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TMJ Disorders


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What is TMD or TMJ?

Temporomandibular Disorders (TMJ or TMD) is a specialty in dentistry and medicine which deals with conditions involving the jaw joints, jaw muscles, teeth, and other associated structures. Many people refer to these disorders simply as"TMJ" disorders. This is not an accurate term, because it implies that the jaw joint (the Temporomandibular Joint) is always involved, and this is not always true.

Temporomandibular disorders represent a major cause of non-tooth pain and dysfunction in the head region. It is estimated that approximately 75% of the population has at least one positive sign of symptom of TMD. The most common age for distribution of TMD is between 15 and 45 years. Men and women are affected evenly. Temporomandibular disorders can in some cases burn themselves out after a number of years. Many cases, however, are very discomforting and can result in permanent disability if improperly diagnosed or treated.

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How did I get it?

There are many causes for TMD. The factors that predispose you to TMD fall into three categories: Traumatic, Anatomical and Psychological. Temporomandibular Joint

A Healthy TM Joint

Trauma
There are many ways to traumatize the jaw structure. Many people grind or clench their teeth at night or during stressful periods during the day. This form of repeated overloading of the jaw and jaw muscles (microtrauma) can lead to a TMD. A blow to the jaw or other overt trauma (macrotrauma) can lead to a more acute TMD which may not resolve on its own. Indirect trauma to the jaws during a whiplash accident (hyperextension) has also been associated with the subsequent onset of TMD.
TM Joint with
compressed, thinning disk
Joint is injured, disk
completely out of position
Severed Disk

Anatomical Disorders
There is some evidence to suggest that unusual anatomical abnormalities may predispose one to a TMD. This may include an unstable bite (malocclusion), a deep vertical overlap of the front teeth (overbite), an excessive horizontal overlap (overjet), or a crossbite. Lack of a firm bite in patients missing back teeth (posterior bite collapse) may be implicated as well.

Psychological Factors
A major causitive factor for TMD is stress. Many TMD patients suffer from excessive stress in their daily lives. Anxiety and depression tend to be more prominent in patients with chronic pain complaints. Psychological factors may pre-dispose patients to, and in some cases perpetuate, TMD.

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How do I know if I have a TMD problem?

The most frequent symptom of a TMD problem is pain in and around the jaw joints, ears and cheeks. The pain is most often described as a dull, achy pain which varies in intensity. It may be associated with headaches, ear aches, tooth aches, ringing in the ears, ear "stuffiness", or restricted range of jaw movement.

Another very frequent symptom is jaw joint noise. These can be described as popping, clicking or grinding sounds. These sounds may or may not be painful. They may represent the parts of the jaw joint not working together smoothly. The presence of joint noises does not necessarily mean you have a TMD. They may reflect normal anatomical variations within the jaw joint which do not signify any disease at all. Joint sounds are common within the general population and can be felt when the jaw joints are stressed. Locking Cycle

Sometimes the noises in the jaw joint disappear and are replaced abruptly by limited opening of the mouth. The limitations mayt be with mouth opening or an inability to move the jaw freely from side to side. This may or may not be painful. This is called locking and is usually associated with a long standing joint noise where the parts of the jaw joint do not work smoothly, and periodically they get stuck. Locking usually becomes more prolonged and bothersome over time as the ligaments holding the Articular Disk, and the disc itself, deteriorate and stretch. Clicking Cycle

Restricted movements of the jaw do not always have to be associated with a history of jaw joint noises. It is not uncommon for the only presenting symptom to be restricted opening associated with a problem with the jaw muscles. An acceptable range of jaw opening can be determined roughly by placing the first three knuckles on your hand in a tier between the upper and lower fromt teeth without provoking any discomfort. If your fingers fit, you are probably opening with a normal range (45 to 60 millimeters).

A common finding in TMD patients is accelerated wear of the top edges of the teeth (Incisal Wear). This is due to teeth clenching or grinding. Patients are frequently unaware of the habit. It is not usually associated with pain unless excessive. Clenching or grinding may be silent, not bothering one's spouse or significant other at night.

Many TMD patients complain of shifting or uncomfortable bite (Occlusion). This may or may not be associated with pain. The changes in the bite may be very rapid and may result from trauma to the head or neck such as a dental injection, sports injury, or a minor traffic accident. The bite changes can also occur more slowly over time and can represent a variety of underlying conditions, including changes caused by night time clenching and grinding of the teeth, arthritis in the jaw joints, or other health problems. Correction of the bite problem may help resolve your discomfort for a short period of time, but will not usually eliminate the TMD.

Most presenting symptoms are aggravated by jaw functions including chewing, yawning and talking. If you suspect a TMD and it is not made worse by moderate jaw use then it is important to realize that these symptoms may be accompanied by other health problems in the head and neck which cause pain and dysfunction at the same time. These other disorders do not fall into the classification of Temporomandibular Disorders and they may, in fact, be the cause of your pain and discomfort.

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What is the Anatomy Involved with TMD?

The structures involved wiith TMD include the jaw joints (Temporomandibular joints), the jaw muscles (masticatory muscles), and the teeth. Within the jaw joints themselves, separating the jaw bone from your skull is the Articular Disk, composed of cartilage. When the jaw is functioning normally, the lower jaw bone and the Articular Disk move forward and back as the mouth is opened and closed. This movement is controlled by your jaw opening and the jaw closing muscles. The movement is usually quiet and pain-free.

There are a number of jaw muscles which control the movements of the jaw joints. They fall into three categories, the jaw opening muscles, the jaw closing muscles and the side to side moving muscles. There are also a number of ligaments which help brace the jaw joint during its function. A number of nerves and blood vessels run through this area bringing feeling and muscle control to these structures along with a healthy blood supply.

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What do I do if I think I have a TMD problem?

If you suspect that you may have a TMD the place to start is with your Medical doctor or your Dentist. Explain to them your symptoms and ask them to evaluate whether or not you should see a TMD specialist. Due to the intimate relationship between TMD and your teeth, most TMD is evaluated and managed by Dentists. Many Dentists are familiar with TMD or can refer you to a colleague who specializes in the field.

The Consultation Visit
At the consultation visit a list of your complaints will be recorded. A detailed history of each complaint is noted, including:

  • where the pain is
  • what makes it worse or better
  • how long it has been present
  • has it changed over time
  • is there a daily pattern of the pain
  • what kind of treatments have you had in the past to treat the pain
Supplemental information may be required before a diagnosis can be determined. Data such as past dental records, relevant medical records and various types of imaging (X-rays, etc.) of the jaw joints may be needed.

Following a complete history a clinical examination will be performed which includes palpation of the jaw joints to determine if any popping or clicking is present, range of jaw movements, palpation of the jaw and neck muscles, and a examination of the bite. Oral habits such as clenching or grinding of the teeth are noted. Other habits such as gum chewing, tongue thrusting, fingernail biting, pencil chewing, etc., will also be noted. A brief neurological examination may be performed if the examing Doctor feels it is important.

As part of the clinical examination, the Doctor will try to provoke the painful symptoms you are experiencing. This helps him confirm their source and is the firt step in formulating a diagnosis. Failure to replicate your chief pain complaint during the examination does not mean you are crazy, it may simply reflect a condition that does not happen to be active on that particular day. TMD symptoms tend to come and go.

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Is my TMJ Disorder "All in my Head"?

There are many factors involved in the diagnosis of TMD, and not all of these factors can be traced to anatomic problems. One of the most important areas to be explored by your TMD Specialist is the role played by stress. Frequently, emotional or physical stress, anxiety, or depression can be a significant factor in perpetuating the pain associated with TMD. It is an important part of the examination procedure to discuss the stresses in your olife and how these stresses impact on your pain complaint.

An integral part of the healing process involves changing bad habits. This requires behavioral modification to replace the bad habits with the good ones. Treatment in this regard is highly individualized and is usually best provided by a qualified Pain Psychologist. A common approach is relaxation training, using biofeedback. Traditional stress management and counseling programs can be very helpful.

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What is Included in the TMD Problem List and Treatment Plan?

Once the interview is finished and the clinical examination completed, a list is made which includes each and every problem associated with your TMD. This may include financial stress, having to travel far distances for treatment, overlying illnesses unrelated to the TMD, anxiety and deptresion, etc. These findings along with the exact TMD diagnoses, make up the Problem List.

The next step is to formulate a Treatment Plan. Your TMD Specialist will outline for you a step-by-step treatment plan which may be very straightforward. In many cases treatment for your TMD can be performed solely by your TMD Specialist. In more advanced cases, a team of health care providers may be required to treat your TMD.

This is the time when you must ask questions. Treatment will most likely fail if you, the patient, do not fully understand and feel completely comfortable with everything on the Problem List and the Treatment Plan.

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What Treatments are available for TMD?

Temporomandibular Disorders are rarely cured, but rather managed over time by appropriate treatments by the health care providers and you. To accomplish this, all of the underlying casues need to be addressed.

At the present time, there are no universally accepted standards for diagnosis or treatment of TMD. The goal of treatment of TMD is similar to that of other bone (Orthopedic) and arthritic (Rheumatologic) diseases. The objective is to decrease pain, increase or restore range of jaw motion, and improve your jaw function.

TMD is oftem managed by a team approach. Your TMD Specialist will coordinate treatment with the other health care providers who will be treating you. The team may include Physical Therapists, Psychologists, Radiologist, Neurologists, Restorative Dentists and your Family Physician.

Since there are no broadly accepted standards for treatment, prudence would dictate that TMD be treated by non-invasive, reversible and conservative therapies if at all possible. Many patients can be returned to normal pain-free function by conservative therapy performed by your TMD Specialist. This may include short term use of over-the-counter non-steriodal anti-inflammartory medications, soft diet, moist heat or ice packs, mild stretching exercises, and head, jaw and tongue postural education. A competent Physical Therapist may be utilized to perform more advanced physical medicine treatment as well.

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Why did I not Improve with Conservative Care?

Some patients do not improve with conservative home care programs. These patients frequently have underlying oral habits which prevent the sore muscles or joints from healing. There may be changes in the bones that make up the joint, such as arthritis. As in the knee joint, there may be damage to the cartilage and ligaments that support the jaw joint. A number of patients who do not respond to conservative home care fail due to underlying chronic pain problems such as bad backs, past surgical treatments, or trauma to the head and neck.

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What are the Most Common Treatments when Conservative Home Care does not Work?

If conservative therapy and behavior modification techniques fail to resolve your TMD, the next step is to reevaluate the Problem List in order to re-confirm the diagnosis.

At this point, we may utilize injections of local anesthetics (similar to those used for routine dental work) to see if the pain source can be numbed or blocked temporarily. These are called Diagnostic Blocks. This helps confirm the diagnosis. We may also utilize Medication Trials, which are directed at reducing painful neurologic (non-dental or muscular) symptoms which can mimic tooth and jaw pain. In some cases, more involved treatment modalities may be performed by the Physical Therapist utilizing Ultrasound or Transcutaneous Electrical Nerve Stimulation (TENS). Occasionally, with patients who are resistant to traditional treatments, Acupuncture is recommended.

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Will I Have to Wear a Night Guard While I Sleep?

Night Guard One of the most commonly utilized therapies for a patient who does not respond to conservative home care is called a Night Guard or Stabilization Splint. This is a custom-made intraoral appliance which fits over your teeth, and is designed to unlock your bite, reduce muscle tension and protect the jaw muscles, jaw joint and teeth from the stress place on these structures at night time by clenching or grinding (bruxism). In may cases, night time wear of a well adjusted splint can significantly reduce your symptoms. Splint wear will not continue to be effective without periodic adjustments to the splint to re-establish a balanced bite. Depending on how aggressive a clencher or grinder you are, adjustments are usually performed every 4 to 6 months.

Along with consistent night time splint wear you need to keep your diet free of very hard and chewy foods. This includes, in may cases, the elimination of gum chewing. We also recommend continued practice on a daily basis of simple exercises designed to improve jaw posture, tongue position and range of jaw motion.

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Will Braces, Dental Work or Surgery correct my TMD?

Braces (orthodontic work) and/or extensive dental work (caps or bridgework) have not been shown in the scientific literature to be of significant help in the management of TMD. This is because these procedures do not adddress many of the underlying factors that caused you to have TMD in the first place.

Certainly there are indications for orthodontic intervention and dental work, but only if the underlying etiology of your pain can be directly related to bad bite, painful or missing teeth, or if you wish to have the cosmetic appearance of your teeth and smile improved. Keep in mind that dental work can be an added stress to an already stressed part of your body, making your symptoms even more bothersome. It is always a good idea to treat TMD with reversible procedures first, before undergoing irreversible procedures.

Due to the complexity of surgical procedures available, and the potential for serious complications associated with various techniques, surgery should be considered when conservative intervention, including addressing psychological factors, has failed to resolve pain or restricted range of jaw movements. If after conservative management you still have pain and restricted jaw movements, surgery may be indicated.

Frequently, persistent restricted range of jaw opening or jaw joint pain can be treated by Arthorscopic Surgery, similar to that performed on athletes' knees. This involves the insertion of miniature instruments through a small hole into the jaw joint itself to flush out debris, remove or unstick the soft tissue parts which are causing the restriction, and to place medications directly into the jaw joint. It must be performed by a surgeon specially trained in this technique.

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What is the Long-Term Prognosis for My TMD?

The majority of patients with TMD will achieve good results with conservative treatment. Those patients who require more advanced therapy, i.e. night guards, physical therapy, etc., usually respond well to those procedures and regain an acceptable measure of jaw function.

Many TMD patients have self-limiting disorders which will respond well to treatment, and not return. Most TMD, however, tends to be chronic, related to overuse of the jaw muscles through clenching and grinding of the teeth. These cases may persist indefinitely, and require ongoing treatment.

The role of stress as a main etiology cannot be overlooked. We all know how difficult it is to remove stress from our lives. This alone may perpetuate a TMD. Compound stress with a chronic clenching habit and you can see that in may cases it is simply unrealistic to totally eliminate all of the discomfort caused by a TMD.

It is a very small percentage of patients who fail to respond to any intervention. Rarely is a TMD specialist unable to reduce even the most severe and persistent pain to a more tolerable level. Patients who do not do well usually have underlying stresses to the jaw joints or muscles which are not brought under control.

One of the most important factors which predicts treatment outcome is the accuracy of the diagnosis. Another very important factor is the patient's compliance with the treatment plan. The long-term prognosis for these conditions is really up to the patient. It takes a certain degree of discipline on your behalf to control a TMD over many years.

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Last Revision Date: March 20, 2000
This page is Copyright 2000 Ivan L. Lapidus, D.D.S., Inc.