TMJ Disorder Treatment
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Temporomandibular joint (TMJ) disorder affects an estimated 10 million Americans. TMJ disorder is characterized by pain relating to the joints on either side of the jaw, or a compromise in the ability to make normal jaw movements. It can occur for a number of reasons, and there is a range of TMJ disorder treatments, both conservative and extensive, designed to address patients' specific needs.
Neuromuscular dentistry focuses on discovering the optimal positioning of a patient's jaw, and achieving harmony between the jaws, muscles, nerves, and soft tissues. I have been incorporating neuromuscular dentistry techniques in my practice since 2003, and this discipline is making tremendous strides in helping many patients find solutions for TMJ disorder.
If the misalignment of the jaws is found to be the cause of a patient's TMJ disorder, treatments like coronoplasty (reshaping of tooth enamel), placement of certain dental restorations, and even simple lifestyle changes can potentially provide relief. As with any health condition, patient education is a fundamental element of treatment. If you familiarize yourself with the basic principles TMJ disorder, and how specific treatments apply, you and your dentist or physician can determine a way to successfully restore your comfort, peace of mind, and quality of life.
Anatomy of the Temporomandibular Joint
The TMJs connect the jaw to the skull, and they are the most frequently used joints in the body. The part of the jaw bone (mandible) that connects to the skull is called the mandibular condyle. The two uppermost points on either side of the jaw resemble a horseshoe, and the mandibular condyle is side of the horseshoe that reaches the highest. The section of the skull that connects to the mandibular condyle is called the articular surface of the temporal bone, and it lies parallel to the ear. The articular disk, which consists of flexible cartilage, acts as a cushion between these two surfaces as the jaw opens and closes. It could be compared to what happens when you stand on the ball of your foot: the ground is like the temporal bone, your foot is like the condyle, and the sole of your shoe is like the disk, providing a buffer between the two components. A capsule, or fibrous membrane, surrounds both joints, and an intricate system of muscles and tendons controls their movement, allowing the jaw to open, close, and move side to side.
Causes of TMJ Disorder
One of the most common causes of TMJ disorder is an eroded or misaligned articular disk, and it can occur for a number of reasons, including arthritis and trauma. The disk itself can move forward from its proper position, pulling sensitive connective tissue (retrodiscal tissue, which carries the blood supply to the disc) into the point of connection between the mandible and skull. When this happens, the condyle must move over the back end of the disk as the jaw opens, resulting in a clicking or popping sound. The disk itself does not contain nerve endings, but the retrodiscal tissue does. Therefore, when the disk becomes fully dislocated and fails to return to its proper position, it can be quite painful. However, in many cases, a process called natural adaptation occurs. The retrodiscal tissue can develop scar tissue that gives it the same fundamental consistency as the disk. At this point, the tissue can serve the same purpose as the disk, cause little or no pain, and allow the jaws to open and close as normal. A physician may prescribe various pain management strategies as natural adaptation takes place.
In other cases, symptoms of TMJ disorder occur because the upper and lower teeth do not meet properly, and the muscles governing the movement of the jaw must overcompensate to create the best balance possible. This requires prolonged strain that can eventually result in headaches, as well as neck, shoulder, and facial pain. Often, an imbalanced bite is the result of nighttime teeth grinding that places considerable stress on the jaw muscles, and eventually damages the structure of the teeth. It can also occur as a result of natural dental misalignment.
Treating TMJ Disorder: The Neuromuscular Dentistry Approach
As a neuromuscular dentist, I primarily treat patients whose TMJ disorder symptoms are caused by a misaligned bite. I studied neuromuscular dentistry with Ralph Garcia Jr., D.D.S., who practices in Tampa and mentors dentists in TMJ disorder treatment. He says in his 39 years of practicing dentistry, the outlook has never been better for those suffering with TMJ disorder.
"Due to the advances in electrodiagnosis, magnetic resonance imaging, and computerized tomography, along with a better understanding of the problems that beset the TMJ disorder patients, the future for these patients is extremely optimistic," he said. "Neuromuscular electrodiagnostic equipment provides a more scientific and comprehensive evaluation of the TMJ disorder patient that helps unearth any muscle dysfunction, and any qualitative or quantitative anomalies in jaw movement or function."
The ultimate goal of a neuromuscular dentist is to help the patient find a permanent solution that relies on his or her own teeth, usually by making alterations to the bite. I begin by using advanced diagnostics to identify any undue strain on the muscles and tendons.
Diagnosis: Identifying the Cause of TMJ Disorder
Your body is obsessed with what goes on with your teeth at all times. In fact, about 45 percent of the entire motor center for the upper brain controls what happens on the face, and most of that activity is dedicated to maintaining a comfortable balance between the upper and lower jaws.
I use special software to track how the muscles behave when the patient moves his jaw
Because the muscles suffer the greatest in cases of TMJ disorder relating to jaw misalignment, I use special software to track how the muscles behave when the patient moves his jaw. As with an electrocardiogram, which uses special leads to read heart activity, I place leads on the temple and neck. Using a K7 biomonitor, I can accurately detect overactivity in the upper jaw. I look to see what those muscles are being asked to do in order to maintain the balance of the jaw. This involves three primary components:
- Computerized mandibular scanning (CMS) assess the precise movements of the jaw. It guages both lateral and vertical tension, and can determine if the jaw is following a smooth path, or a path compromised by tension or friction.
- Electromyography (EMG) measures the activity of muscles at various jaw positions. EMG can detect if muscles are tense when they should be relaxed, and helps determine the proper jaw position.
- Sonography measures the sound of the TMJ as it opens and closes, and can detect friction or sudden shifting of jaw components.
When we determine those values, we place the patient on transcutaneous electrical nerve stimulation (TENS). This device delivers a very mild electrical charge that calms the muscles. This overrides short-term muscle memory, allowing these muscles to fully relax.
At this point, I can analyze the true relationship of the upper and lower jaws, and determine how the jaws should meet in order to avoid straining these muscles. I recommend subsequent treatment based on the conditions obstructing the proper meeting of the jaws.
Orthotics: Re-educating the Muscles and Tendons
Once the proper positioning of the jaws has been determined, they must remain in that position for a period to allow the muscles and tendons to heal. Orthotics are custom-made appliances that fit over the patient's teeth, keeping the jaws in their proper position. They are completely ergonomic, and designed to look like the patient's natural teeth. They can be either fixed or permanent. A fixed orthotic will help the patient heal faster, because it does not allow the teeth to return to the improper position. Healing takes longer with a removable orthotic, though this is a more affordable option. Some patients just want a crutch so that they don't hurt every day, and decide that they would rather have a removable orthotic.
When the muscles and tendons have completely healed, it is time to consider making a permanent change to the bite in order to maintain comfort and oral health. The orthotic serves as a guide during the next stage of treatment, which will involve either reshaping the teeth, placing prosthodontics, using orthodontics, or combining these procedures for full mouth reconstruction.
Coronoplasty: Changing the Shape of the Teeth
In some cases, the shape of a tooth can affect the alignment of the jaws. Coronoplasty is a process of removing some tooth enamel to refine the shape of the tooth, allowing the jaws to meet properly. However, very few cases can be treated with tooth reshaping alone.
Orthodontics: Moving Teeth into Proper Alignment
Straight teeth are an aesthetic asset, but more importantly, they contribute to good oral health, and allow the jaws to meet properly. Orthodontics involves using various appliances to gradually guide the teeth into proper alignment. The traditional method uses metal brackets and wires that apply gentle pressure to the teeth, usually over a period of one to two years. Tension is adjusted over the course of treatment, correcting malocclusions. Often, orthodontics are combined with coronoplasty to help the jaws achieve proper alignment.
Prosthodontics and Full Mouth Reconstruction
Custom dental restorations, or prosthodontics, can make a significant difference in how the jaws meet. Crowns are tooth-shaped caps most often used to restore a tooth after it has been treated for trauma or decay. If a patient is missing a tooth, a crown can be used to restore a dental implant, which is a titanium post surgically inserted in the jaw to replace lost tooth roots. Bridges (also called partial dentures) are similar to crowns, but are designed to replace several consecutive teeth.
In addition to replacing or restoring teeth, crowns and bridges can correct the balance of your bite. Crowns and bridges are specially crafted to achieve a natural appearance and a shape that achieves harmony with the opposing teeth, resulting in a balanced bite.
In some cases, the placement of crowns and bridges alone can help patients achieve the balance necessary to treat TMJ disorder. However, more frequently, they are combined with some tooth reshaping or orthodontics treatment to best meet the patient's specific needs.
Case Study: Helping Amanda Overcome Migraines and Muscle Paralysis
Amanda is a patient who came to my office because she needed a dental crown. When I first met her, I noticed that her face had begun to slide down on the left side. She had been tested for Bell's Palsy (a form of facial paralysis) and undergone MRIs, but in the end, she was told she had neuropathy (dysfunction of the nerves), and there was nothing more that could be done. She also explained that she had suffered with migraine headaches for many years. I suggested that she undergo a TMJ screening with me, and I detected severe alignment issues in her bite due to improper positioning of teeth in the lower jaw.
I had braces when I was a kid...The doctors just made my teeth look good, but they didn't make my bite work for me
"I had braces when I was a kid," Amanda said. "The doctors just made my teeth look good, but they didn't make my bite work for me."
She remained skeptical that TMJ disorder was to blame for her migraines and the issues with her facial muscles, but she was willing to wear a custom orthotic that would place her jaw in the proper position.
"Within two months, I had no more headaches," Amanda said. "My face also started getting better a little at a time. I just didn't have an issue when I wore the orthotic. The pain would come right back when I'd remove the orthotic to eat. I decided I would never be able to wean myself off of it."
I prescribed braces to achieve permanent realignment of her teeth. She completed orthodontic treatment last fall, and is continuing to live free of of migraines. Meanwhile, her facial muscles have almost completely returned to their proper position.
"If you have consistent migraines, neuromuscular dentistry is perhaps an opportunity to get rid of them permanently," she said.
After TMJ Disorder Treatment: Maintaining Relief
Bruxism is the clenching or grinding of the teeth. It can be an unconscious function, and can occur during the day or night. In many cases, bruxism is the cause of the dental damage or skeletomuscular strain that accompanies TMJ disorder. Often, when a patient has completed treatment for TMJ disorder, I will provide a custom sleep appliance that fits over the teeth and any restorations, protecting them from the effects of bruxism and helping the patient to achieve more restful sleep. TMJ disorder treatment is a significant investment in your health and quality of life, and a sleep appliance can help you maintain your refined bite.
TMJ disorder can cause serious physical and emotional pain for patients. The headaches, neck and shoulder pain, and other symptoms can make patients feel irritable and depressed, in addition to feeling physically uncomfortable. Many patients who begin TMJ disorder treatment continue to experience painful symptoms in the early stages of treatment.
Many patients who begin TMJ disorder treatment continue to experience painful symptoms in the early stages of treatment
In some cases, muscle relaxers or pain medication may be the best solution. However, I am personally more inclined to prescribe pain management solutions such as hot and cold compress therapy.
I sometimes prescribe dry needling, a technique similar to acupuncture, in which a very thin needle is inserted into a trigger point, or muscle knot, to relieve generalized musculoskeletal pain. Wet needling, a variation of this treatment involving the injection of saline through the needle, may be recommended in some cases. Ultrasound can also be very effective in relaxing strained muscles. Sometimes simple changes such as eating softer foods can cause a significant reduction in pain.
Meanwhile, it is important that TMJ disorder sufferers take measures to maintain a positive mental attitude. I tell patients that if they start obsessing about their pain, they should engage in a healthy distraction, such as taking a walk outside. I often recommend making simple changes in a patient's daily routine to engage the mind and avoid concentrating on their discomfort.
These changes often include starting to exercise or enjoy other relaxing activities. You have probably noticed that in times of tension or anxiety, you clench your jaws. By taking time to exercise or become immersed in tranquil hobbies like painting or playing a musical instrument, patients can actually lower their overall stress level, resulting in reduced strain on the TMJs and their governing muscles and tendons.
It is possible that a patient will not achieve relief through dental, non-invasive, or minimally invasive treatments. There are surgical treatments for TMJ disorder, but they are controversial because there are no long-term clinical studies to determine the effectiveness or safety of this approach. If your dentist or physician recommends surgery, make sure the procedure and its risks are fully explained, and consider soliciting a second opinion.
Achieving Relief from TMJ Disorder
TMJ disorder is complicated, and its symptoms can take a significant toll on your quality of life. If you are experiencing a popping or clicking sound in your jaw, headaches, facial pain, back and neck pain, or other symptoms that seem to have no clear cause, it is definitely worth discussing with your dentist. Today, more dentists are becoming educated in TMJ disorder. If your dentist is unable to diagnose TMJ disorder, he or she may be able to refer you to a physician or specialist who can identify the cause of your symptoms. Your best bet is to seek treatment as soon as you notice symptoms. With early diagnosis, your dentist or physician can help restore your comfort and your peace of mind.
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