Dear Friends and Readers.  I appreciate when you read my thoughts on the blog and it is a gift every time one of you reaches out to connect with me

This post is dedicated to John T. Clark III, a wonderful man, a respected judge, someone who maintained a loving marriage for 48 years, a man who lovingly adopted and raised two strong sons who now have families of their own.  He embodied what we from the Jewish persuasion would call a "mensch".  Johnnie was someoneI am proud to have known and loved as my guardian.

Born in Baltimore, Maryland, September 15, 1943 Died Centreville, Maryland February 2, 2014  After I hung up the phone from a long distance hypnotherapy call on Groundhog day, I looked down to see the light flashing a voicemail message.  It was my guardian's wife, Sally, with news that Johnnie had died around 3:20 in the morning.  To those who know me, you must have heard me talking about Johnnie - he was a force in my life and a surrogate father to me, albeit a very young one.  (He would have been 11 years old when I was born.)  Johnnie gave me away at my wedding and drove to another state to rescue me when I totaled the car that my mother left me in her will. Johnnie and Sally welcomed me into their home every holiday and almost every other weekend when I came home to the Eastern Shore from St. John's College .John Clark III was also a beloved (known as fair but sometimes feared) judge in the Queen Anne's County District Court.  His funeral was so packed with people who loved and admired him that the crowd overflowed onto the street.

From the day he took on the job of "legal guardian", I always knew Johnnie was always there for me.  And that connection continued to the day he left this earth. Even though I haven't physically been in Johnnie's presence or breathed air in the same room since 2005.  Even though he hasn't been able to speak to me in a few years. (His progressing Parkinson's eventually made it impossible for him to talk on the phone.)  And even though chronic pain kept me from traveling back to the East Coast to see him in the flesh. 

His wife, Sally, I also dearly love, (She was my matron of honor and a part of all the other stuff Johnnie was privy to in my life).
She told me in her message, not to be sad, they had many good years, and he was suffering so much in the end.  Sally said she was going to remember all the good times and try to forget the last two years which were hell for him and for her (watching him suffer ).  They have had such a rich and full life together - their fullness and love spilled over as they adopted two sons (one is my godson) both grown now with happy families. Their love also embraced two sisters from Spain during their high school years abroad.  I never met Carmen and Soledad Berbegal but from hearing about them from Sally and John,  I know that they experienced the same love and generosity that I did and were shown the same care and kindnesses that I enjoyed.  I am so grateful to Johnnie and Sally that they took me wholeheartedly into their already full lives and always made me feel like one of their own.  They included me on yearly car trips to Sally's mom and dad in Memphis, Tennessee where we got bored and lost in the fog just like a regular family does.

Carmen wrote a beautiful letter memorializing Johnnie in which she said, "When I think of you, I imagine your big smile, your curious eyes behind your glasses, your aura of youth, your charming way of walking, your belly, a book in hand, a mug in the other... I admire you so much, your generosity, your personality, charisma, and your big heart.  I remember you saying 'Hey girl' when you spoke to me... your sense of humor and sarcasm. John, I cannot thank you and Sally enough for having me in your house and getting to know you.."  all that she wrote goes for me too.

The most recent kindness of the Clark family was that they included me in the obituary as one of the survivors - "John T. Clark is survived by his wife, Sally, their sons, David and Johnathan and families, brother Billy, sister Carol, niece Stacey... and Marian Wolfe Dixon of Portland, OR."   Me. I love John and Sally like a father and mother, sister and brother, and they have been the best friends that ever could be.

thanks for listening

Recently I spent a delightful afternoon exchanging information about temporomandibular joint disorders (TMD) with my colleague Bruce Austin, DMD, LMT, a dentist and massage therapist from Corvallis Oregon.  He wanted to meet with me because in 2002 I developed a massage protocol for research on temporomandibular joint disorders in conjunction with Oregon School of Massage (OSM) and Kaiser Permanente's Center for Health Research (CHR).  To prepare for this task, I had to learn about TMD and what experts in physical medicine recommended for it and other dental pain, then synthesize and test a basic protocol which I still use for clients today and teach to advanced massage practitioners at OSM.  Here are some facts about TMD.

The Temporomandibular Joints (TMJ) are the two joints that connect the jaw to the skull -- the only bilateral joint in the body.  They slide and rotate in front of your ears, and if there is a problem on one side, it will most likely affect the other.

Temporomandibular Disorder (TMD) is any problem that prevents this complex system of muscles, bones, and joints from working together in harmony. “TMJ” or “TMD” refers to a broad range of symptoms.  TMD patients may experience several of these symptoms or only one. 
Symptoms most commonly associated with temporomandibular disorders include:

• Stiffness, tiredness, and/or pain in the jaw
• Chronic, recurring headaches
• Clicking, popping or grating sounds in the jaw 
• Earaches, which may actually be pain in the jaw 
• Pain in the jaw when chewing or opening wide
• Restricted jaw opening, catching or locking
• Difficulty or pain when closing the teeth together comfortably in a normal bite 
• A bite that feels off
• Sensitivity to touch and temperature.
  

The National Institute of Dental Research, part of the National Institutes of Health, recognizes three categories of TMD:

• myofascial pain - the most common form of TMD, which is discomfort or pain in the muscles that control jaw function and the neck and shoulder muscles.
• internal derangement of the joint - meaning a dislocated jaw or displaced disc, or injury to the rounded edges of the jaw.
• degenerative joint disease - such as osteoporosis or rheumatoid arthritis in the jaw joint.

Brief Anatomy of a Healthy Jaw
A healthy jaw is made up of teeth and gums, with a temporomandibular joint on each side and its attaching muscles. In the entire human body, there is no other joint system that has such a complex interplay of functional components.  The jaw functions optimally when the joints are healthy, when the teeth come together in a way that supports and protects the joints, and when the muscles are able to function in a relaxed manner.

Each TMJ (one on each side of the head) is made up of two bones, the mandible (jawbone) and the temporal bone (located at the side of the skull - your ear goes through here).  These two bones are attached to one another by ligaments and are surrounded by small muscles which control the position and movements of the jaw..  A small fibrous pad known as the disc acts as a friction absorber, preventing these bones from rubbing on each other, thus allowing an easy and smooth function. Nearby muscles of the neck and shoulders can indirectly affect the jaw are and/or can become tense and painful as a result of TMD.

Problems in the Jaw System
30-40% of the general population has clicking, popping or other sounds in the jaw joints during jaw movement. Joint sounds indicate a structural change that may predispose the person to developing pain and other difficulties. As long as this continues to be no more than uncomplicated clicking or popping, without pain or catching in the joints, there may be no reason to be concerned. However a dental evaluation at this point can prevent a problem from progressing and becoming more difficult to treat.

It is a myth that something called “TMJ” is a single discrete disorder.  The term “TMJ” (or more appropriately, “TMD”) is a broad, term, covering a wide variation of musculoskeletal disorders of the masticatory system and may include relatively minor, easily treated conditions that involve only the muscles of mastication. However, at the other extreme, are conditions that involve teeth, muscles and the temporomandibular joints which may require complex treatment strategies. The origin of TMD can even be remote to the head/neck, such as pelvis or sacroiliac mal-alignment or even leg and feet issues.

TMD can be brought on by a variety of traumas such as traumatic injury to the jaw or neck, whiplash, arthritis of the temporomandibular joint, and uneven bite (malocclusion) or poor postural habits.

Muscles of Mastication
Jaw problems  are most commonly seen first in stiff, tight muscles and perhaps in difficulty opening or being able to hold the mouth open.. This may gradually lead to painful jaw muscles that can appear as headaches or as an aching or tired feeling in the jaw.

The muscles of the jaw will adapt and accommodate to a bad bite to some degree if they can.  However, this is a little like taking a hike with a rock in your shoe. With each step, certain muscles are now used to “compensate” to avoid stepping on the rock over and over.  After a while, the result can be sore muscles in the leg or hip. In this way, jaw muscle pain can develop over time from muscles having to function in a “compensated” manner.

When pain does develop in the jaw, surrounding muscles tighten further to protect the painful joints. This chronic, prolonged tightening, referred to as “splinting”, can also result in more jaw pain. Clenching and grinding the teeth also contributes to excessive use of the muscles. Very often a combination of these factors, occurring at once, cause muscle pain or headaches.

Dental Role in Treating Temporomandibular Disorders
In the TMJ, the fit of the teeth dominates; i.e. people always close their mouth where the teeth fit together best. The TMJ is unique in that there is no other joint system in the human body that has a structure comparable to the teeth that can so profoundly affect structure and function.. If the masticatory system was like other joint systems of the human body, massage and other manual therapy would be entirely capable of managing TMD without help.

With orofacial pain that is not from TMD, the underlying cause of the pain frequently cannot be directly addressed and, thus, treatment of the pain (reduction of symptoms) is the best that can be hoped for. An example of this would be neuropathic pain,  frequently treated with medications or massage and hydrotherapy.

But for most TMJ disorders, knowledgeable TMJ dentists can address underlying causes of the pain and  reduce chronic exacerbations by means of a properly designed and appropriately adjusted intraoral occlusal appliance (splint).  The splint provides an environment in which all of the affected components of the system can achieve a return of normal function, or as near to that as is possible. Two Portland dentists who specialize in TMJ treatment are Arthur L. Parker, DMD  and Samuel J. Higdon, DDS.

The significance of appropriate and effective dental therapy combined with well-executed physical medicine must not be overlooked for the vast majority of TMD patients  The first objective of treatment of a jaw problem is to eliminate the pain. Patients with relatively mild and TMD symptoms that have not become chronic may experience symptomatic relief from several approaches to treatment, including massage, medications, rest of the joint, and home exercises.  The chronic or otherwise difficult patient is more likely to require a coordinated interdisciplinary approach to achieve significant and lasting results.

Manual Therapists who focus on TMD management should be knowledgeable about the dental role and develop a working relationship with at least one dentist who is knowledgeable, skilled, and experienced in non-surgical TMD management.

Massage Therapy's Role
Gentle mobilization inside the mouth can be very helpful in relieving pain and discomfort that can accompany TMD. Relaxation of the neck and low back is correlated with less severity in TMD symptoms as well.  However, the unique anatomy of the TMJ and the widely varying types of dysfunctions that can occur in this joint system make aggressive manual manipulation contraindicated in most cases due to the potential for compounding the condition.

Furthermore, if a therapist lacks
1)    Knowledge of the anatomy of the TMJ  and the wide variation of potential dysfunctional
2)    Familiarity with the effect of the dental occlusion on joint position and function, and
3)    Confidence of the specific diagnosis in a patient
aggressive manual manipulation is definitely contraindicated.  As not all massage therapists are trained in intraoral techniques or have a sense of the complexity and vulnerability of the TMJ, it is best to find professional bodyworkers who have specifically been trained in a TMD class like the one I offer at Oregon School of Massage.  Of course, TMD /intraoral massage is one of my specialties and you click here to contact me.

Massage will relax the muscles around the joint, thereby changing the bite so that some dentists want manual therapists to perform massage with the patient wearing their occlusal appliance (splint).  Dentists may also want to modify the appliance immediately following the manipulation to assure proper support for the joint in the corrected position.

In summary, an ongoing working relationship, involving regular communication and good rapport between a dentist and your  massage therapist is essential to treat the complexity of disorders collectively known as TMD.