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Programme 1. - The Jaw
RADIO 4
THURSDAY 03/08/06 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
CYRUS KERAWALA
PRODUCER:
ERIKA WRIGHT
NOT CHECKED AS BROADCAST
MYERS
Hello and it's very good to be back with you. And we start the new series by taking questions about the jaw, jaws that click, jaws that ache, jaws that just don't meet properly. There's a lot that can be done for a disproportionate jaw, whether it's one that sticks out too much or not enough and reconstructive surgery can even build back a jaw that's been eaten away by cancer. But everyday sore jaws, it may be just a matter of unclenching the teeth and learning to relax. Whatever your question the number to ring as ever is 08700 100 444 or you can e-mail us at checkup@bbc.co.uk.
And joining me to answer your questions is maxillofacial surgeon Cyrus Kerawala, welcome Cyrus.
Let's go to our first questioner who's waiting for us in Somerset, she's Tessa. Tessa, who's got a clicking jaw and it's causing problems in the family, how is that Tessa?
TESSA
Yes it is. Well I didn't know I had a clicking jaw until my husband and children, they were very small at the time, pointed it out. And they just said that every time I ate a meal in their presence and it was very unpleasant sitting at the table with me because my jaw clicked. What is quite interesting now of course is that actually my daughter, we were talking about this earlier today, my daughter informed me this morning that in fact her jaw's started to click but it's only when she wakes up in the morning. So two different problems there I'm afraid but if somebody could tell me something about it, it would be very handy.
MYERS
Well we've got just the man who can tell you all about it. Cyrus, clicking jaws, we know it's quite common, didn't bother Tessa but it certainly bothers other people in the family, so is there anything that you can suggest?
KERAWALA
Yes Tessa thanks for ringing in. I think perhaps the first thing to comment is to appreciate that jaw joint problems are actually very common, at least three quarters of the population will suffer from some sort of jaw joint problem at some stage in their lives and that's particularly common in and around teenage life and particularly in early adult life. So the fact that your daughter has a problem is probably not related to anything that you've passed on to her but really more coincidental. Of all the problems that can affect jaws, clicking is a very common one and the medical terminology is something called internal derangement of the temporomandibular joint, desperately complicated phrase, like all medical phrases I'm afraid but if you break it down it's relatively straightforward. Temporomandibular joint is the medical term for jaw joint, also called TMJ. And internal derangement suggests that there's something wrong with the inner mechanism of that joint and the reason why your jaw clicks is that a disc of cartilage that normally lies within the centre of the joint has slipped out of position. And as a result when you open and close your jaw the lower jaw hits that cartilage and it causes the click.
MYERS
Well we've got another caller, hold on if you will Tessa because I'm sure we'll try and get some more information if perhaps there's anything you might be able to do about it, which I'm sure is what's behind your question, but Alex John joins us and Alex is also suffering from embarrassing clicking jaws. Does it sound similar to Tessa's tale or does it cause you even more problems?
JOHN
I think I've got slightly more problems. I've got a click on my right temporomandibular joint and what I'm having problems with is actually opening my mouth, I can open my mouth easily about an inch but if I want to open it more, like if I've got a strawberry on a dessert spoon or something and want to put it all of the way into my mouth it can absolutely lock and then I have to force it open, at that point there's a really loud snapping click and sometimes it can be quite painful. So I actually find myself choosing what I'm eating and also cutting things up into quite small bits so I can eat it with just a small opening of my mouth. And obviously it's quite embarrassing in company because if you're out and eating something in a restaurant and with friends when you suddenly produce this really loud click when you go to eat things it's embarrassing.
MYERS
Sure, well let's see if we can get some comment on that and perhaps you could say Cyrus, to start with, whether, if you like, ordinary clicking, of the kind that Tessa was describing, perhaps can lead on, if it's not checked, into something a little bit - what sounds like a little bit more serious, the sort of thing that Alex has been describing.
KERAWALA
Yes hi Alex. Alex's problem sounds - it's really a progression from Tessa's problem. Tessa has a painless click, which interferes perhaps more with her family than it does with her, Alex's click is obviously something more of an imposition to her. And really what it reflects is we talked about that bit of cartilage slipping out of position, essentially as the click becomes painful it simply means that the cartilage is moving further and further out of its normal position.
MYERS
So what's the answer - how do you get it not to do that?
KERAWALA
It's difficult not to get it to do it in the first place but the good news is it's relatively easy to get it back in the right place. The important thing to realise about these internal derangements is that vast majority will respond to conservative management and by conservative management I mean without the need for surgery. There are lots of various things that you can do, if your joint is painful then perhaps you can do simple things like take painkillers and adopt a soft diet for a while and perhaps one of the most easy ways to get the discs back into the right place is to have some sort of splint fitted. I'm not sure Alex whether you've had any treatment as yet to try and make things better?
JOHN
No, last time I was at the dentist the dentist did comment on it and - because obviously there was trouble opening my mouth for him to look in and he said he thought I was grinding my teeth in my sleep probably.
KERAWALA
Yes grinding can be a cause of the problem but essentially dentists can make splints, these are like clear plastic shells that fit over either your top or your bottom teeth. And essentially what they do is they reposition the lower jaw, you usually wear them at night. And in repositioning the lower jaw it tends to push the discs back into the right place. So that's probably the first thing that anyone should consider doing in your case Alex.
MYERS
Okay, well I'm sure we'll have some more clickers as we go through, so Tessa thanks for your call and Alex and stay listening. But I'd like to pick up an e-mail from Lisa who again has a clicky jaw when she opens her mouth as widely as possible and she is wandering whether that is the cause of what she describes as her very frequent migraines and if so is there anything that can be done about that, what would you say Cyrus?
KERAWALA
As far as jaw joints are concerned we talked about internal derangement, there's another problem again with a ridiculously long name I'm afraid - myofascial pain dysfunction. Essentially that's just a clever medical term for muscle spasm. And muscle spasm usually occurs because of muscle overuse - clenching, grinding etc. Migraines are a specific entity, they cause sickness, they cause visual disturbances and they're not usually associated with jaw joint problems. But certainly simple headaches, particularly headaches in the temple, can be related to muscle spasm in and around the joint and certainly can be one of the things that people with jaw joint problems present with.
MYERS
So to push you a bit further in terms of maybe perhaps avoiding this happening in the first place, is there anything that people are doing perhaps inadvertently even, maybe chewing food that's too tough or yawning too widely and actually making the problems worse or is it something that some of us may be prone to, just the way we're built, the way our jaw lies?
KERAWALA
Yeah I think for the vast majority of people it's just one of those things. About three quarters of people will suffer from it at some stage, it's not necessarily something that they have done wrong that's precipitated the problem, it's something that was just going to happen anyway. If you have the symptoms then minimising what makes them worse obviously helps - so eating slightly less chewy foods etc., in and around the time of pain etc. But for most people it's just one of the things that's going to happen and not necessarily something they've done.
MYERS
So is it worth coming to see, for example, yourself as a maxillofacial surgeon, a specialist in this, or is it something you have to put up with and perhaps maybe take painkillers if it's that bad but what would be the point of pursuing this further or is it going to go away?
KERAWALA
For the vast majority of people it will go away. I think the reason for seeking specialist advice is several fold, one is perhaps a bit of reassurance - I think a lot of patients that I see present because they're worried that their jaw joint problems represent something serious, a lot of them are worried that if they've got jaw joint problems they'll go on perhaps to have arthritis in their jaw joints.
MYERS
And can that happen?
KERAWALA
Not as a result of the processes that we've been talking about. Arthritis can occur in jaw joints but is very, very uncommon. So I think for a lot of people simple reassurance helps them an awful lot. I think perhaps being referred to somebody like me is a little bit worrying for some patients because I'm obviously a surgeon and it's also nice for them to realise that the vast majority of these problems can be sorted out without the recourse to surgery. So perhaps reassurance and reiterating some simple advice that doctors or dentists can give sorts most patients out.
MYERS
Let's go to Graham, he's got concerns about his jaw and he thinks he's causing something of the problem to do with grinding his teeth, have I got that about right Graham, tell us more?
GRAHAM
Yes, I've been to the dentist today, grinding my teeth has been an occurrence in the past. It's causing damage to the teeth leading to potential expensive dentistry. My question is: would there be any way of stopping the grinding in the sleep through, I don't know, hypnosis or stress management, is there any approach that would remedy the grinding?
MYERS
Okay and before we answer that Graham, if I may, I'd like to bring in Janet who's in Falmouth and I think has a similar problem - you talk about clenching your jaw, is this at night or are you conscious of doing it during the day Janet?
JANET
No it's mostly - mostly at night and I was waking up with severe head pains, temple pains, neck ache. My dentist actually referred me to a specialist who's fitted me with one of these see through splints for my lower teeth. But although it's actually helped the headaches - that I don't wake up with them in the mornings as much - I still have very tender jaws and temples and neck pains and I think I'm a clencher rather than a grinder.
MYERS
Okay, well let's see for a start whether there's much of a difference between clenching and grinding or is it in effect it's the same thing - you're really putting quite a big strain on your jaw as a result of what you're doing overnight when of course you're not able to control it.
KERAWALA
It's essentially, as you rightly point out, it's two ends of the spectrum, there's really little difference between clenching and grinding. Although it does produce some damage to the jaw joint that's really very minimal and most of the symptoms that people get are related to the muscle pain, which goes back to that myofascial pain dysfunction that we talked about with the listener's e-mail. Clenching your teeth at night is obviously not really something you can do very much about but splints, as Janet has been fitted with, help because they reduce the amount of trauma that occurs to the teeth and that will perhaps answer Graham's point, he was worried about the end result of his grinding at night producing damage to his teeth.
MYERS
Janet, I've heard people say that splints are all well and good but they really can't get on with them for more than a day or two or a week or two, are you able to sort of tolerate yours and is it making much difference?
JANET
I took quite a long time to get used to it and it was a few seconds at a time initially before I was absolutely gagging with the thing in my mouth. I thought I wasn't going to be able to manage to wear it but I persevered because I really wanted to get rid of this problem and I can now keep it in, as long as I don't think about it and I manage to sleep with it. But I've had it for 18 months and although I'm still seeing the specialist on a six monthly basis I don't know - is there an end to it, will I eventually be able to stop wearing it or have I got to continue wearing it forever?
KERAWALA
I think perseverance, as you pointed out, is excellent, the vast majority of patients when they have something strange put inside their mouths just immediately want to get rid of it. And ultimately the treatment for the vast majority of these problems is the splint, so you've done superbly well to persevere, particularly for as long as you have. The good news is that for the majority of people between two and two and a half years, I know two and a half years sounds a long time when you're only 18 months down the road Janet. But for the vast majority of people they can eventually dispense with the splint. We talked, I think, Graham gently put on the point about stress the trouble is with stress is it's universal in life, there is no doubt that people who are stressed are more prone to getting these muscle pains and it may well be that after another six months, Janet, when you can dispense with your splint if there is a particularly stressful period in your life, maybe 5 or 10 years down the road, you get similar symptoms again in which case usually wearing the splint but the good news is for much less time than the 18 months that you've persevered with it to date, sorts things out. So there is light at the end of the tunnel, even though it seems a long way away at the present time.
MYERS
Janet, thanks for sharing that with us and Graham I hope the answers have been helpful for you as well. If we may we'll go on to another call - Bernadette is waiting to speak to us and she's ringing from Bristol with problems about not being able to open her mouth wide. So what is not opening your mouth wide - an inch, a couple of inches?
BERNADETTE
It is about yeah, an inch, maybe an inch and a half and the biggest problem is at the dentist, when he has to look in my teeth or do any treatment he has to stop and I have to be able to close my mouth and if I have left it open too long then it will click. And there was one incident when it was left open too long and it did actually lock and that was painful. I'm not sure exactly what it did but he manipulated my lower jaw and was able to put it back. Yeah that does cause me stress when I go to the dentist now.
MYERS
So let's get a bit of information about this then, the jaw actually locking, because we talked about these discs sort of slipping in and out and making the sort of clicking noises and now we're talking about jaws actually really locking and not being able to open your mouth to any considerable extent, which is obviously whether it's eating or talking that's really rather awkward and obviously in the dentist almost impossible, as you've just said Bernadette. Can you say, Cyrus, a little bit about what's going on here then in a bit more detail?
KERAWALA
The disc tends to slip out of position and if it slips out of position just very slightly people do complain of clicking. Really what happens there is the disc has moved a fraction or fractions of millimetres, when the mouth is opened the lower jaw moves forward, it hits the back of the disc and it causes the clicking sound. In fact the clicking sound is the disc flicking back into the right position again. If that displacement of the disc gets worse it moves further and further forwards and eventually when you open your jaw it hits the back surface of the disc but the disc doesn't regain its normal position and as a result the jaw can't move forward any further and it locks, so classically people describe exactly what Bernadette describes - her mouth opens a couple of centimetres, if that, and then they get a lock. A lot of people, Bernadette, are like you - they have problems some of the time - but particularly when they go to the dentist. One useful trick, and it's worth asking your dentist if he can do this, there's lots of dentists have props that they use to keep people's mouths open, they're a bit old fashioned, I have to confess, but when you're lying in the dental chair what you are physical doing is you are concentrating to keep your mouth open and as a result all your muscles are going into spasm. And that spasm makes your problem worse. If your dentist puts a little rubber prop in the mouth the opposite side to the side that he's working you can actually relax completely, all your muscles can be relaxed, and your mouth will still stay open. And you should find that if your dentist does that you'll get far less in the way of problems, both during treatment and after it.
MYERS
So it might be worth forewarning your dentist.
KERAWALA
Absolutely yes, yes and of course the other thing is most people it's prolonged dental treatment that causes the problem. So if your dentist can - if he's got three fillings to do - it would be perhaps more advisable to do one at a time, rather than just have a long appointment with him to have all three done.
MYERS
Okay, hope that's helpful, thanks for sharing that with us Bernadette. Angela's got I think possibly again a similar problem, which is about having - biting and hearing a crack, tell us more it sounds quite dramatic and I wonder what has happened Angela.
ANGELA
Yes, I had a bit of cuticle annoyingly just hanging on my finger so I bit it off with my front teeth. I heard a crack and now I find my bite has changed, I can't make my front teeth meet at all anymore and my back teeth have changed position, it's also a bit painful to chew and I can't open my mouth very wide.
MYERS
It sounds as though you've actually dislocated your jaw but that would be my impression, what's going on here then would you say Cyrus?
KERAWALA
It's not actually a dislocation per se but it's rather similar to Bernadette's problem. We were mentioning when we were talking about Bernadette that the disc of cartilage slipping progressively out of position, it normally slips forwards, in other words away from the ear, but it sounds in Angela's case as though the disc has slipped backwards and as a result it doesn't allow the lower part of the jaw joint to sit properly in the upper part of the jaw joint, it's almost as though there's a foreign body there and as a result if the jaw joint can't close properly then the teeth can't close properly either.
MYERS
So if Angela came to see you what would you do for her?
KERAWALA
Well Angela how long have you had the problem for?
ANGELA
Well about six months really, I've had various other problems so I haven't dealt with it and I always hoped it would go away.
KERAWALA
I mean it's obviously been going on for a while and if it's imposing on your life then the good news is simple things can sort it out. We talked initially about the fact that the vast majority of things can be settled conservatively without the need for surgery and certainly that's true in your case as well. Believe it or not slightly different forms of bite splints will often reposition the discs and they can reposition the discs forwards or backwards, or as I say there are slightly different designs and that may well help. There is some suggestion that there's something wrong with the joint fluid and as a result the disc isn't moving properly and a relatively new procedure - something called an arthrocentesis - which is just simply washing the joint out is a very simple non-invasive procedure, often helps as well. So although Angela has got a sort of progressively worse end of the spectrum, compared to some of our other callers, things that are relatively simple can sort these things out, so it's probably worth seeking some advice, particularly as it's been going on for so long.
MYERS
Thanks very much I hope you'll follow that up Angela. We'll move to another e-mail: Jo has messaged us and she says that she has a jutting lower jaw, it makes her very self conscious and she says she feels ugly. So she tries to avoid letting people see her inside profile, as she thinks that's the worst aspect of the shape of her jaw. She says, she thinks it makes her look like a witch. She's saying she's been teased a lot and I'm sorry to hear that and she'd really like to try to get to grips with this, is there anything that she can do about the shape of her jaw?
KERAWALA
Jo, it sounds like you've got quite a problem there and obviously it's having some impact on your life and I'm obviously sorry to hear that. The good news is there are things that can be done. Jaw disproportion is not uncommon, some people have over developed jaws and some people have under developed jaws and that can affect both the top and or bottom jaw. The only solution for a particularly bad disproportion is surgery, now surgery sounds terrible and perhaps if I describe it in some detail you'll think it sounds even worse than that but actually it's a relatively simple procedure regularly carried out in this country and in the unit that I work at perhaps we would do 150 of such operations a year. Not to go into the gruesome details too much, essentially during surgery while you're asleep, obviously, the jaw is cut and broken in a very controlled fashion, the jaw is then moved into a new position and it's held in that position with tiny little plates and screws, the similar sorts of plates and screws that orthopaedic surgeons use to fix fingers. Now if that operation takes place on just one jaw we're only talking of something like an hour and a half's worth of work, overnight stay in hospital, obviously a bit of soreness and obviously some difficulty eating but usually within about a week or two people are almost back to normal. The problem with that surgery is obviously if you're moving the position of your jaws you will move the position of the teeth as well and therefore you can't do the treatment just on its own, invariably it demands some sort of orthodontics - orthodontics, if you're not aware Jo, is brace treatment and essentially there's a period of brace treatment prior to surgery, then surgery and then perhaps a period of tweaking the teeth into the right place to get a good bite afterwards. So it's a long haul but certainly a very, very worthwhile one.
MYERS
It certainly sounds extensive, does that also mean that it's expensive?
KERAWALA
The good news is that for the very, very vast majority of patients treatment is available on the NHS and I wouldn't hesitate to suggest Jo, if things concern her as much as her e-mail suggests, seeks the advice of a dentist or doctor and attempts an NHS referral and certainly if a referral like that came into our unit we would accept it and I wouldn't image that Jo would have any trouble, I don't know where she lives, but any trouble receiving similar treatment.
MYERS
And we don't know how old she is, is there an optimum age for this sort of treatment, can you have it done, as it were, too young or too old?
KERAWALA
The majority of patients that we treat they're aware of the problem in late teens, early 20s, there are advantages to operating in that age group, we talked about having to move the teeth orthodontically with braces, the nice thing about that is if you're young you have bone that's not particularly dense so the teeth move quite quickly, if you are young you tend to bounce through surgery, so I suppose the optimum age is the sort of late teens, early 20s and I think probably 90% of our patients would fall into that age bracket.
MYERS
Jo, I hope that's been helpful, thanks for letting us know about that. We'll go to Peter Rutherford who's in London and has broken his jaw. How are you doing?
RUTHERFORD
Well not too bad at the moment, this is week four and for the first three weeks my mouth was full of elastic bands holding it together, eating liquids but now I've just got two elastic bands either side. And next week hopefully the bands will come out and in week six the wiring comes out that holds the bands in place. But really I wanted to know whether everything will be okay, I've got this dread if I sort of yawn or - I'm a keen cyclist if I go over a bump I wouldn't break my jaw, so reassurance needed please.
MYERS
So anything you can offer to Peter then?
KERAWALA
Peter, I'm sorry to hear of your problem. Jaw joint fracture - jaw fractures are really quite common, I suspect that some of the treatments that you've had is similar to that that I discussed with Joe, you've probably got some little plates and screws put in there. The good news is that by about six weeks your jaw will be as strong as it was before the accident. The plates and the screws are made of a metal called titanium, a lot of people are worried that if they go through an airport lounge ...
MYERS
Security.
KERAWALA
That's it, that it will set it off but it doesn't. So when all the bands which were there just really to guide your bite in the right place, once they're removed you should find that it's absolutely fine. So six, eight weeks you'll be as right as rain.
MYERS
That's good news. Peter, thanks very much for that call. I know Peter's a taxi driver, I think he's actually driven off. But safe and sound I hope, hope he didn't have an accident and cause his broken jaw.
That's all we have time for today. Thanks very much to Cyrus Kerawala, our expert. Thanks to all of you and there were a lot of you who rang and those who got through and those who didn't, I hope anyway the answers have been helpful to everyone who's been listening.
There is more information, you can get that by going to the 大象传媒 website and follow the prompts which will take you to our own website, the Check Up website. You can, if you prefer, call the help line, that's 0800 044 044, calls are free and they are confidential. And join us again, if you will, next week when our topic will be bladders.
ENDS
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