Pre-surgery note

Tomorrow.
Tomorrow is the day.
Tomorrow it will all change.
Tomorrow I will get my life back.

My surgery - the right TMJ eminectomy - is scheduled for tomorrow, at 08:30am.

On August 6th, I received a phone call from the Dental Hospital confirming the new date for my surgery. Since then, it has been extremely hard for me to rest, to sleep, to concentrate or focus on anything. Hence no new posts lately. My apologies.

Two days ago I had the pre-clerking appointment, in which all the pre-op medical exams were done. The surgery and recovery period were explained in detail and discussed once again with Mr. C. and his team of surgeons. After three hours of consultation, I signed the surgery consent form confirming I understand the procedure and was informed of all possible side effects.

The eminectomy procedure is exactly as I described on my post The surgery explained. However, contrary to Dr. P. C.'s* judgement, Mr. C. has no intention of removing the disc and replace it by a graft, even if it shows signs of severe damage. According to Mr. C., a damaged disc still provides a better joint functioning than any graft, and it must be kept for as long as possible.
In Mr. C.'s opinion, removing the eminence is already intervening too much on such complex joint. He will do his best to minimise the surgery's impact on the joint by avoiding touching the disc. However, if during TMJ function testing the disc fails to return to its position above the condyle on its own, Mr. C. will put it manually and secure the disc with a few stitches to avoid further disc anterior displacement. But this procedure is only done as a last resource.
From the discussions we had, Mr. C. seems to be a very sensible surgeon. I am so glad that he avoids disc replacements at all costs.
As for side effects, my lower jaw will shift slightly to the right side upon mouth opening. I already have this offset, and I consider this a minor thing when compared to the pain and discomfort I have to live with at the moment. Because some branches of the trigeminal nerve have to be moved out of the way to have access to the joint, there is also the chance of paralysis of the portions that control cheek and forehead movement. However, this paralysis is only temporary, and the nerve recovers after a few weeks/months. Also, I will leave the surgery theatre with a new hair cut - a lateral head shave, which is quite fashionable these days.

The surgery is planned to last one hour in total. I will stay at the hospital overnight in observation, with a drain placed in front of the ear to remove excessive blood and avoid swelling. I will come back home on the following day (Tuesday, August 14th), for a week of post-op pain and swelling. The only medication I will need to take is tramadol (for the pain), since antibiotics and anti-inflammatories will be injected straight into the joint. According to what I was told, I will be able to open my mouth fully straight after the surgery, but due to the natural swelling, on the first week it will be quite difficult. A week after, I will return to the Dental Hospital to remove the stitches and for an overall check.
Obviously I won't be able to start eating normally straight away. I will be on a liquid diet for the first days, slowly introducing soft foods as I feel the TMJ improving. They are confidant that my pain will reduce significantly, being the post-op pain much more bearable than what I have now.

I am extremely nervous and anxious for tomorrow.
I am sure I have another sleepless night ahead of me.
But be calm, little heart - the end is near.

Tomorrow I will have my life back.

_________________________________________________________________________________

I will do my best to keep you all updated regarding my surgery and during recovery.
Once again, thank you all for your love, kind words, and support.

*Dr. P. C. - the oral-maxillofacial surgeon I went to see for a third opinion in April 2012.

The surgery explained

Eminectomy.

The surgical procedure that will be performed on my right TMJ, date still unknown.

For several months, Davide and I didn't know the name of the surgery. For several months we lived in despair for not knowing exactly what would be done to help me. To help us.

We were only told by my surgeon (Mr. C.) that a small portion of bone would be removed from my right TMJ, in order to create more space for the disc to return to its original position, hopefully on its own. But we didn't know from where this portion of bone would be removed. We were told by an orthodontic dentist (Mr. P. B.) that this procedure wasn't appropriate for my case, and it would only bring more complications to my already complex situation. We were left in the darkness, a groundless empty space of ignorance - alone, not knowing what to do, or where to go, or in what to believe.

And then, in one of his endless nights of TMJ research, Davide came across a surgical technique that fit the description of the procedure I am waiting for - eminectomy. This is it. It must be it!

Orthopaedic orthodontics - part II

March 26th, 2012 @ 14:20:

We were back to Mr. P. B.'s dental practice for my second consultation. "Any changes, any improvement?" No, not really. Despite feeling the muscles surrounding my right TMJ slightly more relaxed (as it was expected from taking diazepam), I didn't notice any improvement or worsening regarding my pain or jaw function. I stopped taking the amitriptyline completely due to the awful way it affected my mental health (delusions, hearing strange noises and voices in my head), but I followed Mr. P. B.'s instructions on wearing the hard splint.

However, Mr. P. B. was hoping that the splint had produced changes on my bite, and so I was asked to lay on the dental chair to check for these. After a few minutes of torture (open mouth "wide", close mouth, bite hard, tap teeth...), it was confirmed that nothing had changed. But Mr. P. B. had something else in mind - he had prepared a soft paste on a special appliance that hopefully would fit into my mouth to produce a full mould. And so the torture continued... Once my mouth was full of "play dough", I had to bite as hard as I could until the paste was fully solidified. He actually "helped" me on this, by pressuring my lower jaw against my upper teeth. The worse came when the paste became solid - I couldn't move my lower jaw for the paste to be removed. It was as if my whole mouth was cemented, upper and lower teeth glued against each other. I was in great pain and almost in panic. After a lot of effort and with his help, the mould was finally released from my teeth. I had never suffered this much on a dental chair.

Chiropractics

My chiropractor - B. M. - was doing everything he could to help me. He is by far the sweetest and most dedicated practitioner I have encountered during my TMJ journey. I owe him a lot.

B. M. proposed a twelve-treatment plan to begin with. According to my response to this treatment, he would either continue with it or refer me to a more experienced chiropractor in cranial disorders, with whom he was already discussing my difficult case. My treatments would have a short time gap between them, so that my body would be on constant "pressure" to heal. I would visit the clinic every Monday, Wednesday and Friday for the following weeks.

The first thing to do was to stabilise my pelvis, increase my general core strength and release some of the tension on the right side of my body. This stage went relatively well and took only a couple of treatments. The aim was to concentrate my pain around the right TMJ, instead of having it affecting the entire right side of my head, neck, right shoulder and back. This goal was partially accomplished - I noticed a considerable reduction of the pain on my shoulder and back, but from the neck upwards it remained the same. There was this really really annoying thing on my neck posture that was making things extremely difficult for the treatment to be effective.

Alternatives?

Davide and I spent hours and hours, days in a row, searching for anything that would reduce my TMJ pain, an alternative to the excessive use of drugs. An alternative that could give us back a little of our life prior to the arthrocentesis - no pain, no medication side-effects, no frustrations. And especially, an alternative that would allow me to follow my dream (the IODP scientific cruise in Japan) and grab the opportunities that I had been offered recently (summer internship in Norway). We found a chiropractic clinic close to where we live, offering acute and chronic pain relief through the use of neurostimulation technology (InterX therapy). We arranged an appointment for the following week (January 31st, 2012), hoping the chiropractor B. M. would be able to help me.

Usually in B. M.'s clinic, the initial consultation and examination (including X-rays) is one hour long, followed by a second appointment where the findings are reported, and a treatment plan is proposed. However, my initial consultation took almost two hours, and I still had to go back to the clinic on the following day for more physical examinations and X-rays. I was not the first patient with TMJ disorder that B. M. had seen, but I was definitely his worst case.

Big changes

A lot of things can happen in two months. Especially if these are December and January.

The deadline for Davide to submit his PhD thesis was before Christmas. Things were going quite well, but nevertheless there was some pressure, restlessness and anxiety in the air we breathed. Davide's thesis submission was followed by a medley of weird feelings and sensations. I guess it took a while until Davide sunk in this new reality. As for me, I couldn't stop feeling useless. I wanted to be there for him, help him going through this final stage and transition, witness every moment as great accomplishments (as in fact they were!), and express the proud and admiration I feel for him. I did my best. I helped him with everything he asked, but I couldn't help myself from feeling that it wasn't enough, that I should've been doing more for him. I did my best. But there was this thing setting me apart.

How things can go wrong

I was once again nervously awaiting for Mr. C.. He entered the consultation room smiling, and very kindly asked how I was feeling. "Not so good, I'm afraid..."

I explained all the new symptoms I had during the past month, since the right TMJ arthrocentesis. Limited mouth opening (max. 23mm/0.9inch), inability to chew anything solid, more pronounced lower jaw shift to the right side, and the pain. Severe pain. "Please, help me cope with the pain..."

He thought for a few moments before speaking. I took a deep breath and prepared myself for it.

One of two things had happened with the arthrocentesis: either I was taking a little more time than usual to recover from the procedure, or things had gone wrong. In the light of my symptoms, he was inclined to believe it was the second case.

TMJ arthrocentesis results

TMJ arthrocentesis

I opened my eyes. It took some time until I realised where I was and what just happened. A nurse stood on the left side of my bed, checking my blood pressure in intervals of few minutes. "How are you feeling?", she asked. "Thirsty..."

My first word after waking up from the arthrocentesis came out strange. Not the voice, but the mouth movement. It felt odd as if my lower teeth wouldn't fit into the upper, being the whole jaw misaligned. I tried to open and close my mouth slightly a few times to check how was the right TMJ. Spongy. That's the best word to describe it - spongy. There was something spongy inside my right TMJ, some extra volume that somehow felt like a thick cushion preventing the right side of my lower jaw to close completely.

"How is the pain?"

"It hurts..."

"Can you tell me from one to five how bad is the pain?"

"Errr... Don't know... Four?...", I asked myself out loud. I was still confused from the anaesthesia, although I was awake enough to start feeling the pain kicking in. I saw the nurse injecting a fluid through the needle I had in my left hand.

Sometime passed, although I can't precise how long it was.

"How's the pain now from one to five?"

"Still hurts... A four, I think..."

"Can you take codeine? Are you allergic to it?"

"I don't know... Never had it..." I never even heard that name before. What was codeine for?

Well, codeine and I would become "best friends" later.

I was waking up after a TMJ arthrocentesis performed whilst under general anaesthesia. But what kind of procedure is this? What have they done to me exactly?

TMJ in the UK

I graduated in geology in 2006, and soon after I moved away from home to work. For six months I lived in a beautiful village located in the Azores islands, right in the middle of the Atlantic. During this time, Davide and I became good friends. Once our contract was over, we both found jobs in the oil industry, working offshore in rotations of two weeks on/two weeks off. However, a few months later Davide got a scholarship to do a PhD in Cardiff, Wales (UK). From then on, my time-offs where spent there.

In January 2009, I left my family, friends and sunny Portugal to live with the best guy ever, and to fully enjoy the "great" british weather.

During these years I felt my right TMJ slowly deteriorating. I could tolerate the pain, but the discomfort on the joint was becoming more and more intense. Mouth opening was not smooth as I felt like having  sand grains being crushed inside the joint. From time to time, the lower jaw would get locked open. Although I was able to find a technique to put it back in place after the first few times it happened, it was always a really scary and painful experience. The joint noises were a constant torture. They reminded me of chicken leg bones getting broken.

Regarding the pain around the joint, it was usually more intense in the evenings, with all the normal eating, talking and general mouth movement the TMJ had to go through during the day. However, it wasn't uncommon waking up in the morning already feeling pain, or having quite strong headaches. Knowing I used to grind my teeth during the night (bruxism) ever since I was little, I considered the morning headaches quite normal.

It all started when...

... I was leaving the room in a hurry. I can't recall the time or the day; I don't know exactly how I did it. I just remember the pain I felt when the door hit my face.

But I was in a hurry - no time for tears or complains. The pain would ease sooner or later.

But it didn't.

A month went by and the pain on the right side of my face was still there. The right TMJ felt weird, uncomfortable. Even worse was the noise the joint was making every time I opened my mouth. Someone standing next to me could hear it, just like fingers getting cracked.

It was time to get it checked. My mum got me an appointment with a oral-maxillofacial surgery specialist at a private clinic. Going private would be faster, and it wouldn't be so expensive with my health insurance.

The specialist barely looked at me. He gave me the papers for an MRI scan to be done, and prescribed me a medicine. He sent me away telling me to come back with the scan results. I wasn't inside the consultation room for more than 5 minutes. I didn't like the guy at all.

Later that day, my mum and I went to the local pharmacy to get the medicine. The pharmacist found the prescription odd and asked us what was it for. The reply to my mum's explanation was "Your daughter should be given an anti-inflammatory, not diazepam!". DIAZEPAM. We didn't have any clue of what could be the problem, but surely diazepam was not going to fix it! Or so we thought...

We left the pharmacy without the drug, thinking the guy was nuts and promising we would never go back there. At least we had the papers for an MRI scan.

Background info

Temporomandibular joint (TMJ) disorder is one of the few health problems where laughter is definitely not the best medicine...

Smiling hurts. Laughing is even worse - it can be excruciating.

But however painful, the joy of a good laugh is what gets me through the day.

The temporomandibular joints (TMJs) are commonly referred as the jaw joints and are located in front of the ears, where the lower jaw is attached to the skull. They are the most frequently used joints of our body, and their function is responsible for the most elementary needs - eating, chewing, talking, yawning, and general mouth/mandible movement.

 Lateral aspect of the left TMJ 

(source wikipedia.org)

The term temporomandibular disorder (TMD) groups several disarrangements affecting the TMJs, masticatory muscles and associated structures (tendons, ligaments, blood vessels, and other tissues). The symptoms of any of these disorders include pain in the jaw and surrounding muscles (commonly extending to the neck, shoulders and back), limited mouth opening and joint noises.