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One of the biggest issues I hear about daily is patients complaining of muscle pain (both in the head and neck), tension at the temples, headaches, joint pain, popping and clicking. You might have heard the term “TMJ” problems. This stands for temporomandibular joint disorders, which can present with different symptoms. The most common factors that cause TMJ symptoms are nighttime clenching and grinding of the teeth. This puts a lot of pressure on the teeth and the muscles, causing the muscles to spasm and overwork. The masseter muscles are the ones directly at the angle of the lower jaw and they connect upwards to the temples, which can trigger both tension headaches and migraines. Sometimes patients also do daytime clenching and grinding, especially when they are focused on something else like driving or working at the computer. We tend to hold a lot of tension in our teeth and high stress is the number one contributing factor! Who would have thought…high stress in the DMV area… 😊

These are the treatment options:

1) Orthodontics! Correct or improve the bite of the teeth with Invisalign or braces. If the bite is not aligned well, then there is uneven pressure among certain teeth, which causes the muscles to spasm more. While this can certainly improve symptoms it will usually not completely resolve or get rid of the clenching and grinding. The biggest problem with grinding and clenching if the bite is not ideal is fracturing of teeth, chipping teeth, and gum recession due to heavy pressure. I correct a lot of deep bites after the teeth have already broken so come see me sooner to prevent issues.

2) Nightguard. About half of my adult patients and many older teen patients need a nightguard. I cannot tell you how many nightguards I make a week. A nightguard is a custom-made thick piece of thermoplastic material that has about a 1.5 mm thickness at the back teeth. This thickness (in theory) doesn’t allow the muscles to clamp down as much and should reduce clenching. A professionally made nightguard is also equilibrated, meaning that all the teeth are touching evenly and the pressure is evenly distributed. I do not recommend an over-the-counter guard or one you mold yourself online. The online bought ones have "chewy" material that is not hard on the surface. This can cause more grinding and clenching – like a doggie chew toy. Also, I have had to correct a lot of side effects of the bite, like bite opening, if the guard is not properly fitted. Give us a call today to schedule a scan appointment if you need a guard: 703-774-3070.

3) Botox. Botox is a muscle relaxant and helps to relax the masseter muscles so that patients are not able to clench and grind. This is an immediate fix and can be life-changing for relieving muscle pain and headaches. The downside is the cost, since about 60-80 units are required, and botox will wear away over the course of 3-6 months. I am certified by Aesthetic Medical in dental specific botox. This came out of personal necessity and since so many of my patients need additional treatment options. Our patient testimonial about TMJ botox. Shoot me an email and I can give you more information about what to expect at the appointment:


4) Massage. This temporarily will help with spastic muscles. You need to ask specifically for a head massage since they will then massage the temporalis muscles and the smaller muscles connected to the neck.


The best ways to combat a TMJ pain episode when the muscles are very spastic and painful is to do the 4 treatments above at once. Get nightguard, botox, massage, and fix the bite! Always reach out to me if I can help in any way!


Happy de-stressing,

Dr. Crissy Markova

Today I’m writing about early evaluations for kids. I've lectured to the Pediatric and Orthodontic Dental Residents at the University of Maryland on this exact topic for years so it’s something I’m quite passionate about. All children should be evaluated by an orthodontist around the age of 7-8 years old. I’m checking to make sure that all of the adult teeth are there, that there are no eruption problems, and that the jaws are developing normally. Please schedule a FREE consultation for your child to see me.

Not enough space for adult teeth and eruption problems: The most common issue I see is overcrowding of the adult teeth. About 20-30 years ago, the philosophy was to wait until all of the adult teeth erupt, which is usually around age 12, and then start with orthodontic treatment. The problem with this philosophy is that many times kids do not have space for all of the adult teeth and a lot of people in the past had to have at least 4 adult teeth extracted. The other problem with waiting is that teeth can cause a lot of issues if there is not enough space for them to come into the mouth, which means very lengthy treatment and other procedures needed as teens. My personal philosophy is to create space for teeth and prevent problems when kids are younger, referred to as “Phase I” of orthodontic treatment. Usually what is required is an expander with a combination of a few mini braces. The expander is placed on the upper jaw and the ideal time to create space for teeth is when the upper jaw is flexible around the ages of 7-8 years old. The upper canines are very large and develop high up, on either side of the nose. The upper canines are the teeth most likely to become impacted (which means stuck up in the jaw) or cause root resorption on the adjacent teeth (which means eating away the roots of the lateral incisors) as they try to come into the mouth without enough space. The upper jaw has a “soft spot”, which is the midpalatal suture, and can easily be expanded to create space ages 7-8.

Jaw development: I’m screening for crossbites or problems with the jaw development, especially as it relates to breathing. There are many missed or misdiagnosed sleep disordered breathing issues in kids at ages 7-8. There are certain jaw patterns, like a hyperdivergent facial pattern, that are apparent at this age, which correlate with breathing problems. A constricted or narrow upper jaw is one of them. By using an expander to expand the jaw we can hopefully improve some breathing issues.

Speech development: I’m also screening to make sure that the jaws and teeth are erupting properly so that children can articulate sounds. If a child had a long-standing habit of pacifier use or sucking on fingers, this will create an open bite. This means that the upper jaw is narrow and the front teeth don’t come down properly over the lower teeth to allow the child to seal their tongue and annunciate properly. The treatment is usually early braces or expander. Missing teeth: I cannot tell you how many times I see a teenager that doesn’t know they are missing an adult tooth. Missing permanent teeth have a strong genetic link (sometimes it skips a generation) but I’ve seen many cases where it’s just a random occurrence. With missing teeth, it’s important to have a plan when kids are younger. My philosophy is to try to use the other teeth to substitute for the missing tooth and keep the natural dentition, if possible. Sometimes, implants are needed to replace missing adult teeth. Implants are a lengthy dental process, expensive, and are placed when kids are done with growth, which is about age 18-22 years old. Implants present esthetic challenges since we now need to come up with a solution for maintaining a spaceholder for a missing tooth. When I see kids at age 7-8 years old, we can discuss options and possibly plan for alternatives: sometimes this means preserving some of the other baby teeth or sometimes this means taking out the baby tooth to allow an adult tooth to erupt into a better location.

All of these topics are hours of lectures but it’s just a brief intro! Please schedule a complimentary consultation for your child to see me this summer! Call us today: 703-774-3070. It’s FREE and I just assess to make sure everything is coming in okay! Many times no treatment is needed but it’s much harder and longer to do treatment in the future if I can help prevent issues.

In-office bleaching: Most of our adult patients and some of our teen patients opt for some whitening at the end of orthodontic treatment. I've been testing different whitening methods over the years and developed a protocol for in-office whitening with excellent results. This is a 1.5 hour procedure in the office. I do a polish on the teeth first with a surface abrader to remove surface stains. Then, the gums around the teeth are blocked out with a gingival barrier to prevent the strong bleaching gel from getting on the gums. With this barrier, it allows me to block out areas of recession, sensitivity at the gums, or target specific teeth to prevent sensitivity. Multiple rounds of strong bleaching gel are placed on the teeth, while you listen to a Podcast or answer work emails. Once the bleaching process is completed, we give you 3 take home trays that you use for the next 3 days that take 15 mins each. I recommend that you do NOT eat or drink anything for 4-5 days that stains the teeth, such as coffee, dark tea, red wine, or curry. The teeth are transiently more porous with bleaching and we do not want to counteract the bleaching with any stains. If you need to drink coffee, you can do it through a straw and rinse out with water afterwards. Quick espresso shots!

Most patients will find the results last around 6 months. You can always do some touchup bleaching with custom bleaching trays after 6 months to maintain the color bright.

Custom bleaching trays with bleaching gel can also be used instead of the in-office bleaching. This process takes about 2 weeks and the bleaching is more gradual. If you have sensitive teeth, then the bleaching trays are more comfortable. I have many patients with sensitive teeth and they are able to do the custom bleaching tray protocol well. I've tested different professional grade bleach over the years and have found that my overnight protocol works well for the longest-lasting results.

Over the counter bleaching kits: There are different kinds of "at home" bleaching kits. I'm not a big fan of whitening pens since I haven't seen them to be very effective. The gel that you put on your teeth rubs off pretty instantly. Something like Whitestrips can be fine but the bleaching chemical is more abrasive and causes more sensitivity. Also, if you are using a whitestrip of any kind make sure to cover all of the upper teeth. The strips are usually short and cover up to the canine, whereas a lot of patients will show teeth further back on smiling. So you'll need to use 2 strips to cover the upper teeth. Zoom whitening or whitening activated by a blue light (for example, Snow). The blue UV light acts as a catalyst to activate the bleach. Light emits heat and I have found that many patients can have extreme sensitivity with blue light activated gel. While it looks cool, my personal opinion is to opt for other methods. What will bleach: Keep in mind, fillings, crowns, veneers, or implants will not bleach. If you have a filling on your front tooth, it usually looks fine and can blend in with the lighter color of the tooth since the light will reflect from the adjacent tooth structure. A crown or veneer will maintain their color as is. If you have white spots on your teeth, the white spots will absorb the bleach more and look even whiter, giving a more speckled look. These white spots can be naturally occurring enamel differences or hypocalcification spots. Teeth have different underlying shades (some are more brown, yellow, or grey). If your teeth have an underlying grey tint, these are the hardest to bleach whiter and I would recommend the in-office bleaching for a better result since the bleach is a higher concentration. Whitening toothpaste: Almost all toothpastes will have "whitening" on their marketing. I am not as familiar with the more "off brand" toothpastes but I've had patients tell me that the Crest 3D White Brilliance 2 step kit seems to work well to keep up the white color. I do not recommend using this kind of toothpaste (or any more aggressive bleaching toothpaste) as your regular toothpaste. Bleach is usually composed of hydrogen carbamide or hydrogen peroxide and if you excessively bleach your teeth, then the teeth can become more brittle and very sensitive to cold. This kind of toothpaste can be used at the 6 month mark after your initial bleaching session for a few weeks. I personally use Aquafresh Whitening as my daily toothpaste since I like how it foams up more than other toothpastes.

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