Case Study: Barry

In past blogs I made reference to the relationship between jaw problems, TMD and the occurrence of Tinnitus (ringing in the ears). Though I don’t believe that the majority of Tinnitus problems relate to the jaw, there are unquestionably a number of specific Tinnitus complaints that occur as a result of muscle problems in the jaw and upper neck.

The relationship exists as a result of the shared nerve pathways between structures in and associated with the ear and those of the jaw and neck. Tense, inflamed, and hyperactive jaw and neck muscles can adversely impact the Eustachian tube, the tympanic membrane, and the malleus bone, all critical ear structures. In the presence of ongoing TMD problems, aggressive clenching, night bruxism, neck tension, and ear symptoms inclusive of tinnitus can therefore surface. The typical Tinnitus patterns that my patients describe are often present on awakening, vary in intensity from day to day and at times are influenced by opening and closing the mouth, chewing, and jaw/head positions.

Recently Barry, 55 years old, came to the office concerned about his escalating Tinnitus. He was referred from his ENT doctor, as are many of my Tinnitus patients. The tenderness of his jaw, neck, and facial muscles, along with his admitted history of teeth clenching indicated muscles that were in crisis and potentially a driving force behind the Tinnitus.

I starting him on treatment including a combination of muscle injections, dry needling techniques, self-muscle massage, and an oral appliance. This has reduce Barry’s Tinnitus by at least 50%. As a result he is no longer using the Xanax on a daily basis, something that he had come to rely on for a number of months! With the optimism that has been created I will likely continue to see Barry for another month or two to reinforce the achieved benefits.

If your Tinnitus search has reached the end of the line, exploration of a possible muscle origin may not be a bad option.

Dr. Donald Tanenbaum is a specialist with offices in New York City and Long Island, NY. He is uniquely qualified to diagnose and treat facial pain associated with jaw problems, TMJ, referred pain, nerve pain, and migraines. Find out more at www.tanenbaumtmj.com

Headaches & Facial Pain Caused by Emotional Distress

January 3, 2013 — by Dr. Donald Tanenbaum

Caring for the Caregiver

Case Study: Joan

Joan was referred to my office due to her daily headaches and facial pain that had continued to get worse despite taking over-the-counter medication on a daily basis and treating herself to a few massage sessions. She had seen her family doctor who had assured her that there was nothing terribly wrong, that the headaches and facial pain were a result of stress, and that she should start exercising more frequently and try to get more sleep.

Joan came to me when she could no longer tolerate the pain. After careful listening and a full examination, it was clear to me that her pain likely had a muscle origin. For Joan, along with countless other people in America and across the globe, her aching facial, jaw, and neck muscles were undoubtedly the result of an ongoing burden that had begun to dominate her life. Joan’s particular burden was that six months prior, her husband had suffered a debilitating stroke and she had become his sole caregiver.

Joan’s world had changed overnight. She was now a full time, worrier, cook, chauffeur, appointment maker, and sole provider of her husband’s physical and emotional needs. Although she took on these responsibilities with love and commitment, it was clear that she had been unprepared for the enormous challenges she faced. As the weeks and months passed, friends and family retreated to their own worlds, and she was left to fill the voids in her husband’s life, knowing that this job came with an unknown future.

As a result of her daily caregiver obligations, Joan’s sleep suffered, her independence all but disappeared and her ability to exercise and stay healthy dwindled to almost nothing. Suddenly her neck ached, headaches emerged, and she found herself gritting her teeth during the day as she tried to maintain patience and deal with the physical effort it required to get her husband showered, dressed, and fed.

Joan’s headaches and facial pain were clearly the result of muscles that were in crisis as a result of a ‘brain under siege’ and muscle fatiguing behaviors (clenching/raised shoulders…) that were prompted by the realization that she was alone and unprepared for an unknown future. The more Joan and I talked, the more I realized that not only was she suffering with pain, but she was lonely and depressed as well.

To help address Joan’s sore and painful jaw, face and neck muscles, I set her up with number of common therapies. These included “physical self regulation techniques” which help patients identify and change the behaviors that they have developed as a result of ongoing life challenges and stressors.

Just becoming aware of when the brows are furrowed, the lips are tense, the shoulders are raised, the jaw muscles are braced, or the teeth are clenched is the first step. I then taught her a number of exercises and breathing techniques that reduce muscle tension and can lead to significant pain relief over time. To complement these self-care efforts, we added medications, muscle injections, oral appliances, and physical therapy.

Though as a result of these efforts Joan felt somewhat better (in spite of the fact that nothing had actually changed in her life), there clearly was more that had to be done to help Joan not fall back into her acute pain state once formal treatment in my office stopped. That is when I introduced her to the Caregivers Survival Network, founded by Adrienne Gruberg.

By joining The Caregiver Survival Network (CSN), she became part of a community of other caregivers eager to interact, share stories and be a source of support. She found a lot of free services geared exclusively to a caregiver’s needs and links to other organizations and websites for caregivers, as well. As a result of taking advantages of the ideas and services shared on the CSN, her feelings of being alone started to dissipate and I feel that Joan is on the mend both physically and emotionally.

If you are in a similar situation, or know someone who is, please direct him or her to http://www.caregiversurvivalnetwork.com/

Is It TMJ or is It a Tumor?

December 11, 2012 — by Dr. Donald Tanenbaum

In my practice, most patients are referred by their dentist, physician, or other health care professionals because they are experiencing facial pain or the common symptoms of TMJ/TMD (Temporomandibular Joint Disorder) which can include one more of the following: ear pain, jaw pain, limited jaw motion, joint noise, the inability to bring teeth together, facial tightness, and headaches often focused in the temples.

At times, however, the patient’s description of their symptoms and the history of their problem indicates that though their complaints are familiar, the origin of their problem may relate to an underlying medical disease or condition that has yet to be discovered. In other words, things are not what they seem to be!

For instance, the following medical conditions (a small sample) can produce the signs and symptoms of a TMJ/TMD problem:

Sinus Tumors
Acoustic Neuromas
Thyroid disease
Lyme Disease
Tumors in the Salivary Glands
Blocked Coronary Artery Tumors in the Neck
Facial neuralgias

Though these conditions occur much less frequently than a common jaw ailment, they must be considered when a patient’s TMJ symptoms are not responding to common therapies and/or progressing over time. Once a specific diagnosis has been made, the treatments put into place will address the disease first with the result of the secondary symptoms easing or disappearing overtime. Unfortunately at times if making the proper diagnosis is delayed, and the TMJ structures (muscles or joints) are treated instead of the real problem, suffering will continue.

From another perspective, there are times when the treatment for a diagnosed medical problem in the head and neck region, requires surgery or radiation therapy. As a result of these treatment, however, jaw motion can become limited and pain may develop that is continuous or related to jaw function. This, for example, can occur following surgery to remove a brain tumor, which requires cutting through the muscles in the temple. As a result scarring can occur leading to diminished jaw motion. In the presence of these outcomes, however there are a number of traditional TMJ therapies that can aid in the restoration of jaw function and regaining comfort. These could include:

Oral Appliances
Jaw Exercises and Physical Therapy
Home Massage
Acupuncture
Botox injections in the jaw muscles
Trigger point injections

Clearly then, facial pain and jaw related problems are complicated at times. My office is available to assist you if the need arises.

Snorers! Now A Sleep Study Can Be Done in Your Own Home

November 20, 2012 — by Dr. Donald Tanenbaum

Snoring, long considered to be no more than a social nuisance, is now seen by the medical community as a possible sign of more serious health conditions. In order, however, to determine whether a patient’s snoring indicates a more serious disorder, like obstructive sleep apnea, overnight sleep studies are critical to obtain. The problem of course is that many patients are resistant to spending the night at a Sleep Clinic, and after hearing nightmare stories from friends and family that have spent restless nights lying awake in a sleep lab, refuse to schedule an appointment.

It is not uncommon therefore to be confronted by this familiar story. The patient, a man in his mid-thirties or forties, married, with children has a history of snoring. With some gain of weight his nightly snoring has become so disruptive that his wife routinely leaves the bedroom halfway through the night. On vacations, it’s necessary to reserve two rooms instead of one just because of the snoring. Basically, dad disturbs the sleep of the entire family.

Upset and exhausted, the wife finally convinces her husband to see his physician, which he does, though reluctantly. The physician then suggests a Sleep Study, which involves a night away from home at a Sleep Center. This is where the problems really start as men often refuse to spend the night away from home, particularly since they don’t even think they have a problem and deny that they snore in the first place. So, the snoring goes on, the family suffers and more importantly the snorer may be at risk for health consequences down the road.

But, there is good news for snorers and their families. In the past 10 years advances in technology have brought sleep testing equipment to the bedroom. At-home Sleep Study equipment has been proven to provide reliable data and is currently a service that has been embraced by medical insurance carriers. In fact home studies are often being required prior to the more formal and traditional study done in a sleep lab. Although physicians have traditionally been thought of as the primary health care provider to advise patients with snoring and more serious airway problems (like apnea), dentists have begun to play a critical role in terms of assessment, and more importantly in motivating patients to pursue comprehensive evaluations inclusive of overnight sleep testing.

What then would indicate that a home study is needed?

In order for your doctor to ascertain if you are a candidate for a Sleep Study, he or she will ask you questions about your health, and how you routinely feel during the day and on arising in the morning. Pen and pencil questionnaires may also be given to you which ask questions about:

Daytime sleepiness
General fatigue levels
Frequency of sleep arousal
Morning headaches
Irritability in the morning or daytime moodiness
Problems concentrating during the day
GERD
Hypertension

If your answers indicate that a Sleep Study is recommended, your doctor will set in motion a process to pre-certify the home study through your insurance company.

The testing equipment will either be obtained at a local sleep center or it will be shipped directly to your home. The equipment is easy to use and very self -explanatory. You will need to use it for only one night, then return it so that the data can be read and interpreted by a board-certified sleep physician. A report is then sent to your doctor who will then be able to make a recommendation based upon the findings.

In my practice, depending on what the Sleep Study indicates, recommendations for additional consultation or treatment will follow. Snoring that does not carry with it other health concerns can be treated with an oral appliance. Apnea if present can be treated in a number of ways depending on the severity identified on the overnight study. Oral appliances certainly are one option that can be explored.

The goal: Healthy airways and maybe save a few marriages along the way!

To learn more about Oral Appliances for Sleep Apena Treatment, consider reading some of my other recent blogs:

Dr. Donald Tanenbaum is a specialist with offices in New York City and Long Island, NY. He is uniquely qualified to diagnose and treat facial pain associated with snoring, sleep apnea, jaw problems, TMJ, and migraines. Find out more at www.tanenbaumtmj.com.

2 Techniques to Help You Relax During Difficult Times

November 14, 2012 — by Dr. Donald Tanenbaum

Time for yourself during difficult times….

For many of us on the Northeast coast, the last two weeks have tested our physical and mental fortitude in ways that we have never experienced. Despite our best attempts to stay upbeat and positive, the loss of lives, property, businesses, and income have been a tough pill to swallow. As a result of these ongoing stressors that have no easy answers and unpredictable outcomes that have not yet been determined, many of us have felt like we have lost control of our ways of life and daily routines.

Unfortunately when we lose control of our world and our efforts to restore order are met with obstacles that are tough if not impossible to budge, a price is often paid both emotionally and physically. The impact on your body is often seen as symptoms such as headaches, neck aches, back pain, stomach distress, rashes, high blood pressure, and jaw pain. Some of these symptoms occur as a result of the loss of regulation in critical body systems or the loss of quality sleep while others occur due to behaviors that develop during the day as a response to your brain being under constant siege. Specifically shallow breathing and bracing of the jaw, face, and neck muscles are common occurrences when humans are faced with challenging life circumstances.

With the knowledge that there are no easy fixes to the situations many of us are facing, here are some simple concepts and techniques that can be employed simply.

1) Take stock of your body posture frequently during the day. Are your shoulders raised? Are you creasing your brow? Are you jutting your jaw forward or bracing your jaw muscles? Are your teeth resting together or worse still are you clenching your teeth together as you attempt to accomplish a physical task, or is this activity accompanying an unpleasant thought? Are you holding your breath???

If so here is an easy technique to follow. Whether you are sitting or standing throughout the day, make a conscious effort to wet your lips and let the lips lightly touch each other with your teeth part. In this posture you can let your tongue gently touch the inside surface of the lower front teeth or place the tip of your tongue on the roof of your mouth. Once in this position, breath slowly through your nose holding the gentle lip seal. Fill your belly with air (not your chest), hold for 2 seconds and then blow the air out through your lips over 3 seconds. Then repeat this sequence 6 times. At the same time make sure your shoulders are down, your hands unclenched, and your forehead held without tension. To stay reminded of this muscle relaxation technique, place some reminder stickers on critical places like cell phones, computers, the dashboard of your car or watch face, for example. Every time you see these reminders repeat this breathing cycle. You will find the effort calming within several hours or a few short days…

2) Once you have mastered the techniques above, try the following. Once every hour, isolate one minute. During this minute attempt the following. Try to take 6 breaths during this minute, 10 seconds each. Proceed like this: With your lips sealed, Breath air in through your nose, filling your belly, taking 4 seconds to do this. Then exhale air through your slightly parted lips, taking 4 seconds to do this. Then pause for 2 seconds. This is the first 10-second breath. Now repeat five more times…though this is difficult to master you will find that you will look forward to this minute. It is your place to calm the mind.

Remember, taking a few moments for yourself during these difficult times will enable you to remain capable of helping others in need.

Case Study: Botox for TMJ

October 23, 2012 — by Dr. Donald Tanenbaum

At times we are challenged by patients with chronic pain and soreness in their jaw muscles. Though these patients have received benefits using oral appliances, performing home exercises and massage techniques, using medications and even going for physical therapy, they continue to suffer as a result of daily and continuous aching pain in their face. Though we may not fully understand why their muscles continue to hurt, the use of Botox injections has restored hope for many of these sufferers

Consider the case of Carly a thirty eight year old female with a 20-year history of facial pain and tooth clenching activity during the day and at night. She was first treated while still in high school during the stress of exams and applying to college. Her symptoms however continued through college and into her adulthood often with acute flareups prompting the use of pain medications and muscle relaxants at bedtime. Despite professional treatment and ongoing self care she continues to brace her jaw muscles and clench during the day and wakes up with “my teeth plastered together.” As a result her muscles were paying a price!

With the knowledge that Botox can be used to partially incapacitate muscles, not allowing them to contract forcefully, it’s use in this particular case was clearly indicated. Though not FDA approved for this specific purpose at this time, its use with patients has produced encouraging results. By preventing forceful muscle contraction over three to four months after injection, the sore and tender jaw muscles benefit from increased blood flow bringing oxygen and nutrients essential to healing. As a result Carly’s pain symptoms eased considerably and her days were no longer consumed by constant massage and mouth opening movements to “loosen my face.”

Most importantly, Carly regained optimism that her problem could be helped though she would likely require additional injections to undue years of muscle compromise. As Botox is not a cure, Carly understood that any efforts she made to keep her muscles out of trouble would go a long way towards maximizing the benefit of the Botox. As a result of this understanding she continues to use her oral appliance at night and practices relaxation breathing techniques frequently throughout the day.

The end result is that Carly is feeling better and realizes that her life does not have to be filled with pain and suffering.

Chronic Facial Pain More Debilitating Than Back Pain

October 11, 2012 — by Dr. Donald Tanenbaum

A lot of times people deal with aches and pains by simply ignoring it, or taking an aspirin in the morning before heading out to work. In many cases aches and pains are the unfortunate byproducts of getting older or working hard. For some patients, they look at having a TMJ problem in a similar fashion. They’ll take a couple aspirin, massage their jaw muscles or maybe switch to soup for a day, and then try to ignore it. But did you know that TMJ disorders can be among the most debilitating forms of pain people can suffer?

According to a recent study by University College in London, orofacial pain is any type of pain that occurs in the region of the face, including the mouth, jaw (TMJ), nose, ears, eyes, neck, and head are considered more debilitating to its sufferers than those suffering with chronic back pain or headaches. When compared, those who suffered from facial pain reported higher levels of disability and limitation than those who suffered from backaches or headaches by a margin of more than 19%.

Dr. Leeson, a member of the pain study, said. “These initial results suggest that chronic orofacial pain can have a significant impact on patient’s lives, affecting their normal daily activities, ability to work and causing marked disability.”

Though creating high levels of suffering, help is available for these problems. Rather than suffer through the pain and jeopardize your ability to perform at your job, or to have a fulfilling life, consulting with an orofacial pain specialist is the first step in getting relief. It is not uncommon for patients who have been suffering for months or even years to find considerable relief from the nonsurgical therapies that are commonly employed. If, however, care is not provided, these problems can become rather complex and challenging to manage.

Can I Develop TMJ after Suffering Whiplash in a Car Accident?

October 9, 2012 — by Dr. Donald Tanenbaum

Very often I get patients who come to me complaining of limited or painful jaw movement and are looking to pinpoint why. After tests, X-rays, and long discussions with the patient, they might casually let it slip that they were in a car accident recently and banged their head on the dashboard. The light bulb didn’t go off in their heads. They didn’t see a connection. But is there one? Can a patient develop painful or reduced jaw movement from a collision, even if they hadn’t made direct contact with their jaw?

According to a recent Canadian study, released in the Journal of American Dental Association (JADA), a population-based survey has revealed a strong connection between reduced or painful jaw movement and whiplash-associated disorders (WADs).

The questionnaire sent out to Canadians who filed personal injury claims over an 18-month period, and the responses determined:

A greater number of victims with WADs reported limited or painful jaw movement than those without WADs.
Those who experienced limited or painful jaw movement were greater among women.
Those who experience limited or painful jaw movement were greater among younger claimants.

The JADA study threw out respondents who had suffered from limited or painful jaw movement prior to the motor vehicle accident. It also excluded respondents who were hospitalized for more than two days, or who were pedestrians, bicyclists, or motorcyclists involved in the accident.

The message? If you’re involved in a motor vehicle accident and suffer from some kind of whiplash-related pain or injury, you might also be susceptible to symptoms similar to TMJ. In our consultations, we always ask patients details that may seem insignificant, but are backed by research. Some of these questions might pertain to your psychological state, work or life stresses, and yes; whether you’ve been in a motor vehicle accident recently.

Can Mouth Guards Cure TMJ?

October 4, 2012 — by Dr. Donald Tanenbaum

Patients will often come to me suffering from symptoms of TMJ and looking for solutions that don’t involve medication or surgery. Symptoms such as facial pain, headaches in the temples, inability to open to the mouth widely, sensitive teeth, or aching and throbbing jaw muscles can be unbearable. There are numerous remedies, for jaw related symptoms that include massages, home exercises, physical therapy, modified diets, and changes in daytime behaviors/postures. At times an oral appliance is an important part of care. These devices are commonly used for the treatment of TMJ problems and can be used in a number of different ways.

What is an oral appliance?

An oral appliance is a device that fits over your teeth with the intent of reducing tooth wear, tooth mobility, tooth sensitivity, muscle pain and soreness and joint pain and instability. At times but not frequently these devices are designed to “align the jaw.” They can also be used to discourage some of the daytime behaviors many patients don’t realize they’re doing, such as resting their teeth together, clenching their teeth, or biting their nails or cuticles. These appliances can be worn at night and/or during the day

In general the intent of these appliances is based on the problems experienced by patients.

Night guards: Most commonly these appliances are chosen by dentists to address tooth wear, soreness, and mobility that occur as a result of night clenching or grinding of the teeth. Many patients that develop tooth wear do not even realize that they have a problem and often deny grinding their teeth at night. These devices when used in patients without active symptoms (just wear of the teeth) don’t require much adjustment and should be brought by the patient when they return to the dentist for tooth cleaning visits. Typically these devices are custom fit so that they are retentive, not too thick, and modifiable over time. Over the counter devices sold in pharmacies and online are for the most part inadequate, as they are often too thick, poorly retentive, and inadequately cover all of the teeth. As a result these devices can often prompt more clenching, and/or allow tooth shift.

Night appliances to address TMJ problems: Based on the specific jaw problem that is diagnosed (muscle soreness, morning temporal headaches, limited jaw opening in the morning…etc) oral appliances at night are designed to reduce overuse and loading forces to the TM Joints and jaw muscles. The biting surface of the appliance is therefore designed and modified to most efficiently address the problems at hand. Most commonly the biting surfaces are flat but, at times, inclines and ramps are used to confront unstable joint ligaments and displaced discs. When used in patients with active symptoms, these appliances require frequent modifications requiring patient follow-up visits.

Day appliances to address TMJ Problems: At times there is necessity to have a patient wear an appliance during the day. For the most part these appliances are needed when there is extreme instability in a TM joint that has led to clicking, locking, and pain problems. These appliances are not worn all day and virtually never during chewing. At other times, oral appliances worn during the day hours can be used to get in the way of day behaviors and/or remind patients that during the day the jaw should be hanging in a rest position with the teeth apart.

How about oral appliances to re-align the jaw? This concept of jaw re-alignment to address a TMJ problem remains controversial. To date there is no science to support the concept that a poor bite or mal-aligned jaw is responsible for the emergence of TMJ symptoms. At most a bad bite or mal-aligned jaw may be a risk factor but with no more weight than other risk factors such as; female gender, gum chewing, clenching, night grinding, or stress. As long as there remain millions of people with bad bites and asymmetric jaws without symptoms this concept has to be viewed with skepticism. In addition, if an appliance were to be made to re-align the jaw, it would require the patient to bite or rest on it when in the mouth to hold the jaw in the ‘better’ position. This action of course would violate the principle that the jaws should hang at rest during the day. Clearly this option must be chosen with great care.

From an overall perspective the concept of curing a TMJ problem with an oral appliance is probably a bit of a stretch. Their use however is a critical part of TMJ treatment!

These appliances are extremely helpful in reducing the damage from night clenching or grinding. They work by diminishing the forces exerted on the TM joints and by diminishing the amount of contracture that can be generated in the jaw muscles. Night guards are most effective when custom fit, and adjusted over the course of time. Or you can purchase a generic set at a drug store. Obviously, custom-made night guards that have been conformed to your individual bite-print are more effective in treating TMJ symptoms, but the trade-off is that they’re more expensive.

Bite Splints: This form of therapy uses a mouth guard to physically correct the bite, rather than just relieve pain or reduce damage to the teeth. Bite splints are best for you if you have more extreme TMJ symptoms that need correcting in order to have a hope for any long-term relief. The primary difference between a bite splint and a night guard is that bite splints are worn around the clock, 24-7. It’s a full commitment to correcting the misalignment issues that are causing your TMJ.

So, can mouth guards cure your TMJ? The short answer is: Yes. In some cases, particularly with corrective bite splints, you can realign your bite over the course of time and eliminate those painful TMJ symptoms. In other cases, mouth guards can relieve your symptoms to the point where you feel very little pain or discomfort at all. Stop in to our office and see Dr. Donald T. Tanenbaum for a consultation, fitting, and to end your suffering today.

Learn more about Dr. Tanenbaum’s unique qualifications and expertise, here.

Case Study: Jaw Locking All Day With Tremendous Pain

September 27, 2012 — by Dr. Donald Tanenbaum

A patient came to my office four months ago complaining that she woke up every morning with her jaw in a locked position. It was so bad that her morning routine starting by standing in the shower bathing her jaw with hot water until her jaw popped open. Then she could start her day.

Her problem however didn’t stop with this unlocking event. Her jaw would click and then lock numerous times during the day and she had no choice but to manually force it open. Each unlocking effort was accompanied with pain that intensified as the day passed. She also had to support her jaw with her hand in order to chew and she worried that her lockjaw problem would interfere with her ability to talk and fulfill her professional responsibilities as a teacher.

Remarkably her problem seemingly just started one morning. There was no history of trauma, no recent dental visits, and no underlying medical problems that could be responsible for the onset of the jaw clicking and locking. It just started one day and then took over her life.

Treating Locked Jaw

Just like a knee problem, the nature of my patient’s problem was related to compromised cartilage and unstable ligaments in the jaw joint. These problems are “orthopedic” in nature and require treatment that is similar to those used for injured knees and or ankles The treatment planned was designed to stop further injury, stabilize the joint and give the body a chance to heal.

The treatment for this patient had three parts:

• An oral appliance (orthotic) designed to prevent joint locking, relax the jaw muscles, and reduce joint inflammation.

• Exercises and physical therapy to help improve and restore proper jaw mechanics, muscle coordination, and stability of the ligaments

• Daytime behavior modification strategies to ease postural strains on the jaw and neck muscles and jaw joints

The Outcome

After four months of treatment, my patient has responded well with no morning jaw locking, no pain, better eating capacity and optimism that this problem was not going to compromise her ability to hold a teaching job. Though not ‘cured’, her orthopedic problem had stabilized and she was in her own words “better” and not in need of ongoing care in my office. Maintaining a home program would likely be all that she needed to stay comfortable and avoid future problematic situations.

This ability to help patients “get their lives back on track” never gets old and continues to be a source of my daily efforts when patients come seeking advice, guidance and care.

Case Study: Barry

Case Study: Joan

Caring for the Caregiver

Treating Locked Jaw

The Outcome

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