:29
  SPEAKER_02: Totally.
• 20:30
  SPEAKER_02: Um, it's pretty cool, like this, and with everything else too, like referred pain, like if somebody has just neck pain down their arm, you know, shoulder pain, neck pain, back pain down their leg, like all the neural interconnected um links, you know, um that there's so many, there's so much interplay between all the nerves that innervate the whole the your body.
• 20:49
  SPEAKER_02: Yeah, it's so complex, which is really interesting and cool.
• 20:52
  SPEAKER_02: We nerd out on that stuff, but that just kind of paints a picture of how like symptoms can be complex and complicated, and it could be referred from other areas and not just necessarily the TMJ, or it could be both, you know.
• 21:02
  SPEAKER_02: That's what the TMJ issue totally.
• 21:04
  SPEAKER_02: The muscles are getting lit up and guarded and everything in the area, but then also referred from the neck too, that um is adding more symptoms and making it more complicated, more complex.
• 21:12
  SPEAKER_02: So that I mean what you're saying, you know, um is great because like we have to investigate the neck.
• 21:17
  SPEAKER_02: What you're saying is you have to investigate the neck too, in addition to the TMJ, and not leave any stones unturned to see like where exactly a lot of the contributions of symptoms are coming from.
• 21:26
  SPEAKER_02: Just like I mean, like it sounds like similar to when if somebody has like pain in the back of their thigh or their glute area, and they're like, you know, my hamstring hurts or my butt hurt, my glute hurts, whatever.
• 21:37
  SPEAKER_02: It's like what you're saying is you have symptoms in the posterior thigh region.
• 21:41
  SPEAKER_02: Where are they coming from?
• 21:42
  SPEAKER_02: It could be the hip, it could be um the low back, it could be the SIJ, or all those all concurrently together, you know, like so intervene, innervate um uh intervening, sorry, at like different areas to help solve the posterior thigh pain versus like it's the hamstring, you know.
• 22:00
  SPEAKER_02: Know what I mean?
• 22:00
  SPEAKER_02: Yeah, which is way less common than people think.
• 22:03
  SPEAKER_02: Does that fall the same suit?
• 22:04
  SPEAKER_02: Like, is it actually a lot less like the TMJ is like the main problem?
• 22:10
  SPEAKER_02: Um, if they have pain in the facial region.
• 22:13
  SPEAKER_01: I see it tends to be a little bit of both, a little bit of the neck and the TMJ itself, especially with hyper mobility, the people who have a lot of mobility.
• 22:24
  SPEAKER_01: Um, if you just work on like strengthening the jaw, it's not going to necessarily solve all their issues because your neck still, your neck actually has a role with your opening and closing.
• 22:38
  SPEAKER_01: You want there to be a little bit of cervical extension to help you achieve that full opening and closing.
• 22:44
  SPEAKER_01: So if you only strengthen the jaw and you kind of neglect the cervical spine, um you're only gonna get so far.
• 22:52
  SPEAKER_01: We need to stabilize everything and where it's coming from.
• 22:56
  SPEAKER_01: So um by like working on all those the deep neck flexors, your scapular muscles, um I see the best kind of results from people who do that.
• 23:08
  SPEAKER_01: Someone who does have um, like a when I actually did see a woman um who had this, and it's a I don't want to say rare, but not as occasional.
• 23:18
  SPEAKER_01: Um, it's called a trismus, where people will kind of have a um acute, it's like a almost like a spasm of your medial pterygoid, and it's kind of like that locked jaw where feel like my jaw literally won't open um past a certain degree.
• 23:35
  SPEAKER_01: Um, and in that case, it would be super helpful.
• 23:38
  SPEAKER_01: It's the treatment for that is slowly working on where the spasm is occurring, the soft tissue there, and then also like range of motion for the jaw.
• 23:49
  SPEAKER_01: Um, and could you throw in some cervical exercises?
• 23:52
  SPEAKER_01: And I think it'd be helpful to help stabilize everything, yes.
• 23:56
  SPEAKER_01: Um, but for that specific type of diagnosis or the way someone is presenting, um, then I would say treat the jaw.
• 24:05
  SPEAKER_01: We need to work on improving this range of motion, we need to work on settling down the soft tissue.
• 24:11
  SPEAKER_01: Um, but those aren't as common as people who just come in with like generalized um aches, generalized tightness, uh some clicking.
• 24:20
  SPEAKER_01: Um, and even with like disc clicking or disc issues, um, I I would also investigate the cervical spine.
• 24:26
  SPEAKER_01: I treat the cervical spine.
• 24:28
  SPEAKER_01: Um, so I would say, yeah, it leans more towards um both of their being a play versus like nope, it's isolated to just your jaw.
• 24:36
  SPEAKER_02: Yeah, yeah.
• 24:36
  SPEAKER_02: So more often than not, heavily, you're also you're gonna treat the neck at some point in some capacity.
• 24:42
  SPEAKER_02: Yeah.
• 24:42
  SPEAKER_02: Um, the other interesting thing was like the well, okay, so trigeminal nerve five, the cranial nerve five is the trigeminal nerve.
• 24:50
  SPEAKER_02: And there's three branches.
• 24:51
  SPEAKER_02: The third branch is what innervates the m muscles of chewing, the muscles of mastication.
• 24:56
  SPEAKER_02: Um, the trigeminal nucleus, let's see if I get this right.
• 24:59
  SPEAKER_02: The trigeminal nucleus is located at like the front part of the cervical spine, C2, C3.
• 25:05
  SPEAKER_02: The upper cervical.
• 25:06
  SPEAKER_02: The upper cervical.
• 25:07
  SPEAKER_02: So in addition to like the um same pathways as the suboccipital, C1 and C2, there's also the trigeminal nucleus that's at C2, C3, and that also shares pathways and in some interconnected neural pathways of the upper cervical spine too, yeah, that innervate the muscles of mastication, like the lateral pterygoid, the medial pterygoid, the masseter, temporalis.
• 25:30
  SPEAKER_02: Temporalis.
• 25:31
  SPEAKER_02: That's super interesting to me.
• 25:33
  SPEAKER_02: Yeah.
• 25:33
  SPEAKER_02: Well, like I mean, it's just super cool and interesting.
• 25:36
  SPEAKER_02: But um anyway, explain more of that too, like the trigeminal nucleus, how it could play a role.
• 25:42
  SPEAKER_01: So if it's referring pain, if you're getting pain down towards that jaw mandible TMJ area, um, I mean, that's what we have to investigate.
• 25:52
  SPEAKER_01: So is it that trigeminal nerve?
• 25:53
  SPEAKER_01: Is it the trigeminal nucleus, or is it that spinal nuclei from C1, C2, C3 that's just referring the pain there?
• 26:02
  SPEAKER_01: Um, because they share that same pathway.
• 26:05
  SPEAKER_01: Um, that's why it's so important to kind of like it look at both and kind of investigate from there.
• 26:11
  SPEAKER_01: Um, and that's what we were saying, like a lot of the time it is both that's involved because they they share the same kind of like the same runway in that sense.
• 26:23
  SPEAKER_01: So if one is kind of a little more irritated than the other, um we could say they're sharing the same.
• 26:30
  SPEAKER_01: It's it's just a lot of it's that's where it comes to like the differential diagnosis.
• 26:33
  SPEAKER_01: And like you could look up your symptoms and it will tell you, oh, it has to be that, but it's more complex than sometimes Google can can wean out.
• 26:43
  SPEAKER_01: So that's why always going to the professional in that sense.
• 26:48
  SPEAKER_01: I mean, like, all right, this is where our mind's at.
• 26:50
  SPEAKER_01: This is what we're looking at.
• 26:51
  SPEAKER_01: These are the two, and this is kind of how um how's your neck feeling?
• 26:55
  SPEAKER_01: How's it moving?
• 26:56
  SPEAKER_01: Um, okay, how's your jaw moving?
• 26:57
  SPEAKER_01: Like some people will come in and say, I have, I have, like you said, that posterior thigh pain.
• 27:04
  SPEAKER_01: I have the jaw pain, but you can't reproduce the symptoms with any opening, closing.
• 27:10
  SPEAKER_01: Um, some palpation is like, eh, it's painful, it's tender, but it's not that same pain.
• 27:15
  SPEAKER_01: Um, so then it's like, all right, well, let me look at the neck.
• 27:17
  SPEAKER_01: Oh, wow, you pushed right there, and like I feel that referred pain down to my jaw.
• 27:22
  SPEAKER_01: Um, so you can kind of find like the root cause of where it's coming from.
• 27:25
  SPEAKER_02: Yeah, love that.
• 27:26
  SPEAKER_02: That's super interesting.
• 27:27
  SPEAKER_02: Where it's like, yeah, my jaw hurts, but you can't reproduce it with any jaw stuff.
• 27:30
  SPEAKER_02: But then you can investigate the neck, and the neck causes that jaw pain.
• 27:34
  SPEAKER_02: It's like, oh, it's coming from your neck.
• 27:35
  SPEAKER_02: Yeah.
• 27:35
  SPEAKER_02: I'm sure you've like people before have been like light bulb moment, like, holy crap, like really?
• 27:39
  SPEAKER_02: Like, oh my gosh.
• 27:40
  SPEAKER_02: Well, good thing we found it.
• 27:41
  SPEAKER_02: You know, like where else would that, you know?
• 27:44
  SPEAKER_02: Let's roll up our sleeves and dive in.
• 27:46
  SPEAKER_02: Which comes in the next question would be like very common understood in the norm of treatment protocols for this kind of thing.
• 27:55
  SPEAKER_02: Well, we've heard a lot, whatever you say is like night guards or bite guards.
• 28:00
  SPEAKER_02: Yeah, night guards, bite guards.
• 28:02
  SPEAKER_02: To try to like realign their their bite.
• 28:04
  SPEAKER_01: Yeah.
• 28:04
  SPEAKER_02: Is that correct?
• 28:05
  SPEAKER_01: Yeah, it's a there's a couple different reasons uh or ways of bite guard or night guard, and I'm no bite guard or night guard expert.
• 28:14
  SPEAKER_01: Um we don't make them, we don't prescribe them.
• 28:16
  SPEAKER_01: Um, but there's a couple reasons or ways some reasons why someone could get one.
• 28:21
  SPEAKER_01: It could be to help realign the jaw, it could be to help against um that like clenching.
• 28:27
  SPEAKER_01: So someone who has like really bad clenching might be prescribed a night guard just to help with like enamel wear down overnight.
• 28:34
  SPEAKER_01: Um but so the my issue, I guess you could say the issue with realigning the jaw is that it's found that even though realigning the jaw, you could say, oh, your TMJ is bugging you um because your jaw is off.
• 28:50
  SPEAKER_01: Um, they call it malacclusion.
• 28:53
  SPEAKER_01: Even by correcting that malacclusion, people can still have TMJ symptoms.
• 28:58
  SPEAKER_01: And I'm not saying everyone, uh, some people respond to the night guard or the bike guard and say, it feels great and I'm good.
• 29:06
  SPEAKER_01: But by realigning the jaw, we also have to take in consideration like the stress that you're putting on the jaw by realigning it, all those muscles that then are attached to it, the ligaments, that capsule.
• 29:16
  SPEAKER_01: Um, so even if the jaw is perfectly aligned, it doesn't really help, the bike guard doesn't help address any of those soft tissue issues.
• 29:24
  SPEAKER_01: Um, so I have plenty of patients who will wear a bite guard or usually more, I see it commonly for um like clenching.
• 29:34
  SPEAKER_01: Um, but then they'll still have symptoms.
• 29:36
  SPEAKER_01: So that's why I think it's a combination of when you go to get treatment for your TMJ, if a bite guard is prescribed to you, um, also doing other things in conjunction with it.
• 29:47
  SPEAKER_01: Cause I think the bite guard's a great help for if someone's like clenching a ton and they're having wear down of their teeth, and they're like, the bite guard actually helps me like sleep through the night and I don't wake up with like a pounding headache, but no, I still wake up and I feel that tightness in my jaw and like I'm still clenching a lot.
• 30:05
  SPEAKER_01: We do want to address like the reason for why you're clenching.
• 30:09
  SPEAKER_01: I know when we're sleeping, um, it's kind of involuntary.
• 30:12
  SPEAKER_01: You don't realize that you're doing it, but can we work on some other one, some physical therapy interventions, but even other interventions like stress management?
• 30:21
  SPEAKER_01: Um, why is that biting occurring and or the clenching occurring?
• 30:26
  SPEAKER_01: And when you're driving in the car, when you're awake for those other 18 hours of the day, uh, 16 hours of the day, what can we do to help prevent that so that maybe you go into sleeping and you're gonna wear the bite guard, but we've done all we can throughout the day to help settle everything down so that you wake up and you're there's not a better trajectory.
• 30:46
  SPEAKER_02: Set up for success.
• 30:48
  SPEAKER_02: So I it sounds like this is how my brain works with this.
• 30:51
  SPEAKER_02: It sounds like a night guard could be like what an orthotic would be for the foot, where it sets things up maybe for better success, better like less pressure.
• 31:01
  SPEAKER_02: Um, but it doesn't really address the neuromuscular control of the ankle, the foot, and the hip that led to maybe foot issues to begin with.
• 31:08
  SPEAKER_02: Yeah.
• 31:08
  SPEAKER_02: Um, where the night guard would be the same kind of thing, we have to do those interventions.
• 31:12
  SPEAKER_02: The night guard's good and the orthotic is good, it helps set up for success, but the other interventions will help prevent it from coming back and solve the underlying reason why thing all the compensation patterns and the complexities that led to it in the first place, were alone the orthotic won't fix.
• 31:28
  SPEAKER_02: Yeah.
• 31:28
  SPEAKER_02: Or the or the night guard won't fix.
• 31:31
  SPEAKER_01: It's like common like a band-aid, like you put the night guard in and it feels good, and then you stop wearing the night guard and your pain comes right back.
• 31:39
  SPEAKER_01: It's kind of like I don't want to relate it to a pain medication, but it's like I feel great when I take the pain meds, then I stop taking the pain meds and my pain comes back.
• 31:47
  SPEAKER_01: And it's like, well, you just kind of masked the symptoms.
• 31:50
  SPEAKER_02: Problem solved, just take more pain meds.
• 31:52
  SPEAKER_02: Take more pain meds for longer.
• 31:54
  SPEAKER_02: For longer, does it take more?
• 31:55
  SPEAKER_02: Yeah.
• 31:56
  SPEAKER_01: And yes, the night guard is definitely better than having to rely on pain medications.
• 32:00
  SPEAKER_01: But um I think there's I don't think people realize that there's other options and there's other things that you could do besides the bike guard.
• 32:08
  SPEAKER_01: Um and a lot of times too, the with a bike guard is people will like go on Amazon, just be like, I mean, just buy this bike guard.
• 32:15
  SPEAKER_01: It's like 20 bucks and it will, it'll be good.
• 32:18
  SPEAKER_01: I'll it'll fix it.
• 32:19
  SPEAKER_01: And then it actually makes things worse.
• 32:21
  SPEAKER_01: Um, so if a bike guard is like something that is recommended, um, usually people will go to see a dentist and orthodontist first before coming in to us.
• 32:31
  SPEAKER_01: Um and they'll usually be the one to kind of like monitor or suggest, like, oh, let's get a bike guard, let's do this.
• 32:37
  SPEAKER_01: I highly recommend going to like a professional who can take the proper image, can get the um proper like the create the bike guard or the night guard in the way that will help them.
• 32:50
  SPEAKER_01: Because if you get a one offline that's just gonna help correct your jaw alignment, it could one make your jaw more on misaligned, which then just puts more stress on those ligaments, muscles, the joint capsule.
• 33:02
  SPEAKER_01: Um, and then it just at least you know it's the right one for you and you're not like trial and erroring all these different bike guards in that sense.
• 33:11
  SPEAKER_02: So a custom one would be better.
• 33:12
  SPEAKER_01: A custom one would be better, but I'm I advocate for it is just how TMJ, like TMJ is very multifactorial and like why it happens, it's very hard to just be like this one thing caused my TMJ symptoms.
• 33:26
  SPEAKER_01: The treatment of it is also very similar, where you don't just want to do one thing, you wanna uh take a very multi-faceted approach.
• 33:35
  SPEAKER_01: Um, and do a little, I don't say do a little bit of everything, but like, okay, I'm gonna wear the bike guard for a little bit, I'm gonna work on these physical therapy exercises and interventions, dry needling, I'm gonna do um some stress management techniques um in that sense, then that's where usually I see the best results.
• 33:55
  SPEAKER_02: Interesting.
• 33:56
  SPEAKER_02: Um, so the talking about that, like intervention, no thought before that.
• 34:01
  SPEAKER_02: Um, with all this being said, and like the what's the underlying cause?
• 34:04
  SPEAKER_02: What we would describe as like shoulder dysfunction, back pain, hip pain, SIJ dysfunction, ankle, whatever.
• 34:10
  SPEAKER_02: It's like a movement system impairment where it's like microcompensations with a lack of mobility and microcompensations with a lack of muscle strength and control.
• 34:20
  SPEAKER_02: And those disparities and imbalances in mobility and strength lead to somebody doing microcompensations over many, many episodes of many years of doing things, and now it just manifests having pain.
• 34:31
  SPEAKER_02: Yeah.
• 34:31
  SPEAKER_02: Is that kind of similar to this?
• 34:32
  SPEAKER_01: Yeah.
• 34:33
  SPEAKER_01: Um, like I said, it's not you sometimes there's an event where they'll be like, I went, I had this happen and like now my TMJ's flared up, but it's usually not that one event that just made it pop up out of the blue.
• 34:46
  SPEAKER_01: Um, it's usually a series of things over time.
• 34:49
  SPEAKER_01: Um, sometimes there can be instances someone has like extreme trauma to the jaw and they dislocate their jaw in that sense.
• 34:56
  SPEAKER_01: But those aren't as common as someone coming in and saying, I've been dealing with like some TMJ issues that just been getting worse over the past like two years.
• 35:03
  SPEAKER_01: Yeah, yeah.
• 35:04
  SPEAKER_01: Um so in that sense, yeah, it's a lot of factors that kind of play a role.
• 35:08
  SPEAKER_01: Um, and that's why it's always like there's no blame game.
• 35:12
  SPEAKER_01: It's not one person over the other or one thing that something happened.
• 35:16
  SPEAKER_01: Um, but it's like, okay, look, maybe like I I chew gum a lot.
• 35:19
  SPEAKER_01: So like it's a lot of increased stress and movement on my jaw.
• 35:23
  SPEAKER_01: And, you know, I had this procedure done and I had to keep my mouth open for a really long time.
• 35:28
  SPEAKER_01: And that, you know, kind of aggravated it.
• 35:30
  SPEAKER_01: But like I also started a new job and I'm really stressed, and it's like all those events together that I'm clenching a lot.
• 35:36
  SPEAKER_01: Um, that then someone could be like, it's just it's getting worse, like it's not getting better.
• 35:40
  SPEAKER_01: And then, too, like something's not getting better that also kind of increases your stress.
• 35:46
  SPEAKER_01: So that's not helping the case.
• 35:48
  SPEAKER_01: Um, yeah.
• 35:49
  SPEAKER_01: So that's why I there's a lot of different like factors, but similar to any other joint where I mean, there's instances where something happens and you're like, I did this and I felt a pop and strained it.
• 36:00
  SPEAKER_01: Yeah, I I tore my ACL.
• 36:01
  SPEAKER_01: Um, and there's also times it's like I have knee pain that's been like manifesting for like six months, and I don't know what happened.
• 36:07
  SPEAKER_02: And I feel like that is our bread and butter.
• 36:09
  SPEAKER_01: Yeah, that's more common.
• 36:11
  SPEAKER_02: Non-traumatic, obscure.
• 36:12
  SPEAKER_02: It's just been going on for a while, been more noticeable over the last several months or weeks.
• 36:16
  SPEAKER_02: Don't know what happened.
• 36:17
  SPEAKER_02: I don't do anything.
• 36:19
  SPEAKER_02: I didn't do anything, it just hurts now, like worse.
• 36:21
  SPEAKER_02: Um, that's our bread and butter for sure.
• 36:23
  SPEAKER_02: Yeah.
• 36:24
  SPEAKER_02: Um, sleep positioning too.
• 36:26
  SPEAKER_02: Like I know for neck and shoulder, like side sleeping.
• 36:29
  SPEAKER_02: I would imagine that there's like pressure being placed on the mandible, on the jaw, um, side sleeping or putting your hand under your jaw or something at night, you know?
• 36:37
  SPEAKER_02: Does that play a factor?
• 36:39
  SPEAKER_01: Um, that's a good question.
• 36:42
  SPEAKER_01: I would say a side sleeping or even sleeping on your back is not uh or is it indifferent on which one um helps or not?
• 36:54
  SPEAKER_01: Um, I would then see look back at the neck and be like, well, when you lay on your side, how does it feel on your neck?
• 37:00
  SPEAKER_01: Like, are you having more symptoms?
• 37:03
  SPEAKER_01: Like, does it hurt your neck there?
• 37:05
  SPEAKER_01: Is that then causing you to like have to like clench or kind of change the position of your jaw because you're having increased pressure there?
• 37:14
  SPEAKER_01: But I would say side sleeping or sleeping on your back.
• 37:17
  SPEAKER_01: I mean, I never advocate for sleeping on your stomach.
• 37:20
  SPEAKER_00: Yeah.
• 37:21
  SPEAKER_01: Um, but yeah, just getting in like a comfortable position where like your pillows aren't too propped up, but you're also not sleeping with absolutely nothing.
• 37:29
  SPEAKER_01: You still want to have some support and you want to keep everything like as neutral as you can.
• 37:34
  SPEAKER_02: Um I know it's much like if they have if they wake up every morning and they have pain, it's like I feel fine, but then morning I wake up.
• 37:40
  SPEAKER_02: Um, maybe that could be a position.
• 37:42
  SPEAKER_02: I know we talk about that with neck and shoulder and back, you know.
• 37:44
  SPEAKER_01: Yeah, and there's a thing too, um, which I actually haven't dove into a lot.
• 37:49
  SPEAKER_01: It was kind of, I took a course and it was kind of we like dabbled in it, I'd say.
• 37:53
  SPEAKER_01: I think it's a another like avenue that people will um look into.
• 37:57
  SPEAKER_01: But um, like sleeping, like people who are mouth breathers are sleeping with your mouth open.
• 38:02
  SPEAKER_01: Um, and then that's also um it's common to people who have like the sleep apnea machines and they have to wear that CPAP piece, the CPAP, the um piece in their mouth.
• 38:13
  SPEAKER_01: I think that's I think there's a couple ways you could wear it.
• 38:15
  SPEAKER_01: It's like one in your mouth and one in your nose.
• 38:17
  SPEAKER_01: Um, but it's like, all right, well, my jaw is in this like kind of open position all night.
• 38:22
  SPEAKER_01: And then I wake up in the morning and you know, my jaw hurts.
• 38:25
  SPEAKER_01: Um so that's kind of one of those like mouth breathing people who like breathe through their mouth.
• 38:31
  SPEAKER_01: And that's why also looking at like your sinuses and like um even like closely work with like ENTs and being like, all right, so what's is there something going on that they can't, they have to breathe through their mouth, they can't breathe through their nose.
• 38:43
  SPEAKER_01: And I'm not talking about like a cold, um, but something like structurally going on, um, yeah, where maybe that's contributing to it.
• 38:52
  SPEAKER_01: Um, so it's another thing that you don't want to neglect that you can also look into and then kind of refer out to other providers from there.
• 38:58
  SPEAKER_02: Um during the day, what can what's something people can do?
• 39:01
  SPEAKER_02: I know you mentioned like tongue position.
• 39:03
  SPEAKER_02: Is that yeah?
• 39:04
  SPEAKER_01: So um to prevent clenching, an exercise I call it an exercise, but it's really not like an exercise.
• 39:11
  SPEAKER_01: Um education for um patients to do is to help prevent that clenching.
• 39:18
  SPEAKER_01: You want your jaw to be in a kind of position where we're not having all those muscles constantly like contracting and activating.
• 39:26
  SPEAKER_01: Um so if you place your tongue at the roof of your mouth, um, there'll be like kind of a little bit, a little space between um your teeth, like your teeth aren't coming in contact.
• 39:36
  SPEAKER_01: And then you want your lips to be closed.
• 39:39
  SPEAKER_01: Um, so I can't show you in t.
• 39:41
  SPEAKER_01: You can't talk while maintaining this position, but I'll tell people like you're how often are you in the car driving?
• 39:47
  SPEAKER_01: Um, and you're not talking to anyone, you're just kind of sitting driving.
• 39:50
  SPEAKER_01: Try to maintain that posture.
• 39:52
  SPEAKER_01: Can you keep your tongue at the roof of your mouth?
• 39:55
  SPEAKER_01: Can you keep your jaw in that relaxed position?
• 39:57
  SPEAKER_01: Um, because it's the times you're not thinking about it, working, typing on the computer, driving, that you're start clenching.
• 40:04
  SPEAKER_01: Um, so building that habit um can just kind of help like let things settle down.
• 40:09
  SPEAKER_00: Yeah, yeah.
• 40:09
  SPEAKER_01: Not saying it's gonna be the one cure all, but it's like those little, as you always say, like the little golden BBs, like there's a thousand golden BBs that I kind of all led to the issue.
• 40:18
  SPEAKER_02: Yeah.
• 40:18
  SPEAKER_02: And there's interventions, like a thousand golden BBs that's gonna help solve the problem, the tip the scale one way.
• 40:24
  SPEAKER_01: So that could be something that you do that's not as strenuous, that's not taking extra time out of your day.
• 40:31
  SPEAKER_01: Um, but that can make a big difference after you work for eight hours.
• 40:35
  SPEAKER_01: You're like, you know what?
• 40:36
  SPEAKER_01: Like, I don't, my jaw doesn't feel like so tight, so tense right now.
• 40:41
  SPEAKER_01: Um, and I all I did was change the position of how my tongue was resting.
• 40:45
  SPEAKER_02: Consciousness of like tongue roof or mouth.
• 40:47
  SPEAKER_02: Yeah, over and over again.
• 40:48
  SPEAKER_01: Over and over.
• 40:49
  SPEAKER_02: I feel weirdly, I'm gonna start doing that now because like I definitely clench when I work out.
• 40:54
  SPEAKER_02: I didn't realize that.
• 40:55
  SPEAKER_02: Where I'm like, after work, you know, several sets of do whatever I'm doing, and I'm like, my freak, my jaws tender, like my teeth hurt.
• 41:01
  SPEAKER_02: Yeah, I'm like, oh, I've been I'm biting, you know, I'm bruxing.
• 41:04
  SPEAKER_02: Like, this is not good.
• 41:05
  SPEAKER_02: I have to be really conscious about that.
• 41:07
  SPEAKER_02: I had a guy tell me he's like, Yeah, put your tongue between your teeth, because then you definitely won't bite.
• 41:11
  SPEAKER_01: Yeah, you bite tongue.
• 41:12
  SPEAKER_02: Yeah, you're bite your tongue, yeah.
• 41:13
  SPEAKER_01: You can do that too.
• 41:14
  SPEAKER_02: So, like, like you know, go like that.
• 41:16
  SPEAKER_01: Like that.
• 41:17
  SPEAKER_02: But but anyway, it might cause more wrinkles in your face if you're like, you know, that the whole time.
• 41:21
  SPEAKER_01: That's true.
• 41:22
  SPEAKER_02: Like, nope, don't put my tongue in my roof of my mouth.
• 41:24
  SPEAKER_01: What's wrong with you?
• 41:25
  SPEAKER_01: You're like the whole time.
• 41:26
  SPEAKER_02: Yeah.
• 41:26
  SPEAKER_02: Yeah.
• 41:27
  SPEAKER_01: Tongue at the roof of the mouth, I feel it's just an easy thing to to understand.
• 41:30
  SPEAKER_01: Like, okay, look, yeah, like there we go.
• 41:34
  SPEAKER_01: I could do that.
• 41:35
  SPEAKER_02: Um, so based on what you were saying, treatment would be um some neuromuscular control, strengthening of the jaw, joint mobilizations.
• 41:44
  SPEAKER_02: So first we like joint mobilizations, um, soft tissue work with like massage, like stripping, massage, pressure point release, or and also dry needling.
• 41:54
  SPEAKER_02: Yep.
• 41:54
  SPEAKER_02: Um, and then follow that up with neck interventions if needed, like neck mobilizations, or even a manipulation if it's appropriate, neck soft tissue work, suboccipital involvement interventions, um, and then corrective exercises, yeah, like neuromuscular control, postural stability, and strengthening of the TMJ.
• 42:12
  SPEAKER_02: Yes.
• 42:12
  SPEAKER_02: Is that correct?
• 42:13
  SPEAKER_01: You got it.
• 42:14
  SPEAKER_02: Um, dry needling.
• 42:16
  SPEAKER_02: What do you dry needle?
• 42:17
  SPEAKER_01: Um, so you can dry needle a couple different areas.
• 42:21
  SPEAKER_01: Um, if there's more neck involvement, I would go straight to doing like suboscipitals, um, even like perispinals, upper cervical, I mean, kind of depending on where their soft tissue involvement is, um, some upper trap.
• 42:36
  SPEAKER_01: Um, but neck aside, you can also do some dry needling to the TMJ itself, um, which I find to be super beneficial because those muscles are kind of hard to get to with just your fingers.
• 42:49
  SPEAKER_01: I mean, we do I'll do some intra-oral work um where, you know, we're kind of like in your mouth and like, okay, open up and like you can't talk right now because we're trying to find that medial pterygoid.
• 43:01
  SPEAKER_01: Um, but you can dry needle.
• 43:04
  SPEAKER_01: So I will have them lay and like sideline, um, depending on like what side is bugging them.
• 43:09
  SPEAKER_01: And I'll do kind of right along like the joint capsule.
• 43:12
  SPEAKER_01: Um, we can even get deeper into the, so it's hard to say.
• 43:16
  SPEAKER_01: Um, the research is very mixed about whether you're actually hitting the lateral pterygoid or not.
• 43:22
  SPEAKER_01: Um, there's a lot of very smart people who investigate their life into TMJ, and they all are like, I'm on the lateral pterygoid, and they're like, No, you're not, you're on this.
• 43:32
  SPEAKER_01: So you're in the vicinity of it.
• 43:34
  SPEAKER_01: You're close enough that you're creating that vascular response, that um outcome that we want.
• 43:41
  SPEAKER_01: Um, but your pterygoids, and then even if they're like um the temporalis, people like, you know, those like tension type headache places.
• 43:51
  SPEAKER_01: Um, so needling those.
• 43:52
  SPEAKER_01: So I'll I could do temporalis um needling up through here and even masseter, the masseter muscle.
• 43:58
  SPEAKER_01: Um, I find it's very, very tender and guarded for people who do a lot of clenching.
• 44:04
  SPEAKER_01: Um, so putting in a couple right there.
• 44:06
  SPEAKER_01: And there's not sure exactly how many spots because I don't usually do all nine or ten on every person, um, but kind of tailoring it to like where their issues are.
• 44:16
  SPEAKER_01: Um, but I like that you can get more internal into the joint for a spot that's just kind of hard to access with um just your finger.
• 44:24
  SPEAKER_01: Dish your finger.
• 44:25
  SPEAKER_02: Yeah, yeah.
• 44:25
  SPEAKER_02: So intraoral, soft tissue work, intraoral joint mobilization, tread needling for actual internal structure pinpoint.
• 44:33
  SPEAKER_02: And then you can easily do stimulate it with electrical stim.
• 44:36
  SPEAKER_01: Yep, but then you can do some e-stim um in that point.
• 44:39
  SPEAKER_01: And it it's more, I think people get afraid that I'm putting a needle in their face, but like once it's in, they're like, okay, it's not that bad.
• 44:47
  SPEAKER_02: Yeah, yeah, totally.
• 44:48
  SPEAKER_02: Just getting the freak out of like needles totally.
• 44:50
  SPEAKER_01: Yeah.
• 44:51
  SPEAKER_02: Um, awesome.
• 44:52
  SPEAKER_02: Well, um, we'll land the plane here for this time, but um thanks for you know sharing all that super interesting.
• 44:59
  SPEAKER_02: And for people listening, like there is purposeful intervention for TMJ dysfunction versus like a night guard alone, right?
• 45:08
  SPEAKER_02: Or just or just uh, you know, dealing with taking pain nets, like there's actual interventions for that can be helped, which is super interesting.
• 45:14
  SPEAKER_02: And like we said, there's some some complex interplay that other things can be involved.
• 45:19
  SPEAKER_02: So if you have any questions or comments, concerns, um, don't hesitate to reach out.
• 45:22
  SPEAKER_02: We can at least talk on the phone, see what you have going on.
• 45:24
  SPEAKER_02: If you know anybody, feel free to share info.
• 45:26
  SPEAKER_02: We can at least chat with them too and uh get the ball rolling and maybe point them somewhere else if we're not the right fit, you know.
• 45:31
  SPEAKER_02: Um, and we'll uh we'll catch you all next time.