Treatment Options for Tmj

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What symptoms should a patient look for? Many of patients list the following symptoms :

  • Persistent headaches that may start in the front of the head along along the sides, or in the upper part of the neck.The pain may be mild to severe and radiate to all other areas.
  • Ear pain, ear pain when chewing, ear stuffiness or ringing in the ears.
  • Pain above or “behind” the eyes, blurred vision.
  • Jaw pain or facial pain and/or tightness.
  • Neck pain and shoulder pain and pain to move the head.
  • Restricted ability to open the mouth.
  • A jaw that deflects to one side or the other upon opening.

No wonder TMD has been called the “great imposter”. Patients and providers are often confused by the wide range of symptoms. This often results in many unnecessary medical and dental office visits and much unnecessary treatment, with the associated increased cost, not to mention the frustration.




The Philosophy of Tmj Treatment

First, let’s discuss the term “TMJ” versus the term “TMD”. The three letters TMJ stand for the name of the jaw joint. It is named the temporomandibular joint. So… if you think about it, we all have “TMJ”. Actually, each of us is born with two of them, one on the left and one on the right, located just in front of your ear.

TMD stands for temporomandibular disorder. This term is currently the accepted term to describe the collection of symptoms and diseases that are generally found in our TMD patients. Now that we have agreed on that one, let’s talk philosophy.

temporomandibular joint

There is much controversy among health care professionals today concerning the appropriate methods for the diagnosis and treatment of TMD.  Each specialty group and special interest group within the health care field has developed their own diagnostic and treatment protocol.  Generally speaking, that protocol emphasizes the skills of that particular group… sometimes to the exclusion of all other groups.  In truth, TM Disorders is a multi-faceted and complex disease process, most often requiring a multi-faceted approach for complete and satisfactory resolution of the symptoms.

It is true that the TM Joints, and the associated musculature and ligaments comprise a unique system within the human body. The temporomandibular joint is called a ginglymo-arthrodial joint. Don’t let that big word scare you… it simply means that this joint is unique and different from all of the other joints in the body. Like all joints it permits movement by means of simple rotation, or hinge-like movement. However, this unique joint mechanism also allows translation… a sliding of the entire joint complex from it’s original starting point within the articular fossa of the temporal bone (joint socket), forward and laterally down the slope of the articular eminence. This unique design allows the shock absorbing mechanism of the joint, the articular disc, to move along with the bones in a coordinated fashion. This design also allows the jaws to assume an almost unlimited number of various jaw positions and postures. When the system functions correctly, a person is able to chew, speak, bite a fingernail, nip off a piece of thread, and open wide enough to eat a “Big Mac” sandwich. The TM joints are very adaptable. They can take an amazing amount of abuse. However, when they do not function as intended, a wide number of confusing symptoms can occur. This wide variety of symptoms have come to be lumped together and called a TM Disorder.




ginglymoarthrodial joint

When you go for treatment of a TM Disorder, you may be massaged, medicated, cut upon, stretched, twisted, manipulated, injected, consoled and counseled, adjusted, restored, straightened, and have your “bite” adjusted (equilibrated), depending on which special type of professional practice that you happen to consult. Often, the result is a frustrating lack of appropriate response. Finally, many of these confusing symptoms are heaped on the pile of hypochondria, and the patient is judged to have a mental disorder.

tmj muscles

My belief is that a dentist, with additional special knowledge in the field of cranio-facial pain, is uniquely qualified to treat TMD and to lead the treatment team. The reason for that belief is simple. In my opinion, what many practitioners in all of the other medical fields forget to consider when they provide their various treatments for TMD is the role that the teeth play in establishing the end point (tight meshing of the teeth) of closure. As you close your mouth, it is the position of the teeth that determines the final position of your lower jaw at tight closure. How does that affect treatment? Let me give you an absurd illustration.

As you read this… move your lower jaw as far as you can to the left side. Push it and hold it. Can you feel the strain that this jaw position places on your face and in front of your ears. Some of you who came to this site because you are having pain may actually feel increased pain as you try this little test. Now… try to imagine how you would feel every day if the position of your teeth was such that it drove you to this exaggerated position each time you closed your mouth. Should hurt…eh?

Now, suppose that my treatment plan was to give you anti-inflammatory medication for your pain. As long as your teeth continued to force you to return to this jaw position each time you closed your mouth…. the medication may make the pain may go away for awhile, but should you expect it to stay away? No. This is the foundation for my belief that the role of the dentition (teeth) must always be considered when treating TMD.

Although it is a unique joint mechanism, our belief is that in the final analysis, the TM Joint is just another joint. Why should the TM Joints be treated any differently than any other joint within the body? I believe that our diagnosis and treatment protocol, developed over the last fifteen or twenty years, is founded in good, orthopedic principals. CAUTION and COMMON SENSE are the by-words of this practice. A complete medical evaluation should always the starting point. Obviously, it is foolhardy to proceed without ruling out many of the life threatening pathologies. Fortunately, most of our patients have consulted many physicians prior to their coming here.

Following a negative medical evaluation, a complete and thorough head and neck examination must be completed. Once diagnosed, the initial treatment protocol should always involve NON-INVASIVE, REVERSIBLE procedures whenever possible. This point agrees completely with the recent statement of the National Institutes of Health on the management of tm disorders. The injured and abused joint structures should be stabilized to assist the natural healing capacity of the body. Muscle pathology should be addressed with mobility and strengthening exercises. Complicating factors, such as cervical (neck) dysfunction, nutritional deficiencies and skeletal deficiencies must also be addressed and corrected. Muscle spasms and inflammation should be eliminated. Appropriate referrals for physical therapy and stress management should be made as needed. These allied therapies must be coordinated and supportive in nature, with all therapists working as a team and communicating in the patients best interest.

My professional philosophy includes the notion that it is inappropriate to treat any but the most seriously ill of chronic pain patients with continuing medication. It has been my experience that this physical management, neuromuscular approach to treatment almost totally eliminates the need for ongoing medication.

I have found that treatment programs that involve the patient in their own recovery are always more successful. An extensive explanation of my findings and diagnosis will be provided for every patient. This question and answer session may often last twenty or thirty minutes. Armed with a vast amount of knowledge and understanding about their problem, the patient can actively participate in their treatment and recovery. From my clinical observation, I believe that, many times, this is the most important component that I include in my treatment protocol, and, in my opinion, it is the one that is most often overlooked by many clinicians.

Injured joints, muscles and ligaments heal slowly. Our patients are followed closely in this practice. Communication is an important part of recovery. Patients are followed weekly at first, and then in gradually fewer visits as we begin to see progressive improvement. Most patients are asymptomatic in a matter of two to three months. Following an appropriate healing time, which could be six months or longer, the patient is re-evaluated to determine the need, if any, for any additional treatment to stabilize and support the positive result.

So, in short, my practice philosophy is an ongoing evolution. I am very comfortable with change, if the reasons for that change can be demonstrated to be beneficial to the patients that we serve.

Tmj Treatment

About The National Institutes of Health

 

The National Institutes of Health is comprised of twenty-five separate Institutes and Centers. It is one of the eight health agencies that make up the U.S. Department of Health. Periodically, the NIH will make an exhaustive study of one of the many illnesses or diseases. These studies include a review of many various suggested treatments, and their statistical outcomes. In addition, research results from studies published in the scientific literature are added to the mix. The resulting document is reviewed and additions or deletions are suggested at many levels and by many health professionals, and then the finished product is finally published in a report that attempts to clarify treatments and expected results from that treatment.

As you might expect, with that many “experts” contributing to the final document, it sometimes becomes a very dilute, non-threatening product… a document that pleases no one and offends most who read it to some degree. But if the reader can overcome personal and professional bias, often there are statements contained in these reports that can give some direction to interested persons.

The National Institutes of health published a statement on The Management of Temporomandibular Disorders (TMD ). As you might expect, there was considerable disagreement among health professionals concerning the findings and recommendations made in this report.

With all of that said, I do find certain statements in this report to be helpful to the public when evaluating proposed treatment recommendations for temporomandibular disorders (TMD ). So in summary form, here are several statements taken from this report. A full copy of the report ( 23 pages ) can be found on the web site of NIH, which is located at https://www.nih.gov. I have occasionally added italics, bold type, or bracketed words for clarity and/or emphasis.

  •  “In clinical case series studies in which conservative, reversible, noninvasive therapy was emphasized, the presenting signs and symptoms appeared to improve in the vast majority of patients.”
  • “At present the evidence is insufficient to warrant prophylactic [preventative] intervention for management of TMD, nor are their data providing clear evidence that orthodontic treatment prevents, predisposes to, or causes TMD.  Even so, some practitioners have carried out occlusal adjustments [grinding on the teeth], extensive [crown and bridge] restorations, or management of joint sounds or displaced disks in the absence of pain or loss of function. Given current evidence, special emphasis should be placed on the avoidance of extensive restorative procedures to treat a disorder that may change over time.”
  •  “… caution is urged with regard to use of invasive and other irreversible treatments, particularly in the initial management of TMD.”
  •  ” Many experts recommend that patients undergo education directed at eliminating certain behaviors perceived to be harmful, such as clenching or grinding.  Some experts recommend exercise and stress management. Rest and dietary modifications may help some patients.”
  • ” Physical therapy applications to TMD include a wide variety of evaluative and treatment modalities that are commonly used in the treatment of other neurological and musculoskeletal disorders.  These therapies are generally conservative and non-invasive.  Benefits to TMD patients have been described…”.
  • “Stabilization splints [intraoral orthotics ] are considered non-invasive and reversible and are recommended by many experts for early treatment of these patients.”
  • “Occlusal therapies are aimed at modification of the occlusion [ bite ] itself through alteration of the tooth structure.  Given that this … therapy is irreversible, and given that the superiority of this treatment over reversible therapies has not been demonstrated…, this form of occlusal (bite) adjustment probably will not represent the best practice for initial management of TMD.”
  • ” It should be clearly realized that surgery is indicated in only a small percentage of patients.”

In all fields of medicine, things change over time. Treatments are used today that were unknown only a few years ago. These recommendations may well change as new and exciting information becomes available, and research proves it’s validity. In the meantime this report should lead the informed patient to proceed with caution when it comes to invasive and irreversible treatment recommendations.

Accidental Injuries- Tmj

Previously on this web site, we have been discussing the diagnosis and treatment of patients who are experiencing chronic pain. Unfortunately, some of our patients come to us following motor vehicle accidents or on-the job injuries. These people are usually suffering from acute TMD pain… that is, pain of sudden onset, usually trauma related.

Recent published studies seem to confirm that as many as 80% to 85% of the persons involved in rear-end or side collision auto accidents suffer an injury to the TM Joint mechanism. Then, add to that number the many persons who are injured on-the-job. Unfortunately, often these injuries go unnoticed and untreated for months following the accident. Finally, as the other injury symptoms are eliminated, the headache, facial, neck and ear pain associated with TMD injury becomes more obvious. Too bad… because often that delay complicates the treatment and slows the complete recovery of the patient.

car accident

Another very interesting fact has recently been confirmed by at least two published studies. Direct impact of the face and jaw IS NOT necessary to dislocate and injure your jaw in a car wreck. Studies published by Garcia and Arrington and a second one by Pressman both found positive MRI evidence of injury to the TM Joints following a motor vehicle accident in which there was no direct trauma to the face and jaws of the patient. So… if your insurance company is attempting to deny you coverage because you “did not hit your jaw or face”, we now have scientific evidence that they should not disallow coverage based on that presumption.

Physicians who initially evaluate injured victims in the office or emergency room should be aware of the strong possibility of injury to the temporomandibular joints and make appropriate referrals for evaluation at the time of initial examination. Attorney’s representing injured clients should also be alert to the following list of complaints :

  • A “new” popping or grinding sound when the jaw is moved.
  • Persistent headaches, neck and shoulder pain.
  • Ear pain, ringing in the ears, dizziness and blurred vision.
  • Chewing pain or a dramatic change in the “bite”
  • Reduced ability to open the mouth.
  • Numbness of the hands or fingers.
  • Tenderness over the TM Joints.

Remember… many of these symptoms are reported by the patient initially, but they are passed over as the “normal” expected pain associated with the accident. The patient will always confirm that the onset of the symptom is directly related to the time of the injury. At the time of accidental injury, patients are usually placed on medication and told that they should give it some time. But… when these complaints do not resolve as expected, a consultation with a dentist TMD expert should be considered. These injuries could well represent permanent damage, loss of function, altered function, and a permanently altered lifestyle which should be objectively documented for the patient and reported to the appropriate sources.

Fortunately, many of these severe pain symptoms can be controlled with proper management. If the injury report is negative for fractures in the emergency room examination, then surgery is usually only necessary in a small percentage of cases. Most of the pain conditions and lifestyle changes can be managed in a conservative, non-invasive fashion.

In the legal setting, knowledge of Impairment Rating is another important issue. By definition, Permanent Impairment measures the un-resolved symptoms after appropriate treatment has been provided for an appropriate period of time. In this practice, I usually rate Impairment using the two most accepted methods… the rating system of the AMA Guides, fourth edition, and the method developed and published in the Journal of Craniomandibular Practice (CRANIO) by Phillips, et al. Again, by definition, any Impairment Rating must await the outcome of treatment and the comparison of objective testing prior to and following that course of treatment.

Life with Tmj

After a thoughtful review of the information contained in this post, I hope that you will agree with me that most TMD patients can be placed in two very broad categories..

  • those suffering from an acute injury

and…

  • those who are suffering from a painful chronic condition.

Usually, a persons lifestyle does not often contribute to an acute injury (things like sky diving are the exception to this rule). Acute injuries happen when we fall at work, or become involved in an automobile accident or some other type of sudden traumatic event. With appropriate treatment, most of these acute injury patients can quickly be returned to their pre-accident condition. The chronic pain patient presents a more complicated set of conditions.

car accident

It often strikes me as surprising how most of the patients with this chronic painful condition seem to feel that TMD is an illness that has come upon them, perhaps caused by a bacteria, a virus, or the environment, much like a sinus infection or seasonal allergy. Frequently, some will comment that they do realize that stress plays a role in the severity of their condition, yet most of them never give any thought to how they can reduce the stress and tension in their daily life and thereby, become an active participant in the successful management of their chronic pain condition.

Often I will say to these patients that, basically, there are two general types of personality… those who yell, break plates and otherwise outwardly express their frustration and anger… and those who turn those feeling inward. I confess that my personality is the latter. My mother was a proper woman from the old South, as was her mother before her. She raised me to understand that it is not proper for any person to “show out” in public. Because of her training, I tend to internalize my emotions. For example, you will only know that I am upset about something when I get very quiet. And, because of that trait, I will someday have my heart attack, or ulcers, and I daily clench and brux my teeth together. In other words, my stress can cause me physical harm if I do not learn how to manage it. And, many of my patients are the same way.

stress

Stress is not busyness. All of us are busy now days. A “soccer mom”, who has three children, each one due at three different soccer games at exactly the same moment in time, is really busy. But… if that mom enjoys her children and enjoys being an involved mom, she is really busy, but she is not particularly stressed. However, if that mom wishes that dad was helping her manage that busy schedule, and if dad is at home on the sofa watching TV with his favorite beverage in hand… THAT IS STRESS!!!

Life has gotten busy. Leisure time for the family has fallen steadily over the last decade. In most families, it now takes both parents working full time just to make ends meet and to provide the things that most families want and deserve. Often our own personal wants and needs are placed second to the needs of the family. That is an admirable trait, but… most people can not continue in that fashion for too long without eventually feeling some resentment at always coming in second place.

Everyone needs to take some time out of every day to enjoy something that they want to do. Maybe it is a warm slow bath, maybe it is a few minutes to read, write a letter, or call a friend. Some people take a quick “cat nap” during the mid day break at work. Others like to exercise, walk, ride a bike, or just sit outside, daydream and breathe the fresh air. Whatever it is… if it makes you feel good, it helps.

Following are just a few quick suggestions that I have picked up over the years. There is no way to make a complete list, because your list should be personal to you… the things that you like to do. These ideas are offered just to get you thinking in the right direction…

Control the habit of tooth clenching and grinding.

Practice keeping your lips relaxed, teeth apart and tongue relaxed for one minute six times per day.

This is the rest position for the lower jaw. Do not place your tongue between the teeth… this may cause muscle fatigue.

The teeth should only touch together for about four to five minutes per day. This is total time and includes all chewing and swallowing time. Too much more than that can strain and overwork muscles.

Practice slow rhythmic breathing.

Breathe slowly and regularly from your diaphragm. As you inhale, your stomach should move up and out. When you exhale, your stomach should move in as you slowly let the air out.

Slow your breathing rate by counting to three as you inhale. Then count to six as you exhale and pause before inhaling again. This will increase the levels of carbon dioxide in the blood which has a positive effect on the amount of oxygen that gets to your brain.

You are now learning diaphragmatic breathing, which will help to restore normal blood chemistry and helps to relax muscles. This is the way we are supposed to breathe.

Slow, deep breathing is very relaxing, but it takes some time to re-learn.

Monitor Head Position.

Find a comfortable chair. Sit down, shoulders relaxed, place open hands on thighs without crossing your legs. Keep your feet flat on the floor and your head upright. Close your eyes if it is comfortable to you.

While you practice your lips relaxed and teeth apart, exhale and pause while slowly bending your head forward without causing pain.

Then inhale slowly and bring your head upright. Pause 1 second before exhaling and bending your head forward again. Repeat this process six times per minute.

Do not bend head sideways or bend so far forward that you cause pain. Remember that the head is supposed to be upright on even relaxed shoulders. When you move it, you should use both sides of your neck muscles evenly.

This neutral head position prevents neck muscle fatigue and pain.

To straighten rounded shoulders.

Raise your hands up as if conducting a choir. Move arms and shoulders forward and back without causing pain.

Repeat six times in 30 seconds.

You are learning neutral, upright shoulder position and increasing circulation to the area.

Take relaxation breaks.

Start with 5 minute relaxation periods and slowly increase them until each session is 20 minutes long.

Take at least two 20 minute breaks per day.

You are learning to take periods of rest where the mind allows the body to take a break and rest.

Begin your sleep in a relaxed position.

Lay on your back and practice slow rhythmic breathing while keeping your lips relaxed and your teeth apart.

Say out loud “I will not clench or grind my teeth”.

Picture yourself asleep with a relaxed jaw and lips.

Start sleeping on your back, but don’t worry if you move.

These exercises work best if you follow the following additional rules.

  • Eat healthy and take plenty of liquids. Drink enough water to float a boat.
  • Do not cause pain, but push as far as you can to increase mobility.
  • Reduce or eliminate alcohol intake.
  • Eliminate smoking and the use of tobacco products. Nicotine causes constriction of the blood vessels and prevents optimum muscle health and function.

Be patient. It takes time to reverse unhealthy habits.

Practice number 1, 3, and 4 above six times per day. Practice number 2 and 5 anytime. Practice number 6 before going to sleep.

Let me remind you that stress often plays a real role in a chronic pain condition, but it is rarely the only factor contributing to the problem. Learning and practicing relaxation techniques will help, but for a lasting result, you must also discover and correct the underlying physical causes of the pain. Don’t let anyone suggest to you that “it is all in your head”, or “if you would just relax everything would be OK”. The person making that suggestion is not knowledgeable enough and/or they have not looked deeply enough to adequately and thoroughly diagnose your condition.

Finally, lets talk briefly about store bought mouth guards, now available in many stores. Those mouth guards might protect your teeth and dental work from the harmful effects of tooth grinding and/or a clenching habit. But… if you are suffering pain, (and you probably would not be reading this if you weren’t hurting) it is too late for a “niteguard” or “mouth guard” to be of any benefit. Find someone who can really identify the reasons for the pain and get some professional help.

I hope you have found this article helpful. If you have any questions or comments please leave it below. I would love to hear from you.

Wishing you joy and healing,

Dr. Sid A. Holleman, Jr.

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