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The Destruction of Barbara Ostmann
Click here to read a summary of Barbara Ostmann's struggle with TMJD and its treatments.
TMJ: Temporomandibular jaw joint disorder is one of the trendiest and most commonly diagnosed conditions of the decade. That makes it tempting to overtreat, putting sufferers through extensive and costly surgeries. There is no cure, but a University of Minnesota clinic finds success in using conservative methods.
When Barbara Ostmann catches her reflection in a store window, it takes her breath away.
To put a new twist on an old song lyric, it's not her face, it's not a charming face, and it's not all right with her.
It's not that Ostmann's face looks bad. It's just that when 39-year-old food writer for the St. Louis Post-Dispatch looks at herself, she sees a stranger.
In 1982, to correct an impairment of her TMJ (temporomandibular jaw joint), St. Louis doctors surgically repositioned her jaws and gave her a whole new face, replacing her overbite with an underbite. Two years later, she underwent corrective surgery that made her bite more normal but took away her distinctive jaw line. She was left with a receding chin, sinus problems and chronic numbness in her lower lip.
Diagnoses of TMJ disorder are frequently connected with stress, that buzzword of the '80s. Time magazine recently dubbed the ailment the "in" malady of the decade. Even superstars are not exempt - Bruce Springsteen and Burt Reynolds reportedly are among the 10 million American sufferers.
Because symptoms are often vague and confusing, dentists; orthodontists; oral surgeons; ear, nose and throat specialists; neurologists; psychiatrists; physical therapists and chiropractors are all a part of the treatment. Frustrated patients may find themselves reciting their symptoms to specialist after specialist. And the trendiness of the disorder makes overtreatment a temptation, leaving patients like Barbara Ostmann emotionally and physically scarred by the whole experience. Others never find an answer and resign themselves to living with the pain.
The TMJ is located on either side of the face, slightly in front of the ears. It connects the jaw to the skull and allows the mouth to open and close.
TMJ disorder can be caused by something as obvious as a car accident or as subtle as stress. But the one thing that all patients suffer from is pain - most often head pain, jaw pain, neck pain and ear pain.
Ostmann sought treatment because of constant, day-after-day pain. Her case is an extreme example of what can happen when a person goes ahead with radical surgery before trying more conservative treatment. At the University of Minnesota's TMJ and Craniofacial Pain Clinic, clinicians rarely resort to surgery and instead are achieving very good results with something as simple as a hard plastic retainer called a "bite splint" that fits over the teeth to correct the bite, lets the jaw relax and takes the pressure off the TMJs.
But the St. Louis specialists who treated Ostmann decided against the conservative approach. They told her that if she wanted relief from TMJD, they would have to break her upper jaw in four places, removing some of the jawbone and also break and reposition her lower jaw.
"This almost ruined my marriage, it damaged my work, it damaged every friendship I had and I needed a psychiatrist to pull me through," Ostmann says. Earlier this month, she settled out-of-court for $355,000 against the orthodontist and oral surgeon who performed the surgeries.
"It took six years of my life, and I am 39 now," she says. "I was hoping to have kids, but it's too late for that. I couldn't get pregnant while I was continually having x-rays and anesthesia...I didn't even way anyone to hug me, I was so fragile and afraid someone would touch my jaw."
For almost four years, Ostmann was a food writer unable to eat. After her surgery, she had no feeling in her lower lip and couldn't chew her meat unless she cut it up in little bitty pieces. Before the surgery, her jaw joint ached continually and made a loud popping noise when she chewed.
"People sitting next to me could hear it," she says. "And it hurt. It made my jaws ache."
Gradually the problem worsened until one morning she woke up and could not open her mouth. "It was like my jaws were hooked," she says. "I couldn't even get a spoon in my mouth. I had to steel myself and then kind of wrench my jaws open. They would break loose with a big pop."
Finally, in 1982, Ostmann was diagnosed with TMJ disorder.
The popping sound she heard was the cushioning cartilage disk between the ball and socket of her TM joint popping into place. In a normal TM joint, this thick band of cartilage quietly slides forward when the mouth opens. But in a joint that suffers from an "internal derangement," the disk may wad up and not slide forward as it should. It may pop into place when the mouth opens and pop out of place when it closes. This pop can be loud enough to be heard across a room.
If you eat, talk, sing and yawn without pain, you probably take your TMJs for granted. Connected to an intricate network of ligaments and muscles, these joints allow the jaw to move freely. But for many Americans (the estimates range as high as 75 percent), all the moving parts of a TM joint do not work well together. For a variety of reasons - from car accidents to clenching and grinding teeth - 15 percent of all Americans have enough jaw pain to seek treatment.
Unfortunately, there is still so much to be learned about TMJD and its treatments that the typical TMJD patient - usually female - visits five or six different health professionals over several years before gaining a specific diagnosis and treatment. Until recently, dental schools have not taught courses on disorders of the temporomandibular joint and dentists sometimes find themselves in a quandary over how to treat the disease.
Unsure how to treat her, Ostmann's dentist referred her to an orthodontist because she had an overbite that had never been corrected with braces. The orthodontist told Ostmann he could do a full medical work-up, but advised her - during the interim - to buy a $1.98 football mouth guard and wear it at night. It was the best advice Ostmann would receive in the next year. The mouth guard relieved her pain almost instantly, and she began to feel better.
Seeking a second opinion, Ostmann visited a second orthodontist. By this time, the mouth guard was working so well that the popping was considerably improved. The second orthodontist suggested that just putting braces on her teeth would solve her problems.
Trying to get two medical opinions that were alike, Ostmann then sought the advice of a third orthodontist, who was once associated with the dental school at Washington University in St. Louis. After a 15-minute consultation, he told Ostmann she had a "definite skeletal deformity that would require surgery on her upper and lower jaw and full orthodontia (braces)."
The jaw repositioning surgery involved breaking Ostmann's upper and lower jaws and removing bone from her upper jaw. This would probably take care of her TMJ problem, the orthodontist told Ostmann. But he said she might still need joint surgery.
"I couldn't believe it," she says. "I was a relatively attractive person and I couldn't understand how that much could be wrong and not show in my appearance."
Ostmann sought a second opinion from a dentist who is also a medical doctor, but admits she really didn't understand it. Because he, too, recommended breathing and repositioning her jaws, she took that to mean the dentist and the orthodontist were agreeing on treatment. Actually they were not recommending the same surgeries at all. But she didn't find that out until much later.
Still nervous and unconvinced, Ostmann says she consulted the radiologist who had performed her arthrogram (x-ray picture of her jaw). "He told me, 'I think you've got a real problem, and it's not going to get better,'" Ostmann recalls. "I took that to mean the jaw operation was necessary."
Three qualified medical people. Three concurring opinions - or so she thought. Ostmann told the orthodontist to go ahead with the braces and also schedule her for surgery with an oral surgeon.
"The day I got out of intensive care and saw myself, I couldn't believe it," she says. "I looked like Benny Hill, the English comedian on TV. I had always had kind of prominent upper teeth. Now I couldn't even find my upper teeth. Because they had wired my jaw shut, I remember writing to my doctor, 'Are you sure my upper teeth are still there?' He told me I was going to be find; I looked beautiful. Well, I didn't look beautiful."
For nearly eight weeks, Ostmann lived on clear liquid with her jaws wired shut. With her nose completely plugged, she could only breathe through her mouth, and was periodically panic stricken that she could not take in sufficient air. "They told me to carry wire cutters in case I vomited because I could choke to death," she says. "I was so terrified of this happening, I slept with those things."
She was not getting better. "I looked terrible, but the worst thing about it was, I couldn't chew," she says. "I had no sideways movement. My mouth would not function. But the doctor kept saying, 'You are fine. Just do your exercises. Be patient. You are just a vain female.'"
Five months later, Ostmann sought the opinion of yet another doctor. He had been the teacher of the oral surgeon who performed the surgery. He concluded simply: "You have been overtreated."
"This was all unnecessary," Ostmann says. "The whole thing didn't have to happen. And it haunts me."
Dr. James Fricton, the lanky co-director of the University of Minnesota's TMJ clinic, is a mellow and reassuring man. He talks slowly, pausing often to fish research articles from the recesses of his cluttered office.
The U of M advocates a conservative approach to TMJ disorder. Most of the 1.000 patients who come each year to the clinic obtain relief from their pain, but only 1 percent end up having surgery, Fricton says. Capping teeth and putting on braces also are seldom-used remedies for TMJD.
"Number one, they are expensive," Fricton says. "Number two, they are unnecessary. Orthodontia and crowns and bridges have their place, but only after the treatment of TMJD and only to provide good ability to chew."
After a thorough examination and analysis of behavior patterns, most TMJD patients at the clinic are fitted with a plastic retainer called a bite splint. The splint costs between $400 and $500 and is adjusted to correct the bite and take the pressure off the TM joint.
Besides seeing a dentist, patients also work with a psychologist and a physical therapist. To correct their jaw problems, patients have to become conscious of how they clench their jaws and grind their teeth. They learn how to keep their jaws relaxed.
Gretchen Harris is a 35-year-old artists' representative, who finds jobs for free-lance artists and photographers. A car accident six years ago left her with a concussion, whiplash and cracked teeth. As a direct result of the accident, she had seven root canals, five teeth extracted and several gum surgeries.
In four years, she saw 20 different doctors and dentists. But still she had pain. "I constantly had a burning pain up the side of my head," Harris says. "And the lower part of my jaw ached."
Two years ago, Harris was referred to Fricton. He diagnosed her problem as TMJ disorder and myofascial pain, adding that all the time she spent in a dental chair with her mouth open had probably harmed her jaw joint. The cartilage disk between the ball and socket of the joint was not rolling right, and when she opened her mouth, her jaw slid sideways.
After several diagnostic sessions with a team of U of M specialists, Harris was fitted with a bite splint made of clear acrylic. A physical therapist gave her exercises to stretch her neck, back and jaw to help her bite realignment. A behavioral therapist analyzed her responses to stress and made her aware that when she drove her car, she slumped over and clenched her teeth.
"They made me give up chewing gum," she says, "and for a while, I had to set a timer and check the position of my bite every 20 minutes." She learned to keep her tongue on the roof of her mouth and her jaws slightly apart. Keeping the teeth together constantly puts unneeded stress on the jaw.
Harris says her debilitating headaches are gone and she finally feels good. The university program, which she stayed with for one and a half years, weaned her off the painkillers she took for three years and supported her enthusiasm for running and Jazzercise.
"As long as you are physically active, that's half the battle," she says. "My running was really the saving grace through all of this."
Marlene Weston, 46, of Edina is a TMJ disorder patient who might have ended up with radical jaw surgery like Barbara Ostmann's.
She went to an orthodontist for her TMJ problem and was told that it would be necessary to have radical jaw surgery plus a full set of braces.
Weston sought a second opinion from Dr. James Schulte, a St. Paul dentist who is also a co-director of the university's TMJ clinic.
Schulte told her breaking and wiring her jaw would not be necessary, and he suggested treatment that included a bite splint plus extensive dental reconstruction.
"My headaches went away very quickly," Weston says. She also thinks seeing a chiropractor three times a week was beneficial.
After having eight crowns, a bridge and a two-tooth partial plate, Weston says her bite is so good that she no longer needs to wear the bite splint at night. All the dental work cost her between $6,000 and $7,000, but she figures it was worth it.
"After it was all over, I can remember thinking to myself, 'I don't had a headache,'" Weston says.
And unlike Barbara Ostmann, she still has her own face.
Doctor's Advice
Doctors who treat TMJ disorder say:
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