Caring for Face Pain and Sleep Apnea
Rich Hirschinger, DDS, MBA
Diplomate American Board of Orofacial Pain
9615 Brighton Way, Suite 323
Beverly Hills, CA 90210
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Archive for the ‘Jaw Muscle Pain’ Category

TMJ or Simply Muscle Pain?

Posted on: July 30th, 2017 by Dr. Rich Hirschinger No Comments

Overuse of muscles typically leads to pain.

I am a Board-certified orofacial pain specialist. It is a unique specialty of dentistry, which I learned during a two-year residency at the UCLA School of Dentistry Orofacial Pain and Dental Sleep Medicine program. I am now a clinic-co-Director of the UCLA residency one day a week and I have a private practice in Beverly Hills, CA the other four days of the week. I have been treating patients who complain of “TMJ” for the past 7 years and I never need to touch teeth since my training proved to me that the pain patients complain about are not related to occlusion, which is how teeth meet. If it is not related to the bite, what is it related to? I would say the 98% of the patients who think they have pain related to their TMJ, are actually suffering mainly from muscle pain. The pain is mainly due to overuse of the muscles from daytime clenching and/or bad oral habits during the day such as chewing gum, nail biting, and nighttime habits such as clenching and/or grinding during sleep. Any muscle that gets over used needs a break. If the muscles do not get a rest, they will start causing pain.

There are four muscles that close the jaw. These muscles are the superficial masseter, deep masseter, temporalis, and medial pterygoid. The superficial masseter, when measured on a pounds per square inch basis, is the strongest muscle in the human body. When patients come into my office I always have them point with one finger where their main pain is and they almost always point to the angle of the jaw, which is the superficial masseter. When your teeth are touching, the closing muscles of the jaw are contracted. As humans, we do not walk around with our teeth together. If you find yourself clenching your teeth during the day, you need to stop. Your teeth should be apart during the day in the “N-Rest” position, which you can learn about at this page on my website. The graphic below is from a slide I give to dentists and other specialists that want to learn what I do.

Beverly Hills TMJ Muscle Pain

You don’t have to just take my word for it. My training is evidence-based. A fantastic paper by Dr. James Fricton showed that a placebo equilibration is slightly better than an occlusal equilibration. What does this mean? An occlusal equilibration is an irreversible surgical procedure where a dentist grinds a small amount of enamel off your teeth or material off your crowns, fillings, etc. to get your teeth to meet more evenly. However, Dr. Fricton’s paper showed the when you do a placebo equilibration that patients report more improvement. A placebo equilibration is when the patient thinks their bite was adjusted when in reality nothing was done. This is accomplished by “adjusting” the teeth with the smooth end of a dental bur. The patient thinks something was done since they felt the vibration of the drill on their teeth but in reality, nothing was adjusted.

Beverly Hills TMJ Muscle Pain

The bottom line is this. It is incumbent upon all health care providers to try all non-surgical and reversible procedures first before doing surgery. Cutting healthy teeth or existing crowns or fillings is surgery and it is not reversible. If you suffer from what you think is TMJ, try softening your diet, keep your teeth apart during the day, stretch your jaw muscles several times a day, and during sleep wear a hard, full coverage night guard preferably over your lower teeth. I never have patients wear an appliance 24 hours a day, I never have patients wear an appliance during the day, and I never have patients wear an appliance for “TMJ” that is designed to change their bite. If your dentist ever uses the terms “Phase 1 and phase 2,” I would highly encourage you to get a second opinion from a Board Certified specialist in orofacial pain. Here is a link to the American Board of Orofacial Pain member directory. I would be happy to see you at my office in Beverly Hills if you are in the Los Angeles area. Remember, it is not about the bite. It is about keeping your teeth apart.


Fricton J. Current Evidence Providing Clarity in Management of Temporomandibular Disorders: A Systemized Review of Randomized Clinical Trials for Intra-oral Appliances and Occlusal Therapies. Journal of Evidence Based Dentistry March issue Volume 6 Issue 1 pp. 48-62 2006

Occlusal adjustment for treating and preventing temporomandibular joint disorders – Koh Journal of Oral Rehabilitation 2004

Temporomandibular disorders and dental occlusion. A systematic review of association studies: end of an era? – Journal of Oral Rehabilitation Volume 44, Issue 11, pages 908–923, November 2017

TMJ Muscle Range of Motion Measurements

Posted on: June 27th, 2017 by Dr. Rich Hirschinger 2 Comments

The notch fits into the midline of the lower central incisors.

TMJ Muscle Range of Motion Measurements
A patient’s range of motion measurements should be recorded as part of every new patient exam. This adds anywhere from 20 seconds to a new patient exam if you only record the three opening movements, which are “comfort, active, and passive.” If you measure right and left lateral and protrusive movements, you might be adding 60 seconds to your exam time. Yes, it’s that quick.

Normal Range of Motion
Opening: 40 to 60 mm. If a patient opens to 55 mm with either the comfort or active opening, there is no need to obtain the Passive opening. Additionally, do not have a patient open past 60 mm and do not push a patient open past 60 mm. If they can open to 60 mm or you can push them to 60 mm, then they have an excellent opening range of motion.
Lateral: 8 to 12 mm
Protrusive: 8 to 12 mm

Opening MovementsHirschinger TMJ Beverly Hills Range of Motion
Place the notch of the range of motion scale on the midline of the mandibular centrals, and take the following three measurements:
Comfort: ask the patient to open “comfortably without pain.”
Active: ask the patient to open as wide as they can even if it hurts.
Passive: with the patient in the Active opening, the doctor then pushes the patient open using their thumb on the maxillary centrals and the index or middle finger on the mandibular centrals.

Lateral Movements
With the arrow of the range of motion scale centered on the maxillary centrals, have the patient move to the left by tapping the mandible on the left, which causes the patient to move to the side that you are tapping. Measure the distance traveled. Repeat this for the right side by tapping the right side of the jaw.


Protrusive Movement
Fold the range of motion scale in half at the black triangle on the lateral scale. Measure the overjet, then ask the patient to move their jaw forward “like a bulldog” and measure that number. Record those two numbers as separate numbers such as “2+8” so that you know the overjet plus how far they can protrude forward from their centric occlusion.

Note in your chart if any of the movements cause pain and if any of the movements replicate their jaw pain. If a movement does cause pain, have the patient point with one finger where the pain occurs.

If the patient ever has a future problem with opening and/or moving their jaw, you now have a baseline of what their normal movements are. Do you think it is worth spending up to one additional minute of your time to record these measurements? You will if you ever have a patient who has a problem especially if they think you created it with an injection or by keeping them open too long.

As always, I’m happy to help any patient who is experiencing jaw pain or any facial pain including migraines, trigeminal neuralgia, sleep apnea or snoring issues at my office in Beverly Hills. Please let me know how I can help or if you have any questions.