76. Orofacial Pain with Robinson-Smith, DDS

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Linda Bluestein, MD (00:01.351)

Welcome back every bendy body. This is the bendy bodies podcast and I'm your host and founder, Dr. Linda Blustein, the hypermobility MD. This is going to be a great episode. So be sure to stick around until the very end so you won't miss any of our special hypermobility hacks. As always, this information is for educational purposes only and is not a substitute.

for personalized medical advice. Today, I am so excited to have Dr. Julie Robinson-Smith with me. Following dental school, she served in the US Air Force for five years as a general dentist. After her time in the Air Force, she completed a two-year residency in oral facial pain and oral medicine at the University of Southern California. As a UCLA grad, it's amazing we're such great friends and colleagues.

Julie Robinson-Smith (00:55.255)

Hahaha

Linda Bluestein, MD (00:59.459)

She is a diplomat of the American Board of Oral Medicine, a diplomat of the American Board of Oral Facial Pain, and an instructor of oral facial pain at the University of Colorado Anschutz School of Dental Medicine. And Dr. Smith is also my amazing TMD doctor. Dr. Smith, hello and welcome to Bendy Bodies.

Julie Robinson-Smith (01:21.847)

Thank you.

Linda Bluestein, MD (01:23.631)

I'm so excited to chat with you. So we're gonna talk about jaw pain today. Can you start out first by explaining the abbreviations TMD and TMJ, because this is sometimes a source of confusion.

Julie Robinson-Smith (01:37.966)

So TMJ is the older term, TMD is a newer term. TMJ means Temporomandibular Joint. That's what it's an abbreviation for. TMD is more commonly used now because it represents Temporomandibular Disorder, which is more appropriate for most of the jaw pain issues that we deal with. However...

It's still not a comp, not a correct term or it's a correct term, but it's kind of a misnomer. People think that when they use the word TMD, my patients come in and they say, I have TMD. They think I know what's wrong with that. TMD is an umbrella term. It refers to a variety of conditions that can affect the jaw joint or the muscles of mastication, your chewing muscles. So basically when you tell me that you have TMD, you're telling me I have a problem with my chewing system.

That's like coming to your doctor and telling them, my knee hurts. Well, they don't know what's wrong with you yet, or they shouldn't because you could have arthritis in your jaw joint. You could have a disc that's out of place. Your jaw could be open to closed or shut. You could have muscle pain. There's just a very long list of conditions that fall under that umbrella of TMD. So yes, my patients...

walk away after we've had a conversation about their arthritis or what's actually wrong with their joint and they say, well, do I have TMD? Well, yes, if your jaw joint hurts or you have pain in your face, you probably have TMD, but it's not a diagnosis and it's not actually that useful in developing a treatment plan unless you understand your exact diagnosis.

Linda Bluestein, MD (03:20.043)

Okay, excellent. And so TMD is Temporomandibular Disorder, and TMJ refers to the Temporomandibular Joint, which of course we should all have two of those. It doesn't necessarily mean that there's a disorder, but I know you have shared with me that you're okay with people using either term, but I think sometimes people get confused if they hear TMD and they don't know what that means. So I really appreciate that excellent explanation of TMD.

Why is this such an important topic for people with bendy bodies or joint hypermobility?

Julie Robinson-Smith (03:51.874)

So actually, I think TMD and understanding TMD is important for everyone because TMD or joint dysfunction or symptoms is extremely prevalent in the overall population. 50 to 75% of the adult population has something wrong with their jaw joint or their chewing muscles. They can have arthritis, again, it's an umbrella term. So they can have arthritis, they can have a disc displacement, they can have muscle pain, all of those things are TMD.

Linda Bluestein, MD (03:56.017)

Mm.

Julie Robinson-Smith (04:21.426)

And so they affect a huge number of people in the population. Roughly 30% of the population at any given time has some sort of sign or symptom, so pain or something that's actually bothering them with their jaw joint. But most of the jaw joint problems that people have are fairly transient. So you might, a third of the population might be bothered by their jaw one day or another, but it's not enough to seek care. They might take a Tylenol or not chew it.

some a can of almonds for a day. But, but overall, it settles down. 5% of the population has jaw pain that actually drives them in to see a provider about it. And that there was a study done in the 90s that looked at who gets jaw pain, who actually comes in, what are the risk factors for people seeking treatment for their TMD.

or their temporomandibular disorders. And what they found is the single most common risk factor for seeking care and needing treatment for jaw pain or facial muscle pain was not grinding your teeth, was not the amount of stress in your life, but is actually having a comorbid pain condition, such as fibromyalgia, migraine, IBS, or probably very under often,

Linda Bluestein, MD (05:40.819)

Hmm.

Julie Robinson-Smith (05:48.258)

frequently not appreciated is underlying hypermobility, which I see a lot of in my practice now that I'm actually looking for it. So before we get further, I also wanna explain how this jaw joint works. I have a skull here and I'm gonna switch it so you can see the disc.

Linda Bluestein, MD (06:06.127)

And so I'm going to just really quickly before you start, I'm just going to tell people that if they're listening to this as an audio podcast to please go to the YouTube channel and also watch this portion because I don't want them to miss this extremely important demonstration that you're going to do. So if someone's listening to this, please be aware that this will also be available on YouTube.

Julie Robinson-Smith (06:29.006)

Perfect. So I'm just gonna show you a quick demonstration of how the jaw joint works. And then you can understand why the hypermobile population is going to be affected so much by this condition. So it's a little weird, I've never done this on the computer before, so bear with me, I usually show patients and I hold it in my lap. So the jaw joint is unique. It's the only joint in the body that has two motions. So it rotates like this, you can see it rotating.

and it slides like that. So it actually slides in the capsule. And there's no other joint in the body that actually does that. So it has a disc on top of it, a piece of fibrous connective tissue that has no nerves and no blood supply, acts as a cushion between your jaw and your skull to protect everything. And when you rotate, you rotate against it. And when they slide forward, the disc moves with it. So the jaw is rotating against the disc here. And when the two slide forward, they move together as one unit.

However, these two structures, the disc and the jaw joint, are not actually attached to each other. The things that keep them moving in harmony together are ligaments. Ligaments surround that entire jaw joint like a basket. And when they're nice and tight, they keep those two structures moving together nicely. And the jaw joint's about the size of your thumb. So it's extremely small, and it's extremely susceptible to very small changes in ligaments.

So if the ligaments loosen for any reason, that disc and that jaw can start to move independently as two separate structures. And that's when clicking in the disc starts, or in the jaw starts. So what happens is the most common thing that happens is that disc moves forward into the center, so forward and medial. So the jaw now rotates behind the disc. I don't know if you can see it, but there's a little disc right there. And so the jaw sits back there and it rotates against

Linda Bluestein, MD (08:07.315)

Hmm.

Linda Bluestein, MD (08:20.08)

Mm-hmm.

Julie Robinson-Smith (08:24.674)

the retrodiscal tissue. Now remember I told you that the disc itself has no nerves and no blood supply in it. The retrodiscal tissue supplies nutrition to the jaw joint. So it is full of nerves and full of blood supply. And when you pinch it, it can be quite sore. So now you're functioning on this retrodiscal tissue and when you slide forward, you hear a pop as you recapture the disc. So clicking in jaw joints is extremely common and it's often the first thing that happens in traditional TMD symptoms.

Linda Bluestein, MD (08:36.456)

Hmm.

Julie Robinson-Smith (08:54.678)

hypermobile patients are going to have more ligamentous laxity. So they're going to be more prone to that disc slipping out of place. Interestingly though, 30% of the 15 year old female population ends up with clicking starting in their jaw joints just because of the laxity that's associated with the hormones associated with puberty. So those hormones cause the ligaments to relax just a teeny tiny bit.

Linda Bluestein, MD (09:16.859)

Mm.

Julie Robinson-Smith (09:20.574)

When you've got a joint the size of your thumb, you don't need very much ligament relaxation for that disc and that jaw to start moving independently of each other. That is the first sign and symptom of TMD. And that's why it affects the hypermobile population more than the general population because it's all about ligaments. And if it happens a lot in the normal population, people with extra flexible ligaments are going to have even more problems.

Linda Bluestein, MD (09:51.339)

Okay, awesome. That's super helpful. And you had mentioned something to me also about hypermobility and the differential diagnosis relative to age.

Julie Robinson-Smith (10:03.106)

Sure. So one of the things that's also interesting, so I said, we kind of appreciate that 30% of the female population at age 15 starts to develop clicking in their jaw joints, and we attribute that to puberty. However, anyone younger than age 15, that's a pretty uncommon time to have clicking in their jaw joints. So in the absence of significant trauma, and I don't mean like I tripped, fell down a couple of stairs when I was two.

That happens to all two-year-olds. Well, at least my two-year-old. He's pretty crazy. Or falling out of a pack and play or tripping. Those things are pretty normal, but a car accident, now that's significant trauma. So in the absence of really significant trauma, clicking before age 15 in anyone, you should at least consider hypermobility in the diagnosis or the differential diagnosis.

Linda Bluestein, MD (10:34.615)

Ha!

Julie Robinson-Smith (10:59.09)

and any men in their teens that start to develop clipped keying in their jaw joint. Again, in the absence of significant trauma, and that's just my personal experience. There's not a lot of literature on this. There's not a lot of literature on hypermobility and how it affects the jaw joint anyway. But I think if you have any man who's under 20 who has clicking in his jaw joint and hasn't been in a car accident or broken his front teeth from falling off a bicycle or something like that.

you should really consider hypermobility in the differential.

Linda Bluestein, MD (11:32.851)

Okay, excellent. Before I go on to the next question, I liked your camera when you had it tipped down a little bit more. Perfect. If you don't mind leaving it like that, I loved it like that. Okay, and I'll obviously remove that little clip in there. Okay, that's excellent information. So how does a diagnosis of hypermobility change your approach to a patient with TMD?

Julie Robinson-Smith (11:42.186)

Better? Sure.

Julie Robinson-Smith (11:58.99)

So when I see a hypermobile patient, it gives me, one, I'm concerned about open locking. Open locking is not very common, but it is much more common in the hypermobile patient population. In fact, that's another thing that makes me very interested in looking, screening for hypermobility, is if a patient reports a history of open locking. I have yet to encounter a patient who is not hypermobile who has had open locking. No, that's not true, I have one. But...

In general, open locking makes me highly suspicious of hypermobility and in a young hypermobile patient, I'm very concerned about open locking. And open locking is probably one of the most emotionally distressing things that can happen to you because your jaw is stuck open. You cannot close it. That's very, it's very awkward. Everybody's going to look at you funny and it's really distressing to not, and bugs are going to fly in your mouth. That's not very fun. So I want to teach people how to avoid this.

One of the things you can do is avoid, basically we just, I'm gonna show you my skull again, sorry. I wanna show you what happens when you get open locking. So I said you can rotate, those ligaments just don't stop the jaw from moving. So I told you the jaw rotates and it slides forward. The ligaments normally stop it on the top of this articular eminence. And I don't know if you can see that bump, but there's a bump there called the articular eminence that the jaw joint is supposed to stop at. But what stops you? Your ligaments.

Linda Bluestein, MD (13:03.533)

Mm-hmm.

Julie Robinson-Smith (13:27.854)

If your ligaments aren't doing their job properly, then they don't necessarily stop you. And you can fly right over that eminence. And now see how the jaw just pops up into that little divot there? Now you're stuck, especially if you have any tension in these jaw closers that will just pull the jaw tight into that spot and keep you stuck in an open position. So the way to get it closed is to push down on the molars and distract against these jaw closers, the temporalis and the masseter.

Linda Bluestein, MD (13:28.167)

Hmm.

Linda Bluestein, MD (13:38.44)

Mm-hmm.

Julie Robinson-Smith (13:57.538)

so that the jaw will slide back into position. There's lots of ways you can always go to the emergency room. They're pretty adept at getting your jaw closed if that happens to you. But I prefer to let it never happen and try to teach you some techniques to prevent it from happening in the first place. So one of the most likely times, there's two times that you're most likely to get stuck open, well, three. One is in the dental office. So in the dental office,

you want to make sure that you ask for a bite block that doesn't open you too wide. Dentists love hypermobile patients because they can open like an alligator. It's so easy to work on. Even dentists with big hands can get all the way to the back because their patients are opening so wide. But if you get opened so wide that you dislocate, or subluxate is what we like to call it, that's distressing for your dentist and for you. So if you keep...

Linda Bluestein, MD (14:33.744)

Yeah.

Linda Bluestein, MD (14:40.531)

Mm-hmm.

Julie Robinson-Smith (14:54.654)

yourself from going past translation and you just keep yourself in the early parts of opening that first 35 millimeters then you won't your jaw won't slide forward. So bite block, small one, don't ask don't get the adult ones ask for a child-sized bite block and then if they need you to open wider at certain times you can do it for a short period of time but try not to do it for very long that's going to hopefully protect your jaw. So

Another time is when you sneeze or yawn, because the jaw just naturally pops open. So what you want to do is if your neck can handle it, you want to try to guide your eyes down and tuck your chin just a little bit. That allows your neck to hit your chin so that your jaw can't open so wide, and that should help you prevent from open locking. So just looking at the ground whenever you yawn, whenever you sneeze.

Linda Bluestein, MD (15:25.351)

Mm.

Linda Bluestein, MD (15:42.794)

Hmm.

Julie Robinson-Smith (15:51.402)

And finally, if you like to eat really big sandwiches, because let's face it, when you can open like an alligator, you can fit that giant sandwich in your mouth. You don't wanna put that sandwich in your mouth and then find out that you can't actually get your teeth to close around it, you can't bite it, because you got yourself stuck open. So this goes, I was gonna bring this up in the hypermobility hacks, but basically don't eat food that's too thick, and we'll talk about really three fingers. You wanna keep your food to three fingers or less.

Linda Bluestein, MD (16:01.031)

Ha ha.

Julie Robinson-Smith (16:21.238)

so that you don't get stuck open when enjoying a sandwich. And those are my, that's pretty much my most useful information when I first meet a hypermobile patient. And then to address the kind of the central sensitization that affects their pain because jaw pain is very reactive to everything else. And if your whole pain system is out of whack, I'm not gonna have much success at treating just the jaw. It's just gonna keep responding to the rest of your pain.

Linda Bluestein, MD (16:52.199)

That makes sense. So I think I've told you, most all of my patients have jaw pain. And most all, if not all of my patients have evidence of central sensitization. So for people who are listening though, who are like, what is that? I don't know what that is. Are you willing to go into that a little bit more or? Okay.

Julie Robinson-Smith (17:14.05)

Sure, you might be better at explaining it than I am. But basically when you have chronic pain, any type of chronic pain really, the nervous system kind of gets adapted to it. And so that things that aren't supposed to be painful can cause pain, allodynia, or things that should be mildly painful create a whole bunch, create extra pain. And so your pain experience is amplified.

so that every light touch, everything that might hurt some people a little bit is extremely painful for you. And a lot of my patients are really good at ignoring that pain. So they're experiencing it and then they ignore it. But that doesn't mean they're not experiencing pain at a higher level. And when you have to ignore that much pain all the time, what do you think it does to your jaw muscles?

who takes their stress out in their teeth and in their face and their jaw all the time. So they hold a lot more tension in their face, a lot more tension in their neck because they're protecting themselves against all this extra pain input that their nervous system is giving them all the time.

Linda Bluestein, MD (18:27.431)

That makes a lot of sense. And I know I mentioned that most of my patients have jaw pain and central sensitization and it seems counterintuitive. Like if you have a lot of pain, it seems like your nervous system would just filter things out and that you wouldn't feel things so much. But you're right, it's kind of a weird paradox of.

that you have the allodynia, like you said, where things that are normally not painful are painful, and then hyperalgesia, where things that are normally mildly painful are more painful, but at the same time, yeah, most of us are kind of trying to ignore those things, and so it's definitely, that makes sense, that we can hold a lot of tension in our jaw and exacerbate our symptoms.

Linda Bluestein, MD (19:13.503)

Okay, so speaking of symptoms, what can people do who have stubborn symptoms? How can they address those?

Julie Robinson-Smith (19:22.318)

So it's really hard. Again, treating the jaw is really diagnosis-dependent. So there's lots of different things that can happen in the jaw joint to cause pain. So it's really important to kind of see somebody who can address your unique symptoms, but if you can't find someone because there's not a lot of us out there, remember that the jaw joint is just another joint in the body.

There's nothing special. I mean, it's special. It moves in two directions. It's stabilized by ligaments. It's more susceptible, or at least I think it's more susceptible, to ligament injury, or the ligaments play a big role in it. But it's just another joint. At the end of the day, things that, most of the things, the treatments that we use for the jaw joint, we borrowed research from other joints. For example, we do steroids in the jaw joints.

Linda Bluestein, MD (20:03.037)

Mm-hmm.

Linda Bluestein, MD (20:14.948)

Hmm.

Julie Robinson-Smith (20:17.238)

steroid injections in the jaw joints. There's no good research on steroid injections in the jaw joints, but there's lots on using it in the knees. We borrowed their research. So remembering that that's what we as providers are doing, we're borrowing research from other joints. It works on your knees. It's probably going to work on your jaw. Same goes for you as an individual. If there's something that you know works on your other joints, use it for your jaw joint. The same basic principles apply.

anti-inflammatories. I, because most of my patients have a lot of chronic pain, I don't recommend systemic anti-inflammatories. The jaw joint is pretty close to the surface of the skin, so Voltaren can be an effective option. Some people like Aspercreme. I do compounded lotions, but if you don't have a provider to prescribe that, Voltaren is now over-the-counter, so it's a good option to apply to your jaw joint. Heat, ice,

and softer foods, resting it. It's really the same principles that apply to any other joint. I don't recommend, unless you have somebody really that understands your jaw joint, going on the internet and finding a bunch of stretches to do for your jaw. And the reason for that is a lot of pain actually is stemming, even though people experience more pain in the muscles, a lot of the pain is really stemming from the jaw joint itself. And if you start doing crazy positions, you're putting a lot of pressure on that joint.

Linda Bluestein, MD (21:27.387)

Mm.

Julie Robinson-Smith (21:42.21)

and probably aggravating it and kind of perpetuating your symptoms. So if you can massage your face, you can put heat on your face, but try not to do a lot of weird facial positions because that can put some stress on the jaw joint and aggravate your condition unless you're really convinced it makes you feel better.

Linda Bluestein, MD (22:03.755)

Okay, and I know you prescribed a topical for me that was really helpful. What was in that? I'm trying to remember. Do you remember offhand? Okay.

Julie Robinson-Smith (22:10.046)

It's ketoprofen, it's ketoprofen and lidocaine. And so, yeah, those are the, but it's not that easy to get a compounded medication made.

Linda Bluestein, MD (22:24.079)

So that's a combination of a non-steroidal anti-inflammatory drug and a local anesthetic.

Okay, no, no problem. Okay, great. So it was so interesting. When I was searching for a doctor to help me with my jaw pain, I would call around to different offices and it was so fascinating because they would sometimes tell me, like, this is exactly what this doctor does for this problem. Like, they had a specific, and sometimes I could look it up, like, this is the device that they use, this is how they treat, it sounded like pretty much every patient.

And I felt like I almost was the one that had to decide. This is when I was in Wisconsin, living in Wisconsin. I felt like I almost had to be the one to decide which of these approaches were right for me because each of these different doctors and specialists were using a different approach. So if someone is experiencing the same kind of thing, they're calling around, they're looking for a specialist and they're getting this kind of information, how do you suggest that they approach that?

Julie Robinson-Smith (23:27.582)

So like I said earlier, TMD is not a diagnosis. So if a patient calls me and says I have jaw pain, and sometimes they don't even have TMD, sometimes they have something completely different like trigeminal neuralgia, if somebody calls and says that they have TMD, I don't know what's wrong with them yet. So actually it's a question that my office manager deals with very frequently. And a lot of times patients are quite dissatisfied with the answer when they say, well, what's she gonna do for me?

Linda Bluestein, MD (23:45.393)

Mm-hmm.

Linda Bluestein, MD (23:57.256)

Hmm.

Julie Robinson-Smith (23:57.494)

And my office manager is like, I literally have no idea. We don't know what's wrong with you. So I, obviously that's my approach. I think that it's important to see a provider. They can tell you the tools and techniques they use. Okay, she does steroid injections for TMD sometimes. Sometimes we make appliances. Sometimes we do stretching. Sometimes it's just home care therapy.

But if somebody tells you that they know what to do, or they always do imaging, or they have a cookie cutter approach, TMD is not a diagnosis. So you can't treat it all the same, because they're all different things that make up that condition. And so you really should be looking for a provider who wants to understand your condition first, and then give you a treatment plan. I know it's frustrating. It's much easier and nicer to hear.

and know before you go in exactly what they're going to do for you and exactly how much it's going to cost you since a lot of insurances don't pay for TMD treatment. But if somebody says that something's going to work, I am always hesitant in my field of anything that somebody says. If anybody ever says always or never, those are words I run from.

As soon as I say something never happens, the patient with that condition is gonna walk into my office the next day. And if something always works, I'm gonna be wrong. So I can say most of the time, usually, it's always worked in the past, but always, so somebody gives you an idea of a treatment plan that's gonna work always, and this is what they do for everyone.

Linda Bluestein, MD (25:35.142)

Ha ha ha.

Julie Robinson-Smith (25:48.004)

especially my hypermobile patients. They're not everyone.

Linda Bluestein, MD (25:53.275)

Yeah, that totally makes sense. And that was kind of what I was thinking when I was talking to these different people, although I didn't understand it, obviously like you just explained it. So that's really helpful. And as you mentioned, there aren't a lot of people that are treating these conditions. I mean, I feel like I have different levels. So I was first experiencing jaw pain, gosh, at least a decade ago. That's when I had my first appliance made. And at that time it was just my general dentist who made the appliance.

quite stable for many years as you know until I had some dental work done a few years ago. And actually I'm having dental work done in three days so I am so excited about that tip because now when I go in I'm going to ask for a bite block. That's huge and that's what happened was I didn't ask for a bite block when I had this dental work done. But anyway so if people are having difficulty finding someone to address their jaw pain or suspected

Julie Robinson-Smith (26:40.586)

Yes.

Linda Bluestein, MD (26:52.247)

under the umbrella of TMD. What do you suggest that they do?

Julie Robinson-Smith (26:56.874)

Sorry, I was, I spaced for a second. Can you repeat the question?

Linda Bluestein, MD (27:00.747)

Of course, and I was rambling on the question anyway, so I'm going to repeat that. So because that's my little key phrase, I'll find that and delete it. So

and I'm trying to think how to say it in a more succinct way now. I'm just going to ask the question, what do you suggest people do if they have difficulty finding someone to address their jaw pain or suspected TMD?

Julie Robinson-Smith (27:27.318)

That is also a very good question. Hopefully in the future, there will be more people who are trained in diagnosis of TMD. Oral facial pain is the newest approved dental specialty. And so we're working at trying to get really good evidence-based treatments and recommendations in the dental schools, but it's new. And prior to 2020, there wasn't a lot of agreement on how to treat these conditions. So there's a lot of different ideas.

But if you have symptoms and you can't find, first of all, listen to yourself. If you don't like what a provider is saying, don't go with it. Because most of my hypermobile patients know their bodies better than anyone else. They can tell me exactly what's wrong. This has changed, that has changed. It's pretty amazing how much detail they can give me of exactly what's happening in their bodies. And if I listen, I have a lot of information.

But so if you think something's working or not working, then listen to that. Trust yourself is the most important thing. And remember that your jaw joint is just another joint. So don't make big changes. If it's bothering you and you can't find anyone you trust, start with the basics. Switch to softer food. Try using heat. Try using ice. Try not to push it to the edges of its limits. Don't open super wide.

I mean, chew, you want to not just be eating liquids, but try to move your jaw slowly, keep track of your progress. Changes are going to be small, especially if you don't have a lot of outside help and you're trying to do this on your own. So, right, basically keep a diary. What was I able to eat today? And that's one of the best ways to kind of document your progress. It's not even how much pain you're in, but what was I able to do with my pain? So,

Was I able to eat chicken? Or no, chicken was too hard for me today. I was only able to eat a smoothie. Okay, that tells me what your function is and try to keep track of that. If you're getting worse and worse, you probably need to start looking harder to find somebody. Look for somebody who doesn't have a set treatment plan and look for something that's not gonna promise you fast results. You can get better. I can make anybody better for 24 hours.

Linda Bluestein, MD (29:51.823)

Mm.

Linda Bluestein, MD (29:55.891)

Mm. Ha ha ha.

Julie Robinson-Smith (29:56.85)

I have lidocaine. I can make anybody feel better with a combination of marcain. But you don't wanna just feel better for 24 hours. You wanna have a better quality of life. Slow changes, big changes, sustainable changes take time. So.

pay attention, just do what seems right. If it hurts, don't do it. Rest your joint when you need to and just be nice to yourself and know it's hard. And it's hard to find people who do what we do.

Linda Bluestein, MD (30:32.923)

Okay, and I know that we've talked so much at my appointments and things about why this topic again is so important for people with hypermobility and how so many people with hypermobility have jaw pain and everything, but in particular, why do you think people should listen to this episode?

Julie Robinson-Smith (30:52.098)

Well, like I said, 50 to 75% of the population has something wrong with their jaw joints. Some people come in and they don't have any pain at all. They just wanna know why their joint makes noise. And I'm like, well, you're in the 75%. 50% of the 50-year-old population has arthritis in their jaw joints. So these are really common conditions. And sometimes it's just nice to know that it's this common and if it doesn't hurt, don't worry about it. And then for the hypermobile population,

I would say most hypermobile patients probably have a jaw problem, at least a little bit of one, even if it's just clicking. And it's nice to know if it doesn't hurt and your jaw just clicks, don't worry about it. It's common. This is just a normal thing. And if you do have jaw problems or you've had any issues, try to avoid open locking.

Linda Bluestein, MD (31:47.323)

Yeah, that open locking sounds so scary. And thank God that's never happened to me, but I just cannot even imagine that sounds really, really awful and traumatic. Yeah. What do you think we should call this episode? Ha ha ha. I'll think of some ideas. Was there anything that you wish that I had asked you at all or anything that I missed?

Julie Robinson-Smith (32:13.981)

Not that I can think of.

Linda Bluestein, MD (32:16.587)

Okay. You have shared a lot of hacks with me during my appointments. And for example, I know one of the ones we've talked about is like icing the jaw after a dental appointment. Can you share some of those hacks with my listeners? And do you have a favorite hypermobility hack?

Julie Robinson-Smith (32:33.866)

Well, one of my favorite ones, because I'm the one who has to deal with the fallout when people get stuck open, is that your jaw should only open just over three fingers width. This is normal. This is the normal population can open just over three finger widths. So if you're opening wider than that, you're pushing your jaw past its normal limits and stretching it out. So if you can try to keep, when you talk, when you...

sing when you move, keeping your jaw just over three fingers. So, you should not ever need to open wider than that. Keep your food that thick. If you can hold, if you hold three fingers up to it and it's not thicker than three fingers, you're golden. If you're trying to open wider than that, it's probably too wide. So that's, that's really important to prevent open locking.

which is pretty distressing. Usually the first time it happens, you can pop it back into place yourself, but if it happens over and over, it gets harder and harder to do. And some of my patients have problems because their thumbs dislocate when they try to pop themselves back into place. So if you can just avoid it and keep it from ever happening to you, you'll be better off. So that's my favorite one. Another thing is for dental work. Well, I'm gonna talk about, most jaw problems are not caused by sudden...

Linda Bluestein, MD (33:40.989)

Mmm.

Julie Robinson-Smith (33:57.994)

direct trauma. Most jaw problems are caused by micro traumas. So once that disc is out of place from ligamentous laxity, maybe from some micro traumas of clenching and grinding, we don't fully understand all of it. But once that problem has happened, clenching and grinding can kind of wear down that retrodiscal tissue and cause future jaw problems. The more every and inflammation because every time that jaw gets squeezed, you're at risk for

developing inflammation. The jaw heals really nicely, but if you're traumatizing it too much and increasing the inflammation in the joint, you can't always heal from that. So important, this is important for everyone actually. I feel like everyone should know this. There is no functional time for your teeth to touch each other. As dentists, we're very excited and interested in how teeth come together and having the perfect bite.

there's actually no time in life that your teeth should ever touch because when you're talking, your tongue moves between your teeth. When you are chewing food, there should be food between your teeth. And when you're at rest, your tongue should be on the roof of your mouth, your lips should be together, and your teeth should be apart just a little bit. As soon as they touch, it loads your jaws joint quite a lot. So you can even try doing this. Put your teeth, lips together, teeth apart and let your teeth touch.

And you can feel if your hands are on the side of your face, just how much tension occurs in that masseter muscle as soon as your teeth touch. So one of the easiest ways, rather than telling yourself, tongue under my mouth, lips together, teeth apart, to find your rest position is to hum. Most people, not all, will find that their teeth, that they naturally go to that position when they hum. Hmm, hmm, hmm. That is a perfect rest position for your jaw.

and so if you're not sure what to do, how to keep the pressure off, take up humming. It's a really good hobby. It also will elevate your mood. Other people will maybe smile. I don't know if you're crazy, but humming is very good for your jaw. So that's a good little tip to keep your jaw in a relaxed position. I can't remember what else I was going to mention.

Linda Bluestein, MD (36:02.3)

Yeah.

Julie Robinson-Smith (36:19.718)

Um.

Linda Bluestein, MD (36:19.795)

I think you had mentioned to me on multiple occasions about your jaw and a knife doing the same job. Yes.

Julie Robinson-Smith (36:25.21)

Yes. So one other thing, sorry, was ice after dental treatment. So just like most jaw injuries are caused by micro traumas, a dental appointment is not a micro trauma. That's a pretty big stressor on your jaw joint. So if you can think of things that are actually traumatic, or your jaw pops really loud and it is super painful, or it gets stuck and you have to pop it back into place, any of those things are

Linda Bluestein, MD (36:30.4)

Mm.

Julie Robinson-Smith (36:53.554)

significant traumas for the jaw joint. And just you should treat them like if you sprained your ankle. Grab an ice pack as soon as possible and get that on your jaw joint and your muscles because that's not a micro trauma. That's a big trauma. And for the next 72 hours, put ice on it to kind of keep that swelling down. It may not be necessary. It may be overkill, but as long as it's not painful or making you worse for some reason because you don't do well with ice,

it's not harmful and it could really prevent you from having more jaw pain in the near future. So that was my ice tip and then the final piece of advice I have is that your knife and your jaw do the exact same job. So chop your food small. You do not have to stick to mashed potatoes and ice cream and smoothies if your jaw hurts.

You can eat almost anything. And good nutrition is really important for healing. So you can pick any food. You just might have to make it smaller. One of the foods that is the hardest to eat that most people don't think of, they know almonds are tough, biting into carrots and apples is hard, salad is probably the hardest food to chew. Those big leaves, you have to really grind them side to side. And

grinding your jaws moving in all sorts of different directions. So when you pick a salad, because salad's good for you, chop it. Don't do big leafy greens. Pick a chopped salad, chop everything small. You can eat carrots. Shredded carrots are great. Don't bite into a whole carrot. Sliced almonds are fantastic. Whole almonds, not so much.

you can eat anything you want as long as you eat it smaller. And it doesn't have to be pureed into baby food. It just has to be small enough that you don't have to chew it so often. And it also depends on where your jaw is at, but softer, smaller. That's really the trick for, for maintaining good nutrition without injuring your jaw joint.

Linda Bluestein, MD (39:07.939)

When you told me that in the clinic about salad, I was just flabbergasted, because that was not something that I would have ever thought would be challenging. So I'm so glad that you've shared that, because I think that's really important for people to be aware of, because things like dark leafy greens can be anti-inflammatory and very beneficial and healthy for us, but not if they're exacerbating our jaws. So that's great, great advice.

Okay, did you think of anything else that I should have asked you that we didn't cover? Okay, and where can people find you online?

Julie Robinson-Smith (39:40.738)

I don't think so.

Julie Robinson-Smith (39:46.306)

So right now we just have a website, Oral Facial Pain Associates of Colorado Springs. It's O as in Oscar, F as in Foxtrot, P as in Papa, C as in Charlie, O as in Oscar, C as in Sierra.com. I do remember my Air Force days. We're gonna probably be on LinkedIn and Facebook soon, but I've been focusing more on treating patients than building that part of my practice as much as I.

Linda Bluestein, MD (40:01.736)

Ha ha.

Linda Bluestein, MD (40:11.996)

Yeah.

Julie Robinson-Smith (40:15.05)

I'm looking forward to doing that soon.

Linda Bluestein, MD (40:16.815)

You are super, super busy and I'm so grateful that you took the time to chat with me today and we will definitely have a link to your website in the show notes so people can find you easily. And I'm just so grateful to you, first of all, for taking care of me and helping my jaw feel so much better, number one. And I'm also so grateful to you for sharing all of this fantastic information with my listeners because they are

always in need of self-help tips and all of us can use these little hacks and things. So I'm just so grateful to you for sharing your knowledge with me and with my listeners.

Julie Robinson-Smith (40:57.154)

Thank you. Thanks for having me here. This is fun.

40:58.259

Dr. Linda Bluestein

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