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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Posts Tagged ‘TMJ’

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.

Dentists Should Not Use Botox For Chronic Pain

Posted on: May 12th, 2014 by Dr. Rich Hirschinger 6 Comments

Yes, I admit the title is somewhat misleading but not by much. What is missing is the word “first.” A dentist, or any physician, should not use Botox as a first choice to treat patients with chronic head and neck pain and/or headaches. I believe that if Botox is used, it should be used last. I do use Botox to treat patients in my private oral facial pain practice in Beverly Hills, CA but if I do use it, I use it last after I have tried other more effective and less expensive treatment options.

If the doctor suspects the cause of their patient’s pain is muscle pain, he/she should try several things before using a medication that might or might not work, that is extremely expensive, and that lasts for about three months. If the diagnosis is not correct and/or if the Botox does not work, the patient spent a lot of money, and the effect of the medication will last for several months.

What can be tried first? The first, and most important step is to establish a diagnosis. If the doctor can replicate the patient’s pain with muscle palpation, then a diagnosis of myalgia, which is muscle pain that does not refer to a remote site, or myofascial pain, which is muscle pain that does refer to a remote site, can be made. I recommend trying basic physical therapy that the patient can do at home. Basic jaw and neck stretching exercises are a great place to start, and I routinely give my Beverly Hills chronic pain patients a cork so that they know how wide they are actually stretching.

Beverly Hills TMJ Cork Rich Hirschinger

A cork is an excellent therapy device. It can be cut with a ramp to give the patient guidance to where they need to be stretching to help reduce their muscle pain. When the return for their follow up visit, they should be able to comfortably open the full length of the cork. If they cannot, they have not been doing their part to help themselves.

A standard cork is 45 mm and it can be cut down in case the patient cannot open that wide. In addition, the doctor needs to try to find what the patient is possibly doing to contribute to their pain. Are they clenching, and/or grinding their teeth? Are they doing an excessive amount of chewing such as using chewing gum? If they cannot stop the clenching habit on their own, I refer them to a pain psychologist who can help them identify what they are doing to contribute to their pain, and and the pain psychologist can do  some cognitive behavior therapy to help make the patients aware of the bad habits that are contributing to their chronic pain.

Ethyl chloride should be tried in the office to see what effect that has on the patient’s pain. If it is beneficial, teach the patient how to use it and write them a prescription. I prefer the bottle to the can since the bottle is colder, and, I believe, much more effective. If you ask me what one “toy” I cannot live without to help my Beverly Hills orofacial pain patients, I would answer, “ethyl chloride.”

During this time a stabilization splint should likely be made. I prefer hard, full coverage appliances. Patients tend to treat soft appliances like a gummy bear by clenching and releasing, clenching and releasing, etc., which can actually increase their pain. Additionally, a nighttime muscle relaxer such as tizanidine or cyclobenzaprine can be considered.

If those steps have not helped reduce the pain, then I recommend trigger point injections using 1% lidocaine without epinephrine. Trigger points are not simply an injection of anesthetic into the muscle so a doctor should understand how to give trigger point injections if they want to treat chronic muscle pain. Epinephrine is myotoxic to muscles and should never be injected into a muscle. It is well known that plain lidocaine only lasts from two to four hours but a trigger point injection can provide pain relief for a week or even longer. The needle is repeatedly inserted into the muscle, which is called “peppering,” and it is the action of the needle that breaks up the pain mediators such as CGRP, Substance P, glutamate and others. If the trigger point injection helps but only for a week, then repeat the trigger point injection and see how long the benefit lasts. If the second round of trigger points only lasts one week that is when I would consider using Botox.

Lastly, the research does not conclusively support the use of Botox for myofascial pain. I’m not saying that it cannot work, and I’m not saying that the pain relief that some patients report after Botox injections does not decrease their pain. What I’m saying is that Botox should be used last after you have tried everything else. I will also state that any doctor who states that they use Botox for TMJ treatment does not know what they are treating since the TM joint is not made up of muscles, and it is important to left the patient know they do not have TMJ but they have muscle pain. The TM joint is a disc. Yes, muscles attach to the joint but the superior head of the lateral pterygoid attaches to the disc, which is almost never the cause of a patient’s pain. The inferior head of the lateral pterygoid can be the cause of a patient’s pain but Botox should never be injected into the inferior head of the lateral pterygoid without electronic muscle guidance and ultrasound. If a doctor is not using guidance to inject into that muscle, there is no way to know where the Botox is actually being injected. Lastly, if a doctor does inject Botox into the superficial masseter, a short needle should not be used since the needle might not penetrate past the parotid gland.

Be safe, be careful, and use Botox last if nothing else works.

What is OFP – Orofacial Pain

Posted on: October 6th, 2013 by Dr. Rich Hirschinger 4 Comments

What is Orofacial Pain?

OFP, which stands for orofacial pain, is a unique branch of dentistry practiced by Dr. Rich Hirschinger at his office in Beverly Hills, California that involves the diagnosis, and management of chronic head and neck pain using very conservative treatment methods. The types of conditions that OFP doctors treat include primary headaches such as episodic or chronic migraines, tension-type headaches, and cluster headaches, myofascial pain, which is a fancy way of saying pain caused by muscles, neuropathic pain such as trigeminal neuralgia, which is pain caused by damage or irritation of a nerve, TMJ, which stands for temporomandibular joint, and obstructive sleep apnea. What OFP does not involve is the treatment of teeth since evidenced-based research shows that chronic head and neck pain is not related to the occlusion, which is how the teeth come together.

Beverly Hills TMJ Migraine Heacaches

Woman suffering from chronic head and neck pain

There are dentists who practice what they call neuromuscular dentistry, which is not taught in any accredited dental school in the United States, who argue that a lot of the chronic pain patients report is caused by the “bite.” They claim that teeth touch about 2,000 times a day when we swallow, and when we chew food. I agree teeth touch when we swallow but it is a light touch that does not involve a full contraction of the muscles that close the jaw and cause the teeth to meet, and teeth rarely touch when chewing since there is food between the teeth. Additionally, we should not walk around with our teeth clenched during the day so we teach patients the “n rest position” so that addresses the issue of any daytime pain being caused by how teeth meet. Both OFP doctors and neuromuscular dentists agree that patients clench and/or grind their teeth at night but this can be addressed by covering the teeth at night with a nightguard, which should be a hard appliance that covers all of the teeth, is not designed to change the bite, and it only worn at night. This addresses the issue of any nighttime chronic pain being caused by how teeth meet since the teeth contact the appliance instead of other teeth. Lastly, Dr. Hirschinger and most orofacial pain colleagues do not use a dental drill to alter or adjust the teeth. That begs the question that if OFP doctors can treat patients with chronic head and neck pain without touching or drilling teeth, why wouldn’t every doctor try treating patients using the same conservative, reversible procedures before trying any other approach?

The goal of this blog will be to educate doctors as well as the public about orofacial pain by discussing the treatment approach I use as well as posting some very interesting cases. Since very few doctors are aware of OFP, very few patients are aware of it. However, orofacial pain is getting more recognition because starting in 2011, the Commission on Dental Accreditation of the American Dental Association has accredited ten post graduate programs in orofacial pain. The first two in 2011 were UCLA, where orofacial pain was founded by Dr. James Fricton, and Kentucky. Dr. Hirschinger was the first graduate from UCLA’s Orofacial Pain and Dental Sleep Medicine residency after it received CODA recognition.

The key part of treating anyone with chronic pain is getting a diagnosis before treatment is started. For the patients I see, headache and TMJ are not considered enough of a diagnosis to initiate treatment. What type of headache is it, and what is causing the pain? If your doctor does not know, then I would suggest that you find someone who can give you a diagnosis.

Please spread the word about this blog by telling your colleagues and friends to sign up to receive notifications of new posts. I look forward to answering any questions you have about any chronic head and neck pain you are personally experiencing, or if you have a question about a patient of yours.

Rich Hirschinger, DDS, MBA
Diplomate, American Board of Orofacial Pain
Member American Academy of Orofacial Pain
Lecturer, UCLA Orofacial Pain and Dental Sleep Medicine