TMJ and TN - The Orofacial Pain Center

TMJ and TN - The Orofacial Pain Center We are dedicated to finding the cause of and treatment for severe facial pain and headaches

05/06/2026

What is the difference between X-RAY, CBCT and MRI
Why we need an MRI
When examining any joint, especially the temporomandibular joint, you have to be able to see inside the joint to know what is wrong or right, before you know what to treat and how to treat a patient.
An X-ray is a 2-dimensional picture of a 3-dimensional thing, the bones, in this case, the jaw joints. It is generally called a panorex or a screening film. The face is convex, so the machine has to sort of flatten out the face to see the jaw joints. This distorts the joints somewhat. It is a good film to screen for extra teeth, 3rd molars and pathology. It is like looking at someone from across the room.
In order to take the film, you have to push the lower jaw forward, so there is very little of value seen in a panorex, regarding temporomandibular joints, unless the damage is severe.
A CBCT is a 3-dimensional picture of a 3-dimensional thing, the bones, in this case, the jaw joints. It does not flatten out the face or distort the joints, so it does give us much more information. You can evaluate the size, shape and surface of the condyles much better than in a panorex. You can gather information about when the person was injured by measuring certain aspects of the jaw. You can see how the teeth fit together and evaluate for teeth/bone health and infection. The major downside is that you can in no way tell for sure where the disc is. You cannot see the disc and it’s the disc that determines what treatment is needed.
An MRI is a 3-dimensional picture of a 3-dimensional thing, the hard and soft tissues of the jaw joints and face. The gold standard in diagnosing any other joint in the body is MRI. When we are looking at jaw joints, the first thing to get damaged is the soft tissue or disc. Damage to the soft tissue disc can cause bone changes, but only after many years. By the time damage shows on an X-ray or CBCT, it is advanced
The only way to see the soft tissue changes is MRI. The disc position is what determines what kind of treatment is necessary. You can only see that on an MRI. With a CBCT, you can see bones only. You can GUESS where the disc is by the spacing between the bone of the head and the bone of the lower jaw, but not know where the disc is.
I can't imagine any surgeon who likes to guess at what they are doing surgery on, but I am surprised all the time by what people are doing. I might be crazy, but I like to know what I am treating, not guess at what I am treating.

05/01/2026

I answer questions on our other page, "TMJ" support and information. If these frequently asked questions are helpful, but you need more information, please go there and join.

Frequently asked questions (updated November 2025)
1. TMJ/TMD/TMJD as a diagnosis
TMJ stands for temporomandibular joint. It is a body part, not a diagnosis. Getting a diagnosis of TMJ for facial pain is like getting a diagnosis of KNEE for leg pain, too vague. You would say, “What is wrong with my knee?” They would get an MRI of the joint and say something like, “You have a torn ACL and this is how we treat it.” The same thing has to happen with jaw joints. There needs to be an actual diagnosis, like a torn meniscus, for example, in order to know what kind of treatment would be helpful.
TMJD and TMD are no better diagnoses because they just stand for temporomandibular joint disorder or dysfunction. Still too vague. Nobody gets a diagnosis of shoulder dysfunction but might get a diagnosis of a torn rotator cuff. They would never get a diagnosis of a knee disorder but might get a diagnosis of a torn meniscus. The diagnosis tells you exactly what is wrong and how to fix it.
Just like with any other joint, it takes an MRI to diagnose jaw joint damage, which allows someone to know how to treat your pain.
2. Is ear pain, ear stuffiness, ear clogging, decreased hearing, tinnitus, etc, a symptom of “TMJ”?
Yes, ear symptoms are the most common complaint of my patients with jaw joint damage.
3. Is pain in the cheeks and temples related to “TMJ”?
Yes, pain in the cheeks (masseter muscles and temporal tendons) and temples (temporalis muscles) is very common in patients with jaw joint damage and unstable bites.
4. Are headaches common in “TMJ”?
Yes, headaches and migraines are very common in patients with jaw joint damage and unstable bites.
5. Are clicking, popping, grinding and crunching sounds in the jaw signs of “TMJ”?
Yes. They are all signs of jaw joint damage. In a normal jaw joint, there is a cartilage disc, kind of like a gummy saver, centered over the top of the condyle or ball part of the lower jaw and tied down tightly to the condyle with ligaments. There are nerves and blood vessels that lie behind the condyle.
When a joint is injured, the ligaments stretch out and the disc can become displaced in front of the condyle. The nerves and blood vessels are pulled on top of the condyle, where they can cause pain.
When a disc is displaced with the mouth closed, it can come back on top of the condyle during opening and make a clicking or popping sound. The disc comes off again on closing.
If the joint is significantly damaged, the bones can rub together, making a crunching or grinding sounds.
6. Can you have “TMJ” without having noises, limited opening or pain?
Yes. In a normal jaw joint, there is a cartilage disc, kind of like a gummy saver, centered over the top of the condyle or ball part of the lower jaw and tied down tightly to the condyle with ligaments. There are nerves and blood vessels that lie behind the condyle.
When a joint is injured, the ligaments stretch out and the disc can become displaced in front of the condyle. The nerves and blood vessels are pulled on top of the condyle, where they can cause pain.
When a disc is displaced in childhood, it can limit blood flow to the condyle and cause it not to grow (osteochondrosis). If the disc stays displaced, it can cause the bone to die (avascular necrosis).
The more damaged the joint, the less the disc can come back on top, so there is no noise. Any noise that goes away, means a progression of damage, not a healing of the joint.
In a joint with a small condyle and disc locked out, there is generally no noise and no limited opening.
7. I had an X-ray, is that enough to diagnose “TMJ”?
No. When examining any joint, especially the temporomandibular joint, you have to be able to see inside the joint to know what is wrong or right, before you know what to treat and how to treat a patient.
An X-ray is a 2-dimensional picture of a 3-dimensional thing, the bones, in this case, the jaw joints. It is generally called a panorex or a screening film. The face is convex, so the machine has to sort of flatten out the face to see the jaw joints. This distorts the joints somewhat. It is a good film to screen for extra teeth, 3rd molars and pathology. It is like looking at someone from across the room. In order to take the film, the lower jaw has to be pushed forward, so there is very little of value seen in a panorex, regarding temporomandibular joints.
A CBCT is a 3-dimensional picture of a 3-dimensional thing, the bones, in this case the jaw joints. It does not flatten out the face or distort the joints, so it does give us much more information. You can evaluate the size, shape and surface of the condyles much better than in a panorex. You can gather information about when the person was injured by measuring certain aspects of the jaw. You can see how the teeth fit together and evaluate for teeth/bone health and infection. The major downside is that you can in no way tell for sure where the disc is. You cannot see the disc.
An MRI is a 3-dimensional picture of a 3-dimensional thing, the hard and soft tissues of the jaw joints and face. The gold standard in diagnosing any other joint in the body is MRI. When examining jaw joints, the first thing to get damaged is the soft tissue or disc. Damage to the soft tissue disc can cause bone changes, but only after many years. By the time damage shows on an X-ray or CBCT, it is advanced
The only way to see the soft tissue changes is MRI. The disc position is what determines what kind of treatment is necessary. You can only see that on an MRI. With CBCT, you can see bones only. You can GUESS where the disc is by the spacing between the bone of the head and the bone of the lower jaw but not KNOW where the disc is.
8. Is clenching and grinding a cause of “TMJ”?
Clenching and grinding is the brain’s way of trying to fix a bite problem. The bite is set by the jaw joints, so damaged and unstable joints could be the cause of clenching and grinding. It is not the cause of “TMJ”, but a symptom of an issue.
9. How do discs get dislocated?
Trauma, only. Even though things like Invisalign, braces, dental work, etc may be the straw that broke the camel’s back but the forces that can dislocate a disc come from trauma, usually in childhood.
10. Is sleep apnea related to “TMJ”?
It can be. In general, when a joint gets damaged in childhood, the disc that is normally tied down tightly to the top of the condyle is displaced in front of the condyle and can block blood flow to the condyle, causing it not to grow. The tongue grows separately from the lower jaw and the lower jaw grows at the level of the condyle.
If the condyle doesn’t grow, the lower jaw doesn’t grow, but the tongue does; it makes the tongue “too big for the mouth” and can cause airway issues. I believe anyone with airway issues needs to check the joints with an MRI.
11. Is swelling a sign of “TMJ”?
Facial swelling can be related to damaged jaw joints, but all facial swelling should always be evaluated for pathology.
12. Is neck pain and stiffness, tightness a part of “TMJ”?
All of my patients with damaged jaw joints have neck pain and stiffness. That’s because when a jaw joint is damaged, it is no longer stable. The muscles of the face and neck have to try to stabilize the joints. They are not supposed to have to do that and will fatigue and spasm.
13. Are bite changes a sign of TMJ”?
The bite is determined by the jaw joints. If the joints are damaged and unstable, the bite is unstable and will change. I would say 99% of my patients with damaged jaw joints report bite instability and/or say “I don’t know where to put my jaw” or “my teeth don't match anymore”.
14. Is it possible for you to tell me how to treat “TMJ” without an MRI?
No, without knowing the health of the jaw joints, it is impossible to tell you how to fix your “TMJ”.
15. Should I have Botox for my “TMJ”?
If you don't have an MRI, I would never do any treatment. If you have damaged joints, Botox cannot help and it can cause more damage to the joints. Botox is a chemical that causes the motor nerves in the area it is injected into to stop firing. This keeps the muscles in that area from contracting. That can help decrease clenching forces for a short period of time, but over time, the nerve sprouts branches that are not affected by the Botox and movement of the muscle returns. That is why it has to be done over and over.
Clenching is a symptom of a problem: a bite discrepancy. The brain sees a bite that doesn’t match as an issue with eating and, therefore, staying alive, so it tries to fix that bite issue by trying to move the teeth out of the way. It will cause teeth wear and fractures. The problem is bite issues are rarely solely the primary problem. They usually come from joint damage.
In essence, when someone injects Botox to decrease clenching, they are treating the symptoms of a problem and not the problem itself. That problem, joint damage, needs to be diagnosed by MRI prior to doing any treatment, especially injecting a chemical into someone.
Furthermore, there are studies that show that changing the load on a joint, by deactivating the muscles, can lead to bone breakdown of the mandibular condyle.
If a person has damaged joints, they can be fixed and therefore generally don’t need Botox. If the person has damaged joints and can’t have them fixed, I certainly don’t want to cause more damage by using Botox.
16. Can a splint fix “TMJ”?
There are 3 kinds of jaw joints: Normal, Damaged and Stable and Damaged and Unstable.
A normal joint is a joint with a cartilage disc tied down tightly to the top (ball part) of the lower jaw or condyle by ligaments. There are nerves and blood vessels that lie behind the condyle. The condyle is of normal size, shape and signal.
Damaged and stable, One scenario is when the original disc has been damaged and is displaced in front of the condyle. When this occurs in childhood, it can block blood flow and limit the condyle's growth. When a disc has been damaged in childhood, the joint can develop scar tissue or pseudo disc that covers the condyle.
In this situation, the bone is usually smaller than normal, so there is more movement of the joint than normal, but the pseudo-disc is better than anything we can do in surgery to stabilize the joint. Sort of you like you fixed it yourself. I believe this only happens when a person has been injured in childhood. I don't believe it happens in an adult with severe pain.
Another scenario is where the disc is only partially displaced off the condyle. These joints can pretty much function normally, but the bite has to be meticulously corrected.
Damaged and unstable is where the disc is completely out of position and no scar tissue has formed. When a disc is displaced, the nerves and blood vessels that normally lie behind the condyle are pulled on top of the condyle and are crushed when you speak, swallow and chew.
A splint may be helpful when the joints are normal or damaged and stable. In these cases, the pain usually comes from a disharmony in the forces between the joints, muscles and teeth. We use the splint to temporarily balance those forces. The guard needs to be hard plastic, flat surfaced, smooth and of significant thickness. It can be upper or lower and just one.
When you place a splint, it has to be adjusted to your bite. You should feel you’re your teeth touch evenly all around. Having the teeth apart allows the muscles to relax and the joint to move toward the fossa. The bite will change and the splint should be adjusted again to even up the bite.
I adjust the splint until the bite on the splint stays even and doesn’t change and the patient is comfortable. The bite on the teeth will change and has to be changed to correlate with the new, comfortable bite we developed on the guard.
The guard is worn 24/7 except when eating and I generally give myself 4 months to get the bite adjusted for the person, adjusting twice a month, at least.
After getting the patient comfortable, the guard can be worn at night to protect the teeth if the person still grinds or has a lot of dental work.
The guard itself is not magic; it’s the person adjusting the bite on it that makes it work. It has to be hard to duplicate the teeth surfaces. A soft guard just gives the person something to chew on and doesn’t give you a flat surface to adjust.
If the joints are damaged and unstable, the guard allows the muscles to relax and seat the condyle into the fossa, where it will compress the nerves and blood vessels that are pulled on top of the condyle when a disc is displaced. It can and often does cause more pain.
17. Who do I see to get a correct diagnosis?
There is no American Dental Association or CODA-approved TMJ specialty in the US. Therefore, there are no TMJ specialists. Don't be fooled. Jaw joints are just joints. Just like with any other joint, you need to have an MRI of the jaw joints to know what is wrong, if anything, and how to treat.
Posted in the “Guides” section at the top of the page there is a list of dentists I am in a study club with who know how to get and read a TMJ MRI. If one is not close, or you don't want to see one of them, there is a post of tips for getting an MRI and the protocol I use to get the scan. Then I can help you understand the report.
18. How do you fix damaged joints or disc displacement?
There are only 2 successful surgical procedures for correcting disc displacement. Disc removal and fat graft transfer if the condyle is of sufficient size, shape and signal and joint replacement, if the condyle is not of sufficient size and signal. Arthrocentesis and arthroscopy are 100% guaranteed to fail surgical procedures that cause more damage.
19. Who do you recommend for surgical correction?
I only recommend Dr. Brian Shah in St. Petersburg, FL for surgical correction as he is the World’s Leading TMJ surgeon and one of only a few surgeons who even do TMJ surgery. If you can’t see him, there is a list of questions to ask another surgeon that you can print out and take with you to that surgeon. If they can answer the questions satisfactorily, maybe they would be ok.
20. Does “TMJ” pain increase when lying on your back?
Yes, pain in the joints often increases when a person lies down, because this loads the joints. It can also cause occipital pain (back of the head pain) and headache. As always, there needs to be an MRI diagnosis of joint health before we know how to fix this.

04/24/2026

Why TMJ, TMD and TMJD are not real diagnoses.

TMJ as a diagnosis
TMJ stands for temporomandibular joint. It is a body part, not a diagnosis. Getting a diagnosis of TMJ for facial pain is like getting a diagnosis of KNEE for leg pain, too vague. You would say, “What is wrong with my knee?” They would get an MRI of the joint and say something like, “You have a torn ACL and this is how we treat it.” The same thing has to happen with jaw joints. There needs to be an actual diagnosis, like a torn meniscus, for example, to know what would be helpful.
TMJD and TMD are no better of a diagnosis because they just stand for temporomandibular joint disorder or dysfunction. Still too vague. Nobody gets a diagnosis of shoulder dysfunction, but might get a diagnosis of a torn rotator cuff. They would never get a diagnosis of knee disorder, but might get a diagnosis of a torn meniscus. The diagnosis tells you exactly what is wrong and how to fix it.
Several things can be wrong inside a jaw joint. In a normal joint, there is a cartilage disc that is tied down tightly to the top of the condyle or ball part of the lower jaw with ligaments. There are nerves and blood vessels that lie behind the condyle. The position of this disc determines the diagnosis and the treatment.
When a joint is injured, the disc is displaced in front of the condyle, where it can block blood flow to the condyle. If this happens in childhood (osteochondrosis), it can alter the growth of the condyle itself. If it stays displaced in front of the condyle, it can cause the condyle to die (avascular necrosis). In order for the disc to get displaced, the ligaments have to stretch out. When a disc displaces, the nerves and blood vessels are pulled on top of the condyle, which can be painful. This disc displacement also causes swelling inside the joint.
Furthermore, a normal TM joint is braced by bone. When a disc is displaced, the joint is no longer bone-braced and the joint is considered unstable. Muscles surrounding the joint now have to try to support the joint, which they are not made to do. This causes the muscles to fatigue, spasm and become painful.
I talk about this because even if you have muscle pain, you cannot treat it, if you don’t treat the underlying joint instability. You can not know the underlying joint health without an MRI.
No diagnosis means a waste of time and money trying to solve a problem of which you don’t know the origin.

04/02/2026

We continue to have new people join us.
I have been working on some information to post.
Here is some information about the Orofacial Pain Center and me.

About Dr. Margaret L. Dennis
Dr. Margaret L. Dennis is an orofacial pain specialist who has devoted more than 25 years to the diagnosis and treatment of complex facial pain and temporomandibular joint disorders. Her work is guided not only by extensive clinical training, but also by a deeply personal experience that shaped the direction of her career.
Dr. Dennis began her dental career in 1990 after graduating from dental school and opening a general dental practice in Jacksonville, Florida. She loved practicing dentistry and building relationships with her patients. However, just a few years into her career, two events would permanently alter her professional path.
First, Dr. Dennis suffered a significant neck injury in a car accident that made it difficult for her to continue practicing general dentistry. At nearly the same time, her sister began experiencing severe migraines and facial pain that became so debilitating she was bedridden four days each week. Despite seeking care from multiple providers, no one was able to identify the cause of her condition. In fact, one physician suggested that her symptoms were psychological.
Determined to find answers, Dr. Dennis began pursuing advanced continuing education in occlusion and bite relationships with renowned educator Peter Dawson. Through that training, she was introduced to the importance of the temporomandibular joints in facial pain and dysfunction. This ultimately led her to Mark Piper, a pioneer in the surgical treatment of jaw joint disease.
When Dr. Piper reviewed her sister’s MRI, it revealed severe degeneration of the jaw joints that had gone undiagnosed for years. The condyles were significantly deteriorated, explaining the extreme pain she had endured. After careful evaluation and several attempts at joint preservation procedures, her sister ultimately underwent bilateral rib graft reconstruction with fat graft transfer in 1997. The surgery was successful and remains stable to this day.
That experience changed Dr. Dennis’s life. She realized that many patients suffering from severe facial pain struggle to obtain an accurate diagnosis and appropriate care. Motivated by this realization, she dedicated herself to studying temporomandibular joint disease and facial pain in depth.
In 2002, Dr. Dennis sold her general dental practice and entered a residency in Orofacial Pain at the University of Kentucky College of Dentistry. During her training she studied the full spectrum of facial pain conditions, including neuropathic pain, muscular disorders, and temporomandibular joint disease. The residency also included comprehensive training in pain management and treatment planning.
In 2003, Dr. Dennis returned to Jacksonville and founded The Orofacial Pain Center, a practice dedicated exclusively to the diagnosis and management of facial pain conditions. For more than two decades, she has helped patients from across the country who suffer from severe and often life-altering pain.
Dr. Dennis has developed a strong clinical philosophy based on careful diagnosis, advanced imaging, and a clear understanding of the structural conditions affecting the jaw joints. Her approach emphasizes accurate identification of the underlying problem so that patients can make informed decisions about their treatment options.
Throughout her career, Dr. Dennis has remained committed to patient education. She believes that individuals suffering from facial pain deserve clear, honest information about their condition and the available treatment pathways. Her work is driven by the same determination that once led her to search for answers for her own family.
Today, Dr. Dennis continues to practice in Jacksonville, Florida, where she provides diagnostic evaluations and guidance for patients with complex temporomandibular joint and facial pain disorders.

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4237 Salisbury Road, # 102
Jacksonville, FL
32216

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