TMJ Disorder

TMJ (temporomandibular joint) disorders are a family of problems related to your jaw joint. If you have had symptoms like pain or a "clicking" sound, you'll be glad to know that these problems are more easily diagnosed and treated than they were in the past. These symptoms occur when the joints of the jaw and the chewing muscles (muscles of mastication) do not work together correctly.  TMJ stands for Temporomandibular Joint, which is the name for each joint (right and left) that connects your jaw to your skull.

TMJ disorders develop for many reasons. You might clench or grind your teeth, tightening your jaw muscles and stressing your TM joint. You may have a damaged jaw joint due to injury or disease. Injuries and arthritis can damage the joint directly or stretch or tear the muscle ligaments.  As a result, the disk, which is made of cartilage and functions as the "cushion" of the jaw joint, can slip out of position. Whatever the cause, the results may include a misaligned bite, pain, clicking or grating noise when you open your mouth or trouble opening your mouth wide.

Since some types of TMJ problems can lead to more serious conditions, early detection and treatment are important. No one treatment can resolve TMJ disorders completely and treatment takes time to become effective. DSI specialists can help you have a healthier and more comfortable jaw.

Diagnosis

 The diagnosis of a TMJ problem can be based on both patient history and diagnostic procedures.  Common history questions to address include:      

• Are you aware of grinding or clenching your teeth?

• Do you wake up with sore, stiff muscles around your jaws?

• Do you have frequent headaches or neck aches?

• Does the pain get worse when you clench your teeth?

• Does stress make your clenching and pain worse?

• Does your jaw click, pop, grate, catch, or lock when you open your  mouth?

• Is it difficult or painful to open your mouth, eat or yawn?

• Have you ever injured your neck, head or jaws?

• Have you had problems (such as arthritis) with other joints?

• Do you have teeth that no longer touch when you bite?

• Do your teeth meet differently from time to time?

• Is it hard to use your front teeth to bite or tear food?

• Are your teeth sensitive, loose, broken or worn?            

The more times you answered "yes," the more likely it is that you have a TMJ disorder. Understanding TMJ disorders will also help you understand how they are treated.

Managing TMD

Because there is no known "cure" for TMD, people with TMD manage their disorder in a way that is similar to how people with arthritis or diabetes manage their disease. The goals of managing TMD include decreasing harmful pressure or loading on the jaw joints, restoring function of the jaw and resuming normal daily activities. These goals are best achieved by identifying all factors that make your TMD worse and following a well-defined management program to treat both physical and emotional or psychological factors.

Managing TMD is similar to other musculoskeletal disorders found in the body (such as rheumatoid arthritis or carpal tunnel syndrome). Like many musculoskeletal conditions, the signs and symptoms of TMD may be temporary without serious long-term effects. For these reasons, special effort should be made to avoid aggressive or nonreversible therapy such as surgery, extensive dental treatment or orthodontic treatment.

Conservative management techniques such as behavior modification, physical therapy, medication, jaw exercise and orthopedic appliances (orthotics) have proven to be safe and effective in most patients with TMD. Most patients suffering from TMD achieve good long-term relief with conservative therapy. Scientific research demonstrates that more than 50% of TMD patients treated with conservative management have few or no ongoing symptoms of TMD.

Patient Self-care

If you have TMD, there are ways to care for yourself.

• Limit opening your jaw (yawning, etc.) no further than within a pain free range.
• Rest your jaw by avoiding heavy chewing (e.g. gum, bagel, tough meats).
• Avoid grinding and clenching of your teeth by keeping the teeth slightly apart and the jaw relaxed.
• Avoid leaning or sleeping on the jaw.
• Avoid tongue thrusting and chewing fingernails or non-food objects.
• Avoid playing wind, brass and string instruments that stress, retrude or strain the jaw.
• Use ice packs or moist heat compresses as directed by your doctor or physical therapist.
• Use over-the-counter medications such as aspirin, ibuprofen, naproxen or acetaminophen as directed.

Behavioral Intervention

Behavioral intervention is often necessary to help people change harmful behavior or habits that contribute to pain. Maladaptive behavior and persistent habits such as tooth clenching or nail biting may play a significant role in making TMD symptoms worse or last longer. You may be able to control such behavior and habits once you become aware that you are doing them, but a behavior modification program developed and monitored by a trained expert often is necessary for long-term control. Clinical behavior modification programs may include habit reversal programs, lifestyle counseling, progressive relaxation, autogenic training, hypnosis and biofeedback. Programs combining comprehensive stress management, progressive relaxation, lifestyle modification and biofeedback often yield the best long-term result.

Psychological or emotional conflicts can be a major part of TMD and chronic pain behavior. Your doctor may refer you to a mental health professional such as a psychologist or psychiatrist for evaluation and treatment while you undergo physical treatment.

Physical Therapy

Physical therapy performed by a licensed physical therapist is well recognized as an effective and conservative treatment for musculoskeletal disorders such as TMD. Physical therapy helps in identifying and reducing contributing factors to musculoskeletal problems, reducing inflammation, restoring function and promoting repair and regeneration of injured tissues.

Physical therapy techniques may include spinal, head, jaw and tongue posture training.

Exercises prescribed by the physical therapist or doctor are important to maintain normal muscle and joint function and comfort, improve joint range of motion, increase muscle strength, develop normal coordination and stabilize the TMJs. Exercises should be specifically prescribed and monitored by your physical therapist or doctor as improper or excessive exercise therapy can aggravate TMD symptoms.

Techniques to manually move the jaw (mobilize) may be helpful for people with decreased range of motion and pain related to jaw muscle contracture, disc displacement and adhesion in the joints. A patient usually has to use pain relievers and muscle relaxation techniques before his or her physician can mobilize the jaw.

Other types of physical treatment options for TMD management include:

• electrotherapy, such as electrogalvanic stimulation (EGS), transcutaneous electrical nerve stimulation (TENS) and microcurrent,
• ultrasound,
• anesthetic agents, such as Vapocoolant spray or a topical pain reliever and
• stretching and
• massage.

Medications for TMD

Medications can be very effective in reducing pain and inflammation. The most effective drugs for managing pain related to TMD include

• Non-narcotic analgesic drugs such as acetaminophen (Tylenol).
• Non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, Trilisate, ibuprofen, naproxen and prescription strength NSAIDS.
• Muscle relaxant drugs such as methocarbamol (Robazin), orphenadrine citrate (Norflex) metaxalone (Skelaxin) or cyclobenzaprine (Flexeril).
• Tricyclic anti-depressant medications such as amitriptyline (Elavil), nortriptyline (Pamelor) and doxepin (Sinequan).
• Short-term use of opioid medications such as tramadol, codeine, propoxyphene or hydrocodone.

All medications have specific benefits and side effects. The extended use of opioid medications and sedative psychotropic drugs such as Valium, Xanax, and Ativan may lead to depression, drug tolerance and addiction, although addiction is rare. Use of these medications, which often give temporary relief from pain, is discouraged for long-term pain management.

Occlusal Therapy

Occlusal therapy involves changing the bite to reduce pressures in the joint. These therapies include orthodontics, surgery, placing multiple crowns or other dental restorations, or selective grinding on the teeth (equilibration). Since poor occlusion is not a common cause of TMD, using irreversible bite changes to treat TMD is usually not necessary, and not well supported by research. There are cases, however, that require permanent bite changes in order for their joints to stabilize.

Oral Orthopedic Appliances

Oral orthopedic appliances are routinely used in TMD management. Oral orthopedic appliances are commonly referred to as occlusal splints, orthotics, night guards or bruxism appliances. Oral orthopedic appliances are usually made from hard acrylic, are removable and cover the upper or lower teeth. Oral orthopedic TMD appliances are designed to redistribute the occlusal forces (the bite), prevent wear, reduce mobility of teeth, reduce bruxism/clenching, reduce jaw muscle pain and alter structural relationships within the TMJ.

All oral orthopedic appliances should be periodically checked and adjusted by an experienced dentist as the potential exists for harmful changes to the teeth and jaws if improperly used. Complications such as dental caries, gingival inflammation, mouth odors, speech difficulties, tooth movement and psychological dependence on the appliance can occur with excessive or incorrect use of oral orthopedic appliances.

TMJ Arthrocentesis

Arthrocentesis is also known as joint aspiration, a procedure during which a specially trained dentist uses a sterile needle and syringe to drain fluid from a joint. TMJ arthrocentesis consists of using a pain reliever to numb (anesthetize) the affected TMJ with local anesthetic and then flushing the joint with a sterile solution such as Lactated Ringers Solution. The effect of TMJ arthrocentesis is to lubricate the joint surfaces and reduce inflammation. Corticosteroids or other anti-inflammatory agents can be injected into the joint following arthrocentesis. Gentle manipulation of the jaw is often utilized following arthrocentesis to improve the jaw range of motion and in some cases break fibrous adhesions that limit normal jaw opening.

TMJ Surgery

TMJ surgery can be an effective treatment for specific joint disorders for some patients. The complexity of surgical techniques, potential for serious complications, frequency of behavioral and psychological contributing factors and the availability of non-surgical approaches make TMJ surgery a procedure that should be used on very select patients. TMJ surgery should only be considered after reasonable reversible treatment techniques have been tried without success.

TMJ surgical procedures include closed surgical techniques (arthroscopy) and open surgical techniques (arthrotomy), as well as total joint replacements.

TMJ arthroscopy may be effective in treating painful joint hypomobility secondary to displaced discs, fibrous adhesions and arthritis. TMJ arthroscopic surgery has significant limitations related to the limited size of the arthroscopic instruments and limited space within the joint. Recent studies suggest that TMJ arthrocentesis may be as effective as TMJ arthroscopic surgery.

TMJ arthrotomy (open joint surgery) may be required in severe fibrous adhesion removal, ankylosis (bony or fibrous), tumor removal, chronic dislocation, painful non-reducing disc dislocation and severe osteoarthritis that have not responded to less invasive treatments such as medications and physical therapy. TMJ arthrotomy may range from simple removal of adhesions, disc repair or replacement to total joint replacement using cartilage and bone grafts or vitallium metal implants. Patients with TMD should be aware that there is no guarantee for successful surgical outcome and should seek several expert opinions before deciding on TMJ surgery.

Total joint replacement is available for advanced cases of TMD with considerable joint damage.

This information was produced by the American Academy of Orofacial Pain (www.aaop.org). Adapted and printed with permission of the American Academy of Orofacial Pain.