dr. hershkin

8.5 months post-op arthrocentesis

I must apologize that I haven’t posted in so long. Aside from getting married in the fall and the fact that I actually write this blog myself in between doing doctor things, I actually have felt so good that I don’t think very often about my own jaw lately!

The fact is that I have done absolutely nothing in the way of physical therapy, diet change or lifestyle modification since the day of the procedure (although I certainly expect my patients to do all of those things to maximize the quality and longevity of the results). I have had no pain or dysfunction and I can eat anything. That being said, after eating a large bagel I do feel the fatigue in the muscles that I always have for many years. But the acute intra-articular (inside-the-joint) pain that was affecting my ability to eat, sleep and generally function from day to day was eradicated on the day of the procedure and has not returned since.

I have performed a number of arthrocentesis procedures on patients since I had it done and, so far, all have had good to excellent results. I always ask my patients at one and at six weeks, “do you feel that the procedure was worthwhile?” I haven’t had a “no” in several years. I think that when the diagnosis is made properly and the procedure is performed by a skilled practitioner the results are overwhelmingly positive.

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New York Oral & Facial Surgery’s Pumpkin Carving Contest!!

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First of all, we would like to thank everyone that participated in the pumpkin carving contest.  We were very impressed with all of the hard work and creativity that went into carving the pumpkins.  We hope that it was a lot of fun!

It was not easy but we have chosen the winners…

Dr. Berger’s Office: “Scariest Pumpkin”

Drs. Kafko, Kaminsky & Kaufman’s Office: “Best Dental Themed Pumpkin”

Kafko

Dr. Tanners’ Office (Titled “Work Pumpkin & Party Pumpkin”): “Most Original Pumpkin”

We are so thrilled that so many of our friends participated and we truly hope that everyone enjoyed it!

Prizes will be delivered over the next 1-2 weeks as time permits.

-Dr. H, Shahla, Michelle and Kimi

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2 months since arthrocentesis

So tomorrow will be 2 months since the procedure and I feel great.  I purposely treated myself differently during this period as an experiment.  My patients are instructed to slowly advance their diet over the first six weeks after the procedure.  Patients are also referred for physical therapy and continue to perform various treatments at home.  I have not treated myself at all and have been eating with reckless abandon since the night of the procedure (I ate a delicious steak that night).

The first month felt as if I never had a problem with that joint at all.  The second month has seen 3 very short lived (ranging from hours to a couple of days) episodes of mild to moderate pain in the joint.  These episodes have been easily handled with taking naproxen for a day or two.  Aside from that, the results have been phenomenal.  Occlusion is normal and there is no pain.

More updates to follow.

 

Dr. H

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Post-Procedure Day #1

I woke up in the middle of a terrible dream that my jaw was feeling extremely stiff and sore this morning and I was thinking that eating a huge porterhouse steak last night might have been a bit premature. Haha.

When I actually woke up I was very happy to find that it was just a dream. Today my occlusion is perfectly balanced and the pain that led me to undergo the arthrocentesis is 100% resolved. The only complaint I have is that the area in front of my ear is mildly tender to touch from the puncture and I assume that will resolve over this first week.

So far, so good.

-Adam

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First Post

I am excited to start this blog as a source of information for my patients as well as my colleagues. It is my intention to post interesting articles and discoveries in the world of medicine and dentistry. Because I suffer from a fairly advanced case of TMD (temporomandibular joint dysfunction) I believe that I am in a unique position to share my experiences as both a treating doctor and a patient. I always have some degree of pain but it has been fairly stable for the past few years with only very minor flare-ups…

Until now!

Though it might sound perverse, I am a bit excited to say that for the past two weeks I have been suffering since I sprained my left (usually my better) TMJ. I have been waiting for an acute flare-up of symptoms so that I can experience some of my most often used procedures. I was merely talking to my fiance when I felt a "pop" in my left TMJ area (right in front of my ear). Immediately after the pop I felt a searing pain. Shortly after the pain began the surrounding muscles began to slightly stiffen. If anyone reading this has ever sprained any other joint (an ankle, perhaps) you might notice a resemblance to that process.

For the past 2+ weeks I have experienced moderate to severe pain limited to the pre-auricular area (right in front of the ear hole) which is worst when chewing or opening wide. As time has passed I have seen a progressive limitation in opening of my jaw as well as a change in my occlusion (the way that my teeth come together). Specifically, the upper and lower teeth on my right side (the non-painful side) come together in normal fashion while the upper and lower teeth on my affected left side do not come together at all since shortly after the symptoms began. I am able to force the left side teeth together but this elicits an absolutely intolerable level of pain.

So here is a quick lesson to explain the cause of the symptoms:

Pain in this area is due to the sprain of the joint. A sprain is a slight tearing of the ligaments that surround and stabilize the joint. When these fibers are stretched or torn inflammation ensues, which results in pain and swelling just like in other joints.

Limited Range of Motion is secondary to the pain and swelling of the injured joint. Orthopedic studies have proved that fibrous adhesions leading to scarring inside the joint can develop in immobilized synovial joints in as little as 6 weeks. Therefore it is imperative to regain range of motion as soon as possible after an injury because once internal joint scarring occurs, surgery becomes the only option to regain normal function. Needless to say, surgery is to be avoided at all costs.

Change in Occlusion is a result of something called effusion. Effusion is defined as swelling inside the joint space. When there is excess inflammatory fluid in the joint, it doesn't allow the bone to fully seat itself during closing. In other words, the fluid pushes down on the bone, thus making it very difficult and painful to bring the teeth together on that side. This symptom can be easily mis-diagnosed by the inexperienced doctor, leading to attempts to change the teeth to make them fit again.  When the swelling resolves, the patient ends up with a permanent malocclusion. The proper treatment for joint effusion is to resolve the inflammation so that the swelling goes away.

So… back to my current problem. For the past 2.5 weeks I have been treating myself in the following manner:

  1. soft diet
  2. Aleve (NSAID) on a daily schedule regardless of pain level
  3. ice with stretching exercises
  4. heat with massage

I have had minimal relief. I decided to have a procedure today. My reasons for going ahead with this procedure are, firstly, to speed up my recovery so that I may return to normal life and eating and, secondly, because I perform this procedure often on my patients and I wanted to experience the procedure and the results firsthand. Although I usually perform this procedure in my office under intravenous anesthesia, I decided to undergo this procedure while awake to show how quick and easy it is.

The procedure is called Arthrocentesis…

It involves placing a needle that has 2 tubes inside of it into the joint space so that sterile electrolyte fluid may be used to flush out the inside of the joint. The purpose of this is to clean out the debris and the proteins that mediate inflammation that are overwhelming the damaged or diseased joint. Steroid medication is injected into the joint as a potent anti-inflammatory after the washing of the joint. I like to think of this procedure as a "reset button" or an "oil change" because it cleans the joint and allows for the lining cells to secrete new, clean lubricating fluid.

This procedure is virtually free of risk of complications and has virtually no recovery. Results are usually appreciated immediately in the form of increased range of motion and decrease or elimination of pain. There are many excellent evidence-based studies in the dental and orthopedic literature that support this conservative therapy.

The benefits are immediate and long-lasting improvement of pain and range of motion. It is important to note that this procedure works so well only for the properly diagnosed patient. It will not provide benefits to patients who have normal joints but suffer from facial pain that originates in the musculature or nerves. For those patients who are diagnosed with inflammation in the joint itself, the orthopedic literature supports arthrocentesis after failure of more conservative therapies over the course of 4-6 weeks.

I teach the residents at St. Luke's Roosevelt Hospital Center and, during my lunch hour today, I had Dr. Benjamin Jacobs, the Chief Resident of Oral & Maxillofacial Surgery, perform arthrocentesis on my ailing TMJ. The procedure was quick and fairly easy to endure. I went back to work at my office immediately afterwards and am now ready to go home to work out. It is now 5 hours since the procedure was done and I feel only the slightest bit of what I would describe as mild soreness. This sensation is in stark contrast to the actual pain that I was feeling this morning before the procedure. That pain is completely gone. I am able to open to full capacity and my jaw movements in all other directions are normal. I ate lunch a couple of hours ago with no pain or problems at all.

I am very pleased to report that arthrocentesis is as quick and easy as most of my patients have reported to me over the years. It is very soon after the procedure but, so far, the recovery is a breeze.

As a clinician, I wholeheartedly believe in this procedure as an early intervention. As a patient, I am extremely pleased so far with the experience and I will continue to post about my “recovery” (if you can even call it that)

We recorded the setup and performance of the procedure on video and I will post it here as soon as I edit it to make it watchable. Stay tuned for the movie!

-Adam

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