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Did you know that "TMJ" refers to the affected anatomy, not the problem? The soreness, pain, and numbing sensation you feel when having TMJ Disorder can impact your range of motion when speaking. In this episode, The TMJ Doctor, Dr. Priya Mistry, shares jaw-dropping insights about TMJ Disorder and how to treat it. Her expertise highlights the value of our jaw and how it impacts our quality of life. Dr. Priya also shares the reason why she does not recommend braces to help in TMJ Treatment and how the causes of TMJ can be tricky. This episode is quite interesting because Dr. Mistry is the first TMJ Specialist on the podcast, bringing so much value to today's discussion. So don't miss this opportunity!
Listen To The Episode Here
The TMJ Doctor With Dr. Priya Mistry
In this episode, we have an excellent guest for you. We have The TMJ Doc, Dr. Priya Mistry. She is a general dentist and TMJ specialist out of Vancouver, Washington. I'm excited because this is a very common condition that thousands of people are suffering with and we have somebody that specializes in it. It's the first person we had on the show to talk about TMJ disorder. I'm very excited. Dr. Priya has a wealth of knowledge on this subject. She gets great results in her clinic. It was an honor to have her on the show. Please welcome Dr. Priya Mistry.
Dr. Priya, how are you?
I'm well. Thank you for having me.
Thank you for hopping on. I was scrolling through Instagram aimlessly and your page popped up. You have so much content in doing such great work with the specialty of TMJ. Thousands of people are suffering from that. It's an honor to have you on the show.
Thank you. I'm happy to be here.
Dr. Priya, where are you from originally?
I grew up in Washington State near Seattle, but I am in Vancouver, Washington. That's where my practice is, which is a little bit North of Portland, Oregon.
How did you get into this field? Were you a general dentist at first? Did you go right into the specialty? What happened there?
I graduated from dental school in 2007. I practiced for about eleven years until I met my mentor in 2018. My TMJ mentor was one of the big TMJ names in the area. He was in Portland. His name is Dr. Arthur Parker. I met him on a whim. I walked into his wife's jewelry store. She and I got to talking and she told me what her husband was doing. I was so amazed that his whole practice was TMJ only, like no general dentistry. There was nothing else. I thought, “He must be good at what he does to have a practice like that.” I went to a great dental school but we didn't learn too much about TMJ treatment.
At that point, I noticed that maybe I had 3 to 5 patients every year that would come into my general dentistry practice and I realize they had a displacement without reduction. That means the jaw was locked closed. They could barely open. They were in a ton of pain. I didn't recognize the condition or what to do about it more importantly. I would do what I could and keep my fingers crossed and hope for the best. I thought, “Here's my opportunity,” when I met his wife, to shadow someone who treats this probably regularly.
I began shadowing him at the end of 2018. We hit it off from day one. I went home and told my husband, “This is it. This is what I want to do. I'm hooked.” I got lucky. He mentored me for a good 3 years and then he retired in 2021. I bought the practice and moved it about 10 miles North to Vancouver, Washington because that's where my house and my kids are.
I did a very similar thing with the upper cervical. I bought an existing practice and built it off from there. I feel like there are a lot of different avenues TMJ can start from. Does it start in the jaw? Does it start in the neck? Is it muscular? Is it a misaligned jaw? If a patient comes in and says, “I have TMJ,” what's your next step there?
The first step is always an examination. That's for all of us. I found one of the most important parts of the examination is the whole history. My mentor would always say, “The mystery is in history.” Their whole story will paint this picture. You can pick parts out like, “You've had four whiplashes in a row. Your neck is probably super involved and that's feeding up to affect your jaw.”
It could be there is a history of any injury to the head, neck, or jaw. There is no history of fine injury but when you look in their mouth, there's a bite pattern that's very prevalent. A few bite patterns with TMJ disorders and you see, “There's that bite pattern. Plus, you're clenching and grinding so you're enhancing that bite pattern every time your teeth come together.” Eventually, the muscles and joints are like, “Enough. We're done here.” Dysfunction starts.
It's so important to listen to everybody's story. A lot of the exam is that. We do a muscle palpation exam. We feel the joints. I do a postural exam. I check the leg length. You probably know dentists that are doing that. If there are a lot of whiplash incidents and the leg length is off, I start suspecting an upper cervical involvement. I have upper cervical chiropractors nearby that I work regularly with. I feel like TMJ, the causes for it, and the way that it presents can be all over the board. That makes it very tricky.
When people come into my office for TMJ, I'm crossing my fingers hoping the majority of it is coming from the neck because that's what I do. There are cases where the TMJ is not budging. I like to send people out to a TMJ specialist like yourself. If you have somebody coming from an upper cervical practice where their neck is aligned and okay and the TMJ symptoms aren't budging, what are you thinking?
I'm usually thinking it's the bite. That’s because even if the neck is perfect and you get it exactly where you want it, the teeth are still coming together. That can make the muscles and the joints very mad. What an orthotic does is it takes that imbalanced bite that’s likely contributing to the TMJ issue out of the equation. It puts the muscles in the joints in a very optimal position. That has worked well with my upper cervical patients, the ones that have seen the upper cervical chiropractors in the area.
There is an orthotic. There's a night guard. Sometimes, I have patients that there's something permanent in their mouth that they can't take out for a while. How does that work?
The terminology is all over the board, which, first off, is tricky. The way I talk about it is there are two words. There's a night guard and an orthotic. The word splint, which many people use too, I've heard dentists use the word splint for a night guard and an orthotic. That's confusing. I don't even use that word. I'm going to throw that one in the garbage. Night guard and orthotic is what I use.
A night guard, you can get from the drugstore or your dentist. All it does is protect your teeth. It does not treat your muscles and joints. It prevents your teeth from breaking from the forces of clenching and grinding. Night guards have value but they're not going to help you if you have a TMJ issue. What a night guard does is we take impressions of your teeth, so molds of your teeth, scans, or however we get a record of your teeth.
We look at your bite. We don't even replicate it. We give you a flat plane to grind against or clench against. The muscle memory is there so you're going to always try to clench or grind into your usual bite pattern. Some people will grind a little forward to get out of that bite pattern but it's still not guiding your jaw where to go. That's a night guard.
A TMJ orthotic is very different because it does treat the muscles and the joints. In my office, the way I do this, and every TMJ dentist is different so I can only speak for myself, is I have technology and software that measures where your muscles are the most relaxed. It's a very specific position called the correct resting length. Every muscle in our body has a correct resting length. The bicep is resting like this. It's contracted like this.
Many people come to me where all these muscles are constantly contracted. With that, it causes a lot of pain. It builds up lactic acid and toxins, and they're in pain. We have technology that finds where the muscles are in their most relaxed position. We then build a daytime and nighttime orthotic, which is what I do at my practice, to hold the jaw or guide the jaw to that optimal position.
With the orthotics, there are three dimensions that are important. There's the right and left, the forward and back, and then the up and down or the vertical. The most important one to get right is the right and left. Our joints cannot tolerate much right and left movement. The software that I have, I rely heavily on that to get that right. I can't eyeball that.
How does the software work?
We use TENS therapy, Trans Electrical Nerve Stimulation. We use it for about 45 minutes to 1 hour. The TENS that we use is a very specific FDA-cleared one for the small muscles of the head, neck, and jaw. I also put a little appliance in the mouth that discludes the teeth and has these water pillows. That serves as a waterbed for the muscles. Finally, we get a chance to get out of that angry position that they're in.
The TENS is important too. After about 45 minutes to 1 hour of the TENS, the muscles are usually sitting in their relaxed position or optimal position. We record that with very sophisticated jaw-tracking technology. I'm very dependent on that for the right and left position or even the forward and back, which is the next most important.
That will tell you if one of the muscles on the left side is tighter than the right and vice versa. That’s very cool.
It can tell you how much they're firing too. When your teeth come together, it can measure how much your muscles are firing. We have EMGs also we can use with that, which is software. You can put the orthotic in and also measure how much the muscles are firing. It should be way less. It's an objective measurement. It's not me eyeballing it. A lot of people that call themselves TMJ dentists and make orthotics, they eyeball everything. You can't do that. That’s my opinion.
Everybody’s position is different. I use that technology. I also use my knowledge of their condition. If their condition is mostly muscular, I rely heavily on that technology. If the condition is mostly joint, like there's a displaced without reduction and the jaw is locked closed, I use the technology but I also know that the disc is too far forward and in. We have to build the orthotic to help recapture that disc.
The orthotics can recapture discs like that.
They can help recapture it. I don't think they can do it on their own. I've seen that happen maybe twice but usually, you need more than that.
What's the healing process for somebody that gets their orthotic? I'm sure you have people that put it in and it gets better very quickly. You then have people that have been suffering for 20, 30, or 40 years. It's going to take some time. Is it like braces where it's slowly starting to realign? How does the orthotic work over time?
I have my patients wear it during the day and the night except for when they're eating or drinking. The bite does reset. We're trying to hold the muscles and the joints in a specific position to allow things to heal but I'm trying not to change the bite. Any adults don't want to go through braces again. That is a tricky balance because there is a chance your bite can change.
If you're holding the jaw in a different position all the time, your jaw can start to adapt to that position. Your teeth aren't going to line up. It’s a tricky balance. Some people come in saying, “I want braces after all this.” They don't care if their bite changes. Those are easier cases because you can tell them, “Your bite's going to change. This is how it's going to go.” Most people don't want their bite to change.
During the healing process, once I give them the orthotics, I usually see them every 1 to 2 weeks depending on the severity of the TMJ condition. When they come back to my office and it's usually after they've had a neck adjustment and upper cervical adjustment, then I come in and do my therapy. I learned what’s called craniofacial therapy. We loosen up the muscles in the head, neck, and jaw. I do that manually and I start at the base of the neck. I work my way forward. It's a nice massage for your head, neck, and jaw.
If they've had their cervical adjusted, I'm very gentle around the neck. I don't do much there. I come forward. We work on the masseters a lot and the temporalis. I go inside the mouth and release muscles. For those that have severe jaw issues like disc displacement, I manipulate the jaw. I do this in a subtle but effective way to help the disc get back in alignment. Sometimes, during that manipulation, that's when they'll unlock the disc alignment.
Do you do the manipulation with your hands or instrument? How does that work? It’s very cool.
It’s with my hands. Once everything is lined up and loosened up after the therapy, I check and adjust the orthotics. They can't change but the patient can. Once things are lined up well and loosened up, we adjust the orthotics to try to hold what we did. The chair’s side adjustment. I see them again in two weeks and then again.
As they get better, I slowly notice the first thing to go away is ear pain. For whatever reason, that's the first thing to go away. It is then headaches and jaw pain. If the jaw has been locked closed where you can barely open it, it will slowly start to click and pop again. That means it's not locked anymore but the disc is still coming in and out of alignment. Slowly, they regain their range of motion.
It is cool to see but it's not overnight usually. Most people are in treatment anywhere from 4 to 8 months, give or take. There are cases where a lady was coming to me with chronic headaches. She would wake up with the worst headaches. She said it was affecting her marriage and her work. I know it's coming from her jaw. I made her the nighttime orthotic. I usually give people the nighttime one first and a week later, the daytime one. She didn't even want the daytime one. She was like, “I feel so good. I love this.” She was thrilled. She did end up getting the daytime one. For some people, it is overnight. For some people, it is a longer process, depending on the severity of the issue.
For those reading, TMJ is not secluded to jaw pain. It’s what you mentioned before. It could be jaw pain, facial pain, gum pain, migraines, headaches, eye pressure, brain fog, ear pain, or ear clicking popping. There are so many different symptoms. In the work you do, you can clear up a lot of that with a precise jaw exam or orthotic. That's amazing.
I'm very passionate about it. I love it. It's so gratifying. I can help people go back to being happier with their loved ones or being able to work as efficiently as they want to. It’s great.
Is there any case where you recommend braces that will help? Do you ever recommend braces or not?
No. I never recommend braces. The reason is that my mentor drilled into me that when the muscles and the joints are dysfunctional and there is clicking, popping, the jaw's locked, the muscles are mad, jaw pain, headaches, facial pain, pain behind the eyes, or whatever it may be, the phase one TMJ treatment, and this is probably the one thing that most TMJ doctors agree on, is always stabilizing the muscles and the joints. Phase two is then to move the teeth with braces to that stabilized position.
There are a few cases I've seen where I have patients come to see me and they say, “This dentist told me that Invisalign would fix my headaches,” and it made them worse. It didn't help at all or whatever it may be. That's usually what I hear. Invisalign, to me, is so much about lining up the teeth and getting them to balance. That’s great because that can be what caused the problem in the first place but it's not treating the muscles.
I had Invisalign, and anytime I got a new tray, my muscles would be on fire because things are shifting.
My mentor would always tell me also that the way the teeth fit together, like cogs on a gear, in the two joints is there is a tripod-like relationship between them. If these joints are clicking and popping or you have a very limited range of motion and there is something going on in the joints, why would you start moving teeth? All three legs of the tripod are affected. Fix two legs of the tripod and then go on to the bite. That's one thing that we all agree on.
Does it ever come from the teeth or the wisdom teeth? How do you feel about the actual wisdom teeth surgery? Is that affecting TMJ at all or are people getting it done unnecessarily? Do you have any thoughts on that?
It's a tricky one. If the wisdom teeth are positioned in a way where they can damage the teeth in front of them, which I've seen, you've got to get them out. The tricky part is that many times, people have no TMJ issues before the extractions, and then suddenly, their jaw locks and closes. They have a lot of headaches afterwards or neck pain. I've seen that a lot.
That's because the muscles have likely been compensating either because of neck injuries, spine injuries, the way the teeth come together, chronic clenching, or grinding. Suddenly staying open for that long and that wide is like the straw that broke the camel's back. If the patient never had pain before that, how is the oral surgeon that removed the wisdom teeth supposed to know? It's tricky. You don’t have a one-size-fits-all answer for that one.
You said phase one most TMJ doctors agree on. When does the fork in the road diverge there?
I came across one TMJ doctor who doesn't believe in any soft tissue work. He didn't touch the muscles. He was like, “You need to leave them alone. The orthotics will do everything” I don't agree with that at all. I know another TMJ dentist that believes that once you give someone the orthotics, you never touch them again. He was like, “They don't need adjustment. This is the perfect spot. That's that.” I agree with that. These people have probably had success doing it their way so I'm not, by any means, bashing anyone. There are so many different ways.
There are people that will make a night guard and call it an orthotic. I don't like that. I also don't like when many people will make a nighttime appliance and call it an orthotic but it's a sleep apnea appliance. Those are important too but it's a sleep apnea appliance. It's not a TMJ orthotic. There's so much and there's no standardized way of doing things, which is very frustrating for patients. That's why I created my channel. It is a way to put more information out there. I have it on my YouTube and all the socials.
Your office is in Washington. I would like a lot of people to come to see you. Is there anything that you can lay a foundation for people reading and saying, “I have a lot of these issues. How do I know I'm going to a good TMJ specialist near me?” How many people use that muscle equipment? Is it not a lot?
That’s a tricky part. That is a method of dentistry called neuromuscular dentistry. Even among neuromuscular dentists, there are disagreements. Even if you type in neuromuscular dentist in my area code, it doesn't necessarily mean that they've had a lot of success with treating complex TMJ cases. I don't have a great answer for you. There's one guy who I would refer to. He's in Kansas City, Missouri. That’s it. I don't have a lot of referrals. I have a good TMJ physical therapist that I recommend in Miami Beach, Florida. These are so far from me even.
I've had people fly in from New Jersey and Boston. I had a guy who moved here from Toronto for five months. He was like, “Get me better and I'll go home.” We did it. I don't encourage people to come fly and see me because it's so expensive. It's so disruptive to your daily life. I don't have a good answer. I am thinking of coming up with courses over the next couple of years but I'm not there yet.
How does it work when people come and fly and see you for the follow-ups?
I tell them they have to come every 2 to 3 weeks until I see them get stronger. If their jaw is locked, weekly, if possible, I don't try to sugarcoat it. I don't say, “Here's the orthotic. Bye. You're going to be better.” That's not how it works.
It sounds like you closely monitor your patients every 2 to 3 weeks because you don't want the orthotic to shift or the jaw to shift and nullify what the orthotic is doing.
It will, eventually. That orthotic is going to need adjustment. I've had a few people that get the orthotic and take off. I'm like, “Where are you?” They come back and I’d be like, “It isn't helping because you didn't come back.” We get them back on track and then they see the value of those extra appointments. They are super important.
Eventually, we do get to a point where it's stable. I don't have to adjust the orthotic anymore. There are no more symptoms. I release them from active treatment. I say, “Keep wearing the nighttime one.” I taper all my patients off the daytime one. I’m like, “Keep wearing the nighttime one. Let me know if you need me.” They usually come back if it breaks or their dog gets to it. We go from there.
At every single appointment with these follow-ups where I do the therapy, if your number one concern was ear pain in your right ear, number two was headaches, and number three was facial pain, I will say, “How's your ear pain?” They're like, “I haven't had any.” I’m like, “How are your headaches?” They’re like, “It went from three days a week to twice a month.” I ask every single time so that we can monitor what's changing and what's not. I try to be as thorough as I can but I do need people to come back.
For the stabilization phase for the upper cervical, depending on the case, I usually say, “You give it at least 3 to 6 months to get it stabilized. We're going to have to do more work after that.” That's usually a good ballpark figure to get things stable again. I'd imagine it'd be similar to the TMJ work. How long do you tell people? A lot of people want the quick fix. You got to say, “True healing takes time.” What's a good ballpark frame where they have the orthotic in and they're getting it maintained properly for the healing process?
Probably 4 to 8 months usually. In the severe cases where the jaw has been locked for ten years, I have no idea how long that's going to take. I saw one young lady. She came to see me two years after her jaw was locked closed because she didn’t trust anybody. It took us eleven months to get her unlocked and stable out of pain. That's not in my 4 to 8-month range.
This sounds identical to upper cervical work. I'm sure people are still in pain and you have to be like, “Your orthotics is in alignment. There's not much we are going to do today. We got to let the healing continue to work.” Just because somebody's in pain doesn’t necessarily mean that we need to shift the whole game plan around.
With those people, we focus then on the soft tissue work that we do. That usually makes them feel much better for at least a few days. For many people I find, I grill them on this. “Are you clenching hard into your daytime orthotic? That's holding us back. You've got to stop your daytime clenching. You can train yourself to stop. It's not easy but you can do it. Nighttime, we can't help it but if you're clenching all day into that orthotic super hard, you're delaying your progress.”
How do you tell your patients any tips and tricks to consciously stop clenching during the day?
It’s an annoying method but I call it the timer method. For the first week, you put a timer on your watch, phone, or whatever you have with you all the time that goes off every twenty minutes while you're awake. If you catch yourself clenching, you take a deep breath and tell yourself to stop. I had a patient that snapped her wrist with a rubber band. I'm not saying I promote that.
It's like a little reset.
It’s a negative reinforcement that helps. In the second week, you set the timer for every 30 minutes. The third week, every 40. By the time you get to an hour, you're usually not clenching anymore because you've become so aware of it. Twenty minutes goes like this and people are like, “I'm doing this all day long. I didn't even realize.” That's huge. The realization of, “This is what I'm doing,” is a big one.
That's cool. I didn't think about that. It's not even that they need an actual treatment. It was to retrain their brain not to clench. That’s very nice. Is there anything else that you do besides the orthotics and night guards in your practice for the TMJ?
Yeah, the therapy. Soft tissue therapy and jaw manipulation are a big part of it, and then making appropriate referrals when necessary. TMJ issues and airway sleep apnea are very common. All our patients fill out a sleep apnea questionnaire. If they've checked off a lot of yeses that they wake up gasping for air, wake up several times at night to use the bathroom, wake up feeling exhausted, or whatever it may be, we talk about a referral to a sleep doctor to see if sleep apnea is an underlying issue.
If we're struggling for oxygen at night, our body goes into fight or flight mode. We tend to clench and grind with more force, more frequency, and longer durations. That will lead us to TMJ issues. Grinding the jaw forward opens the airway. It's thought to be a protective reflex almost as if you are struggling for air. Many of my patients have sleep disorder breathing. It's probably well over 90%.
I'm sure you see that get better too with the orthotic. That's changing the jaw, which enables the airway to get more air at night.
To be fair, a TMJ orthotic is not approved to treat sleep apnea. If they're diagnosed with mild, moderate, or severe sleep apnea, they usually get a CPAP. They can use that while they use my orthotic. Once the muscles and joints are stable and everything's happy because there are no more headaches, pain, clicking, popping, or whatever it may be, then I say, “I can make you a sleep apnea appliance to treat your sleep apnea with your TMJ prescription built into it.” That's a pretty cool appliance. It helps the muscles and the joints and it opens the airway. I've only done that for maybe a handful of patients because many people can tolerate the CPAP so then we don't need to go there.
How did you come across upper cervical? You worked with a couple of doctors. The upper cervical and the TMJ specialty goes hand in hand too.
My mentor worked with a few in the area. I didn't stop once I took over. My mentor is a very unique man. He is a dentist like me but he took a lot of TMJ physical therapy courses from the renowned TMJ physical therapist, Mariano Rocabado. We took those courses. He worked with a famous osteopath. He learned craniosacral therapy. I'm trained in craniosacral work. He dabbled in everything, took everything he learned, and came up with what we're doing.
He made it his own. That’s very cool. Always be learning, right?
Always be open-minded too.
It can take a team of practitioners to get one person better. There are chemical toxins and physical stressors. There is work-life. Everybody is sitting down all day. It can take a team of people to get someone better. Sometimes, it doesn't work the first time around and you revisit it 6 months to 1 year later and it starts working. Never lose hope. Always keep going. At the end of all my shows, I like to ask my guests, “What is one piece of advice that has resonated with you over the years that you would like to gift the audience?” It could be anything.
There are practitioners that care about you, are compassionate, and do listen. It's just finding them, which can be tricky. I've seen that with bodywork, working with multiple practitioners, and good communication, we can get people feeling better. If you're feeling hopeless, don't lose hope. There is help out there.
Where can people find you on social media?
I am on YouTube, TikTok, and Instagram. Those are probably the main ones I do. I joined Threads too.
Me too, and I haven't posted anything yet.
There are so many. If you type in @The_TMJ_Doc with underscores between the words, you should be able to find me on all of those.
Dr. Priya, thank you so much for coming. It was wonderful having you on. It was the first time somebody sat down and explained the TMJ disorders. It cleared up a lot of things. I would love to have you back at any time.
Thank you so much. Thanks for having me.
Important Links
- Dr. Priya Mistry
- YouTube - Priya Mistry, DDS - the TMJ doc
- TikTok - Dr. Priya Mistry
- Instagram - Dr. Priya Mistry
- Threads - Priya Mistry, DDS
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