Where is the Lateral Pterygoid?

The lateral pterygoid is located deep inside your jaw, and is a key muscle in the function of chewing or mastication. It function is pull the condyle forward, in essence opening the jaw.

The muscle itself is located deep inside the face and it not easily accessible. The actual position is inside of the jawbone, making massage very difficult from the outside.

The lateral pterygoid can be reached inside of the mouth via this method.

Here's a great video from KenHub on how the muscle works. This muscle has a bad reputation for being a key culprit in those suffering from TMJ or TMD pain.

Upset that the NES Classic Edition Controller Cord Is Too Short? Here Are Some Easy Options To Fix The Problem

If you were lucky enough to get your hands on a Nintendo Classic this Christmas, you might have noticed one big problem: the cord that runs from the controller to the console is terribly short.

This leaves you with a few options:

1. Get a 30 foot HDMI Cable to run from the console to the TV so you can move the Nintendo to wherever you are sitting.
2. Get an usb extension cable so that you can leave that new console underneath the TV Set. If one isn't enough - just add 2!
3. Get an wireless remote control for the new Nintendo. 8bitdo makes a wireless bluetooth controller specifically designed for the Nintendo Classic. The controller will be available December 16th, and you can buy it on Amazon.

Want more information about the Nintendo Classic? Click here.

TMJ Disorders, The Pain, The Science, & My Terrible Journey

In August of 2014, I experienced an allergic reaction to cephalexin - more commonly known as Keflex. The reaction was initially minor producing only a slight body rash, but what started 4 days later was anything but minor. Temporomandibular Joint Disorders, or TMJ or TMD, are incredibly painful, and in my case are persistent. This posting is a chronicle of my terrible journey, and my hope is that if you are reading this - there is something in it that can help you gain some sort of relief.

After my initial Kelfex rash, the muscles in face started tightening up. I found it difficult to open my mouth wide, it was difficult to talk, my tongue hurt, and there was a constant dull pain deep in my jaws. Initially, my bite felt normal and I didn't feel that there was any malocclusion. Initial symptoms:

• Tight and sore face muscles

• Jaw popping

• Difficult to talk

• Painful tongue

• Possible coating on tongue

• Sore neck & shoulders

After a week or so I decided to visit a nurse practitioner at our on-site work clinic. Judging by my symptoms, she suspected that I had oral thrush (because of the slight coating on my tongue), and prescribed a short course of difulcan. In my opinion, the coating on my tongue was normal, and didn't look any different, but it was worth a try. After all, I have never experienced anything like this before.

After one week, I experienced no benefit and the tongue pain just became worse. What I discovered at a later date is that because of my dysfunction that my tongue was continually rubbing against my teeth which made the tip of my tongue raw and painful, but more on that later. This pain was the worst symptom and the focus when I visited my doctor. Here are some photos on another site of what my tongue looked like (not me, but tongue looks close).

My Doctor

My doctor didn't really see much wrong, and diagnosed me with a case of glossitis, which is basically a swollen tongue, and recommended that I see an ENT. He also suggested that some of my issues might be in my head, or have manifested by surfing the internet too much. After all, I have never experienced anything like this before, so I decided to see an ENT.

ENT

The ENT really didn't see anything more than an irritated tongue and reiterated the glossitis diagnosis, and speculated that it could be some acid reflex and post nasal drip. He recommended using Mylanta after eating and before bed, and using saline nasal spray to combat the post nasal drip. It also sounded very similar to LPR or silent reflex.

It had been 2 months since my problem started, and since then I have been in constant pain. I was so hopeful that this was the fix, but it was not. It wasn't LPR, and it wasn't post nasal drip. I went back to my doctor, and either I was crazy or maybe it could be some sort of TMJ Disorder he said. So I turned my research to TMD.

I have discovered on my journey that TMD is easy to diagnose and hard to treat. Medical professionals will take standard steps or make you feel like it's in your head. Stay strong and keep trying and you will find help, but it will not be cheap. So prepare yourself.

My Dentist

My initial TMD guess led me to visit my dentist. She verified that I had jaw popping and recommend that I buy a night guard because I am probably clenching my jaws and grinding my teeth at night. I showed no wear on my teeth from grinding, but I couldn't rule out grinding. What I knew for sure is that I never had any issues before the Keflex reaction. At this point I really was desperate and would try anything, so I purchased a mouthguard for $499. Luckily, my insurance covered some of it and my cost was $99. The mouthguard was soft and was custom fitted to my lower teeth.

Initially the mouthguard felt good. It helped me sleep, and I felt that I could "stabilize" my jaws. This feeling was short lived however, and it actually made my pain WORSE. That's when I decided to see a TMD Specialist.

The TMJ Specialist

The first visit consisted of an in depth interview, measurements, and an x-ray. The expertise of this Dr. was immediately apparent. After months of self research, she took the time to explain the intricacies of the jaw (and concepts like the coronoid process), and gave brutally honest expectations. Finally, i felt like I was going to get some relief, but it would not be quick - especially since I waited so long to get treatment (or the right treatment).

The Diagnosis

My problem is the lateral pterygoid. It's in spasm, worse yet stuck in a spasm-pain-spasm cycle. When a muscle is in spasm like the pterygoid, its change in motion may affect other muscles in the face and body. The muscle spasm, through the central nervous system, creates more contraction, which then creates more spasm, and this cycle goes on and on. 

Initially, it was hard to blame the lateral pterygoid solely, as all of the muscles in my face (and neck) were sore, but there was great confidence. Regardless the treatment was the same. 

The Treatment

You have to break the cycle and get those muscles to relax, which is a real challenge if you have to talk most of the day at work. The initial treatment consisted of an had acrylic mouthguard and a pain relieving cream.

The mouthguard took a bit to get used to as I was used to both no guard, and a soft guard on the bottom teeth. Here is the type of guard (except on top):

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The splint is adjustable, and it is usually adjusted on every visit. Adjustments typically consist of adding and removing material from right or left side of the splint to balance jaws. 

The cream is a topical cream that you actually rub on the jaw muscles, and it is wonderful. The first time I applied the cream, I immediately felt the burning pain go away. This was the first time in nearly 18 months, that this pain had left. The Flurbiprofen and Cyclobenzaprine combination cream was custom ordered from an apothecary and was nearly $200 for a tube the size of a toothpaste tube. It takes very little cream to feel relief. Flurbiprofen is a pain reliever and Cyclobenzaprine is a muscle relaxer. The great thing about the topical cream is that you can use it and it does not have the side effects of an oral muscle relaxer. I used this 3x a day in the beginning. Warning: also it applies unnoticed it will stain your collar on your dress shirts - like an oil stain.

One Month

After just one month I felt some noticeable improvements. My range of motion was a little better, and the pain was much, much, less. When the mouthguard is in, it relaxes the muscles of mastication, and the pain literally just goes away. However, the bulky mouthpiece makes it hard to talk, so you will find yourself continually taking it in and out during the day. After getting pain relief from this condition, you really do not want to go back to being in pain - AT ALL. 

As a result, I went back to the TMJ Specialist and she was able to provide me a low-profile day splint that went on my bottom teeth, that is "hidden" and is much easier to talk with.

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Gelb Splint

I wear this splint 4-5 hours throughout the day, and I wear the hard splint at night when I sleep.

6 Months

I return to the TMJ Specialist monthly, and get adjustments on the splints. I can feel when a splint needs adjustment, and the feeling is a deeply sore jaw. Overall, I feel much better still. My back, neck, and face feel better, but my bite is still out of alignment, and my jaw still gets sore after talking and eating. 

The treatment remains the same, but now we add lidocane injections into the face and neck muscles, including attempts at the lateral pterygoid. These offered minor short term relief, but have failed to be the solution to the problem.

9 Months

My relief has plateaued. It hasn't gotten any worse and the splints continue to relieve the pain, but there has been little improvement the last few months. At this point I am running out of options. The next step is to try a stronger muscle relaxer called Clonazepam. interestingly enough, if you look up Clonazepam, you will see it does much more than relax muscles - it was originally intended as an anti-seizure or anti-anxiety medication.

The doctor's hopes is that will cause further relaxation during the night time and will reduce any clenching that is going on. The first few mornings after I began the drug, I felt a little better. My pterygoids still had not released, but I felt my range of motion was slightly better. However, if i take the pill too late at night, it is difficult to get going in the morning, so be careful and give yourself 8 hours before you have to wake up.

Looking Forward

This is where I am at right now: using splints and taking Clonazepam. If this doesn't work, the next course of action is ultrasound guided botox injections in to the ptergoids themselves. Botox will paralyze the muscle, ergo causing it to un-spasm. This is a last resort to my doctor as Botox is a toxin. Click here to read more about this process.

12-24 months

After 12 months, with some improvement, I hit a wall with the TMJ Specialist. She tried all of the conservative treatments, and is very reluctant to move forward with more aggressive treatments like Botox, surgery, or orthodontics. She recommended getting a second opinion, or just continue the maintenance injections. I don’t blame her for giving me an ultimatum. On the contrary, it was nice getting some truth: she’s stumped by my situation, and its not bad enough to try something more severe/permanent (easy for her to say).

So I went to a second TMJ Specialist and an Orthodontist. The TMJ Specialist just wanted to do it all over again, offering no real, new solutions but listen to relaxing, meditation music. The orthodontist was very knowledgeable, and confirmed what I already knew… there is nothing wrong with my teeth (bite), and my issue is muscular.

So for the next several months I continued on with the 3 splints (1 daytime, and 2 night time), and took the occasional muscle relaxer before bed. For pain relief ibuprofen continues to be the best option, and Miller Lite. At this point, I feel 35% better, which is a big difference. It still hurts, my bite is still off, but at least i can forget about the pain/discomfort once in awhile.

24 months +

In the midst of this I decided to switch jobs and of course medical/dental insurance. I had to find a new dentist, which was a godsend! I was fortunate to visit someone who actually wanted to help. The dentist didn’t know how to fix my problem, but he remembered a patient who had something similar, and found a sports medicine doctor locally who cured her problems. He also said he would call around and see if his colleagues have any insights.

I was given 2 things on my follow of visit which dramatically improved my condition:

1. I was given the name of a Chiropractor/Sports Medicine doctor in West Phoenix.

2. I was taught the pencil trick.

The Pencil Trick

Now the idea shared in the next few sentences will sound like one of the dumbest things that you have ever heard. In fact, I told my dentist that it was the dumbest thing that i have ever heard, but I was desperate and would try anything. My worst pain is when my jaws are idle. They will not find a resting position for whatever reason, and because of this they are always spasming and working against each other to find their equilibrium. So my dentist said we are going to give them something to rest on: a #2 Pencil. Quite simply, open your mouth a 1/3 of the way, and push the pencil back as far as you can so it notches between your teeth and let your bite rest on the pencil. If you have to bite down to keep the pencil in place, it probably needs to be further back. So once in correctly, your top and bottom teeth will be touching the pencil, but you aren’t using any energy to bite down on it.. rather your jaws are resting on it and keeping it in place.

Like this, but without the smile and further back.

After 5 min you should feel your jaw relax. I would do this for 10-15 min, 7 or 8 times a day. After a week, everything felt dramatically better! The only downside is if your lips are dry then you will get cracks in the corner where the pencil touches.. It’s still worth it! For the first time in 2 years, I could sit and watch a whole movie without being distracted by jaw pain.

Chiropractor

I was referred to a Chiropractor/Sports Medicine Specialist who had extensive knowledge about the issue. Honestly, more so than most of the TMJ Specialists that I have visited. He does the standard chiro stuff, but also focuses on massaging the muscles of the jaw and face. The first time I went it was extremely painful - almost like a muscle that had been tight for year, which in my case was exactly what he said it was. The knots were pretty severe, but after a few rotations I felt immediately relief. My bite increased and the dull ache was 85% better. I continue to visit once a month, for the same treatment. Although, I haven’t gotten back to the 100% point, I am happy with 90% compared to where I was 2 years ago. If you can find someone who understands those muscles and will work to rehab them.. I highly recommend that you visit!

Responsive Web Design: Are We Missing The Point?

There is no shortage of articles about responsive web design (RWD) out there. It seems like every time that I pick up a trade magazine (automotive industry), there is an article about responsive web design and if you are not doing it - you might as well close your doors. Of course that is a drastic example, but for the most part many of these articles really are missing the point. Too often we get caught up in trends, the latest and greatest, and fail to truly address the root need of the products we “must have.” So, really, why does my website need to be responsive? First, lets dig a little deeper and learn some definitions.

RWD has a different meaning for marketers than it does web developers.  To web developers the aspects that define a website as responsive are technical in nature. How content is displayed and by what method is just as import as the look and feel of the site.  Ethan Marcotte, a web-designer out of Boston, and an authority on the subject, maintains that a responsive website must utilize certain techniques, such as media queries, flexible images, and fluid layouts to make a website properly functions across different environments. If you do not have any idea what that means, that ok. This is not a discussion about the technical implementation of a website, but it is important to recognize the technical aspects of this concepts as they are seldom discussed in conversations about RWD, especially in the car business. (I am leaving "Adaptive" completely out of this entry)

Why are they important? They are important because if your website does not load quickly or properly you are losing money - regardless of how pretty and functional it looks.  Efficient web design has not been a top priority for automotive web vendors over the past several years. The vast majority of dealer websites still focus on an cumbersome desktop model, and with broadband penetration at over 70% website, regardless of how improper the design, pages will still load in an acceptable amount of time. However, on slower connections, the experience will not be so acceptable.

 Typically we are given 3 choices as the solution for our mobile customers:

• mobile formatted website, usually via a subdomain i.e. m.stokebrand.com
• adaptive website, which relies on a library of device resolutions, same domain regardless of the device
• responsive website, which resizes for the device and typically uses the same domain regardless of the device

Today, mobile sales representatives are quick to dismiss the old ways of mobile formatted website in favor of the “new” responsive model. In fact, the pitches are very aggressive (or passive aggressive), and are quick to discount the mobile formatted website altogether. Like I said earlier, if you are not doing “responsive” design  - you might as well close your doors. Bottom line, if this is the pitch you get – feel free to laugh or hang up the phone, because… They are missing the point.

The purpose of your mobile website should be to deliver the best user experience possible for your customer – regardless of the technique. For marketers, this can be further broken down into 2 elements:

• Speed
• Content (content, functionality, and design) 

Speed. Everyone has smartphones with broadband access, so why is speed important? Easy, not everyone has fast broadband access.  4G networks are not available everywhere, in fact only 22% of users have a 4G connection, and 40% of the time they do not have 4G access. If you are located in the city, you probably have better usage numbers than this, but it is still very likely that users will be connecting to your mobile website on a slower-than-4G connection – so design for it. Start by:

•  Choosing a vendor that understands this and can offer a mobile product that is responsive to typical and non-typical mobile connection speeds
•  Choose a template that is light on high-resolution graphics and backgrounds, and use color fills whenever possible.
• Test, test, test. Tell you spouse. Ask your boss. Ask his teen-age daughter. There is no better way to find performance issues than to have mobile power users test it for you. This is true for performance issues as much as it is “hiveminded” design flaws.

Content. Your index page on your mobile site should never mirror your desktop site unless you only have one page on your desktop site. Even then it still shouldn’t look the same and should at least serve the content differently. The user expectations for a desktop site and a mobile site are different – and both must serve their content effectively. Desktop users are very likely on a broadband connection, and have a huge screen with lots of real estate. Mobile users are on a smaller screen with a slower connection. How will you change your design to accommodate this (check out my upcoming posting on mobile site design tips for more in depth ideas)? To start you can:

• Visit top 100 sites. See what the big boys are doing. This is not to say they are all doing it right, but it certainly will expose you to different designs and techniques.
• Visit your competition, see what you like and don’t like. You are an expert critic here. Don’t repeat their mistakes.
•  Do not be pressured to switch to a “responsive” site just because it’s the thing to do. If they tell you that everyone is doing it, tell them that only 12% of the top 10,000 website are actually responsive and send them this link.

RWD is a very effective technique, and is probably the best way to display your company’s digital storefront across multiple devices – if done correctly. The problem is that it is rarely done correctly, and you have to pick out the best vendor or designer available to you at the time. So if that means your mobile site has a separate mobile subdomain, so be it! What is for certain is that when your customers have a terrible mobile experience, they are leaving for good, responsive or not.

Sales Pitch: Responsive Web Design is best for SEO

If you have decided embark on your responsive website design journey, you were probably sold a bills of goods that included promises of improved SEO.  How true is this? How much benefit will you receive? Did you abandon your successful mobile web site for improved organic results?

The Promises:

Promise 1: Google’s algorithm recommends responsive as the best way to target mobile users. Here’s what Google actually says on the subject:

 "Google supports smartphone-optimized sites in three configurations:

1.  {C}Sites that use responsive web design, i.e. sites that serve all devices on the same set of URLs, with each URL serving the same HTML to all devices and using just CSS to change how the page is rendered on the device. This is Google's recommended configuration.

2. Sites that dynamically serve all devices on the same set of URLs, but each URL serves different HTML (and CSS) depending on whether the user agent is a desktop or a mobile device. 

3. Sites that have separate mobile and desktop URLs." Source

Although, they go on to say that they recommend responsive over mobile URL’s, this preference is based on efficiency as fewer pages have to load and Google’s crawlers only have to search one page instead of 2, not searchability.

In fact, some SEO experts argue that most responsive sites actually have problems connecting searchers with platform specific content. For example, users searching for “mobile games” might be sent to a responsive site that offers the desktop version of the game that will not work on their mobile device. It’s also fair to assume that mobile searchers might be searching for device specific content, and a responsive site might not deliver the relevant results the searcher is looking for. For example, I am looking for “TTT Game for iPhone” because I want to play this game on my iPhone, however the keywords triggered the link to their responsive website which loaded a resized desktop version of the game. 

Promise 2: Customers will have a better experience on a RWD. This isn’t necessarily true. If built correctly a RWD will deliver the best user experience, however as I talked about in another post, many RWD offering leave much to be desired and you might be better served by maintaining your optimized mobile site (if it’s working).

 There is much criticism of a “stripped down” mobile site as being a bad thing, but is that the case? Can you imagine if the New York Times had a straight-up RWD, where content was removed or simplified for mobile users? Having a functional, clean presentation specifically for mobile users is the best way to go. We analyze visitor information in Google Analytics to see what are users are looking for and optimize our mobile landing pages (RWD or Mobile URL) to fit that demand. You don't necessarily have to strip content off of your mobile site, but prioritize the information for optimal performance (and preference). Learning what the majority of your mobile users are looking for is crucial when designing your mobile website. 

Design Notes:

If you use a separate mobile URL for your mobile site, make sure you have the proper annotation for your desktop and mobile pages. This will ensure proper crawling of your website. For instance Google recommends:

• "On the desktop page, add a special link rel="alternate" tag pointing to the corresponding mobile URL. This helps Googlebot discover the location of your site's mobile pages.
• On the mobile page, add a link rel="canonical" tag pointing to the corresponding desktop URL."

Click here for more on the subject.

Closing Thoughts:

Responsive Website Design is the way to go - if it is done right, but its not the "SEO holy grail" that it is often presented as. If you go with RWD over mobile URLs, think through the design and make sure your site truly responds to the needs of your mobile users.