Innovations in TMJ Disorder Treatment

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology-head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on X, formerly Twitter, @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following @CleClinicHNI on X. That's @CleClinicHNI. You can also find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology.

Today I'm looking forward to speaking with my colleague, Dr. Karyn Khan, staff in ours Section of Dentistry and Oral Surgery. Dr. Khan is also a consultant for pain and jaw dysfunction with the Cleveland Clinic, as well as a Clinical Assistant Professor in the Department of Otolaryngology-Head and Neck Surgery at our Lerner College of Medicine. Dr. Kahn, welcome to Head and Neck Innovations.

Karyn Kahn: Thank you for having me.

Paul Bryson: Well, let's start by having you share some background on yourself for our listeners, where you're from, where you trained, and how you came to Cleveland Clinic, and maybe a little bit of how your practice has evolved since you've been here.

Karyn Kahn: Sure. I graduated from Case Western Reserve School of Dental Medicine, but my interest in dentistry really began at an early age while I was in high school and working at a neighborhood dental practice after school and on summer vacations. And my interest really took hold to pursue a dental degree while working at a Cleveland restorative dentistry practice. It was here that I'd learned and gained experience in the function of the jaw and its relationship to oral health. I benefited from so many mentors similar, Dr. Hudson Heidorf, who was a consultant one day a week at that time in the Department of Dentistry, and he invited me to join him in his pursuit of conservative management of temporomandibular disorder patients along with Dr. Heidorf, and continuing education courses with Dr. Pete Dawson. As some of you might know, another outstanding mentor. I developed my knowledge and approach to conservative management of temporomandibular disorders. You've probably heard the saying that if you see a turtle on a fence post, it probably didn't get there by itself.

Paul Bryson: I haven't heard that, but I like it.

Karyn Kahn: I'm going to use that. This is true of mentoring, and I apply this to our dental residents by providing them with a two-day didactic and clinical course on the conservative management of temporomandibular disorders. So that's where I was, and this is where I am right now. My particular interest is in conservative management of temporomandibular disorders, which could involve the temporomandibular joints, the muscles of the jaw and the neck or the occlusion itself.

Paul Bryson: Well, I would say as a non-dental provider, I do have some awareness and knowledge of the jaw and the TMJ, but I will say it seems like an area that at least to me, is somewhat shrouded in mystery and can seem to play quite an important role in a number of different things other than just chewing our food. Can you share a little bit what sort of captures the imagination about this complicated area and what are some of the things that the TMJ is involved in or some of the patients have sometimes a host of complaints that can be related to this area and it's not easy to unentangle?

Karyn Kahn: That's exactly correct, and I think what I enjoy most about the practice of temporomandibular disorders is the patient interaction and the co-discovery of what is going on with some of their symptoms. The symptoms of a temporomandibular disorder can vary in from headaches, to ear pain, to ear stuffiness, tooth pain, TMJ clicking, popping, limited jaw opening, painful mastication, and it can oftentimes affect their quality of life, and then they've been to a provider and with ear pain and there is no pathology noted or reason for their pain. Where does this come from? Well, we can then look a little bit further, look at the oral habits that are going on. I look at the temporomandibular joints to see if the function and the source of pain is actually in the joints. However, in the majority of patients, I would say it's more of a muscle related.

When we say muscle, we're referring to myofascial pain with referral. That's when it gets very, very interesting and very, very confusing to patients. For example, ear stuffiness can be the result of a clenching muscle, but we can't rule out any pathology either, so that's how we work hand in hand with our head and neck providers to clear them for any pathology. Then let's go ahead and look for another cause for their pain, and with that, I look upon that as a co-diagnosis. We work with our patients to identify parafunctional habits such as gum chewing, clenching, grinding at night. We look at their occlusion to see if that's relating to an overload to the joints and the muscles, and we come up with a plan then.

Paul Bryson: Yeah, I mean it's fascinating to see. If you think about the TMJ, you could say it's sometimes at the crossroads of the muscles of the head and neck. Exactly, and I guess what surprises you the most about treating patients with these conditions? If you can elaborate on that?

Karyn Kahn: They are oftentimes referred to me with, and they come in and say that I have TMJ, and they're hearing it and getting quite concerned because they've heard of the TMJ being the cause, and maybe surgery, and they are quite frightened and also confused. But what I attempt to do is to clarify that we'll be looking at all the structures, not only just the TMJs and oftentimes the temporomandibular joints can have a little bit of dysfunction, but they're really not the source of pain. So, I think by explaining this to patients doing a thorough diagnosis and an interview, I can come up with a possible working diagnosis and then we can address their issues that way.

Paul Bryson: Yeah, I mean, it seems like it's a nice opportunity to have a pathway for the patient not to just explore the symptoms, but to have perhaps a portfolio of things to explore both behaviorally, structurally with a little bit of experience, perhaps like an appliance or things like that. So, there's a whole menu that I think patients and referring providers should know that are available to patients.

Karyn Kahn: That's exactly correct. What I try to do is establish through a reversible means such as splint therapy to get the temporomandibular joints, the muscles that move the jaw and neck, and the way the teeth occlude on the appliance, the splint, you want to call it a night guard and occlusal guard. They're all basically the same and they're referred to as a stabilization appliance. Let's get the joint in harmony with the muscles, in harmony with the teeth and the occlusion and with that, then we can see what is affecting their symptoms the most. After that, we can go into some more irreversible procedures if conservative therapy doesn't really improve their quality of life. We have two excellent oral surgeons on staff, Dr. Craig Mangie and Dr. Sagar Khanna, who we form a great team and they can provide maybe some conservative minimally invasive surgery to the TMJ such as arthrocentesis, and we'll get into that probably a little bit further, but in Botox, I think it was Dr. Mangie who said, it's a stepladder approach to TMD management. We don't have to jump right into a surgical procedure so we will find out what works conservatively.

Paul Bryson: Yeah, no, it's great. I've been here for a little bit, and I continue to learn more from you and your group. It really is, it's a great team, and just like you said, there's almost like a rehabilitative and reconstructive ladder for the approach to disorders in the TMJ region, so I applaud you and the team, and it's been great to see it grow.

I wanted to ask what else is on the horizon? I know you've been an educator with the dental residency program for a long time. I know you have academic interests. What are some things on the horizon, both from research and an education standpoint for your program?

Karyn Kahn: More research is really needed regarding some of the conservative approaches to temporomandibular disorder, including Botox to the masseter muscles in the temporalis muscles. Right now, it's a very effective treatment, but yet the literature's not supporting it, and that's what we need to have things approved. That and the minimally invasive procedures of arthrocentesis with platelet rich plasma PR.

Paul Bryson: Yeah, PRP.

Karyn Kahn: It's been very helpful to stimulate the growth centers in the temporomandibular joints for patients who have some pain in the temporomandibular joint and dysfunction. We're also working to establish a team approach with pain psychology. We have wonderful pain psychologists who can help patients through the very difficult transition from chronic TMJ or TMD disorders and conservative and surgical management, so we're trying to work on establishing a team approach.

Paul Bryson: Yeah. I really thank you for this time given to the podcast today. As we wrap up, any take home messages for our listeners or maybe listeners that are looking to refer a patient? Anything you could share? Any advice?

Karyn Kahn: Yes. If at the first onset of any type of facial pain, see your dentist. Talk to them about if they observe any parafunctional habits like grinding and clenching wear on the teeth. Have them listen to your temporomandibular joints, see if they hear any clicking or popping, and then if they feel comfortable in pursuing management, conservative management, that might just be the course you should do before it starts to become a more chronic problem. The other recommendation is keeping your teeth apart. Don't overuse your jaw. It's meant for speaking. It's meant for chewing. It's not meant for grinding and clenching or gum chewing or nail biting or cheek chewing, and so all those things perpetuate a temporomandibular disorder.

Paul Bryson: That is very good advice. I think people need a reminder sometimes or even a sense of awareness for some of the behaviors that get ingrained into just our daily day to day.

Karyn Kahn: Many patients don't realize that their teeth should only touch when they swallow, which is amazing because so many of them, many people in our practices think that the teeth are supposed to come in contact. No.

Paul Bryson: Well, I really thank you for your time today, and I would tell the listener, for more information on TMJ disorder treatment at the Cleveland Clinic, please visit ClevelandClinic.org/TMJ. That's ClevelandClinic.org/TMJ. And to connect directly with our Section of Dentistry and Oral Surgery or submit a referral, visit ClevelandClinic.org/Dentistry or call 216.444.6907. That's 216.444.6907. Dr. Kahn, thanks for joining Head and Neck Innovations.

Karyn Kahn: Thank you.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website at clevelandclinic.org\podcasts, or you can subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. Don't forget, you can access real-time updates from Cleveland Clinic experts in otolaryngology - head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.