A recent article “Development of temporomandibular disorders is associated with greater bodily pain experience” published in the the Clinical Journal of Pain shows that the development of TMD also leads to widespread pain throughout the body (abstract below). The study was done at the University of North Carolina at Chapel Hill by the Center for Neurosensory Disorders. The 3 year study looked at 266 female patients who were free of TMD symptoms and almost 6% developed TMD symptoms. The patients who developed TMJ symptoms also developed widespread body pain including Headaches, Migraines,Muscle Pain and Soreness, Joint Pain or Soreness, Back Pain, Chest Pain, Abdominal Pain and Menstrual Pain. This is not at all surprising. Two seminal articles published in Cranio on TMJ disorders by Shimshak et al showed a 200-300% increases in medical expenses in every field of medicine in patients carrying a TMD diagnosis. These incredibly important studies imply that prevention of TMD disorders can dramatically decrease medical expenses. These studies were statistical analysis of insurance claims. The current study is a prospective study that shows that total body pains accompany onset of TMD (TMJ) symptoms. Another study by ABDEL-FATTAH RA showed that patients missing one or more first molars had a 100% increase in symptoms of headache, migraine, ear ache, sinus pain, jaw pain and TM Joint pain.
If removal of a single tooth can result in TMD symptoms and if the onset of TMD symptoms increases widespread body pain as well as causing 300% increases in all medical expenses that it is reasonable to believe that early treatment of TMD problems can avoid disastrous outcomes. TMD is often referred to as “The Great Imposter” as discussed in a Sleep and Health Journal Article “SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTOR” http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor Early treatment utilizing Neuromuscular Dentistry may eliminate this wide spread problem but preventing central sensitization and correcting posture, breathing, deglutition, swallowing and normalizing other physiologic processes.
The NHLBI (National Heart Lung and Blood Institute) of the NIH (National Institute of Health) considers Sleep Apnea to be a TMJ disorder. Sleep apnea is also known to have negative effects on all physiolgical aspects of health. Should all patients with TMD be evaluated for sleep disorders and should all patients with sleep apnea and snoring be evaluated TMD, I believe this should probably be the case for most patients. The American Academy of Sleep Medicine recognizes this fact and now recommends in their parameters of care for obstructive sleep apnea that oral appliances be considered a first line treatment for mild to moderate sleep apnea and a secondary treatment for severe apnea when patients do not tolerate CPAP. They also recommend that dentists treating sleep apnea have expertise in treating TMD. This makes Neuromuscular Dentists ideal for treating TMD and Sleep Apnea and Snoring. An excellent site to learn about the danger of sleep apnea and treatment alternatives emphasizing Dental Sleep Medicine is http://www.ihatecpap.com
Neuromuscular Dentistry is the science of treating TMD and the neuromuscular trigeminal disorders and was created by Dr Barney Jankelson. A new Website http://www.ihateheadaches.org is dedicated to helping patients find relief of Migraines, Chronic Daily Headaches (CDH), Tension-Type Headaches, Sinus Headaches, Episodic Tension Type Headaches (ETTH), Cluster Headaches, Morning Headaches, Facial Pain and TMJ disorders and is one of the best sources on the Web to learn about Neuromuscular Dentistry. There is an excellent article on “Neuromuscular Dentistry” that was originally published by The American Equilibration Society and has been reprinted in Sleep and Health Journal at http://www.sleepandhealth.com/topics/story-topic/neuromuscular-dentistry.
Almost all chronic headache conditions are related to Trigeminal nervous system malfunction and that is why this author believe that due to the low risk of negative side effects with the Neuromuscular Dentistry approach to headache should precede use of dangerous medications. Well Neuromuscular Dentistry cannot always eliminate the need for medication can usually dramatically decrese it as well as ramatically improve the quality of patients lives.
Dr Barry Cooper, a past president of ICCMO published recent papers in Cranio that showed an “overwhelmingly positive response” when treating headaches and TMD with neuromuscular dental techniques. Dr Ira L Shapira is the founder of the Ihateheadaches.org website and practices general dentistry at Delany Dental Care Ltd (www.delanydentalcare.com) in Gurnee, Il. In addition to his Gurnee dental office he has also founded Chicagoland Dental Sleep Medicine Associates (http://www.chicagoland.ihatecpap.com/) with offices in Skokie, Schaumburg, Vernon Hills, Bannockburn and Chicago. Dr Shapira has been practicing Neuromuscular Dentistry and Dental Sleep Medicine for over 30 years as part of his General Dental Practice. He is a Diplomate of the American Board of Dental Sleep Medicine and is a pioneer in the field of Dental Sleep Medicine. He is a charter member of the Sleep Disorder Dental Society which became the American Academy of Dental Sleep Medicine and a Founding member of DOSA, The Dental Organization for Sleep Apnea. He is the treasurer of ICCMO, the International College of CranioMandibular Orthopedics and the representative of ICCMO to the Alliance of TMD Organizations (TMD ALLIANCE) that represents all of the important TMD organizations including the AES (American Equilibration Society), ICCMO, The American Academy of Craniofacial Pain, The IACA, the International Academy of Comprehensive Asthetics that combines TMD, Neuromuscular Dentistry with asthetics, The American Academy of Pain Management (AAPM). Dr Shapira is a member of each of those organizations and has spoken at several. Dr Shapira is also a Fellow of ICCMO and a Diplomate of The AAPM. The TMD Alliance is working to promote better insurance coverage for TMD patients.
The following information about TMD disorders is reproduced from Wikipedia:
“”Signs and symptoms of temporomandibular joint disorder vary in their presentation and can be very complex-but are often simple. On average the symptoms will involve more than one of the numerous TMJ components: muscles, nerves, tendons, ligaments, bones, connective tissue, and the teeth. Ear pain associated with the swelling of proximal tissue is a symptom of temporomandibular joint disorder.
Symptoms associated with TMJ disorders may be:
Biting or chewing difficulty or discomfort
Clicking, popping, or grating sound when opening or closing the mouth
Dull, aching pain in the face
Jaw pain or tenderness of the jaw
Reduced ability to open or close the mouth
This is arguably the most complex set of joints in the human body. Unlike typical finger or vertebral junctions, each TMJ actually has two joints, which allow it to both rotate and to translate (slide). With use, it is common to see wear of both the bone and cartilage components of it. Clicking is common, as are popping motions and deviations in the movements of the joint. It is considered a TMJ disorder when pain is involved.
In a healthy joint, the surfaces in contact with one another (bone and cartilage) do not have any receptors to transmit the feeling of pain. The pain therefore originates from one of the surrounding soft tissues. When receptors from one of these areas are triggered, the pain causes a reflex to limit the mandible’s movement. Furthermore, inflammation of the joints can cause constant pain, even without movement of the jaw.
Due to the proximity of the ear to the temporomandibular joint, TMJ pain can often be confused with ear pain. The pain may be referred in around half of all patients and experienced as otalgia (earache). Conversely, TMD is an important possible cause of secondary otalgia. Treatment of TMD may then significantly reduce symptoms of otalgia and tinnitus, as well as atypical facial pain. Despite some of these findings, some researchers question whether TMD therapy can reduce symptoms in the ear, and there is currently an ongoing debate to settle the controversy. The dysfunction involved is most often in regards to the relationship between the condyle of the mandible and the disc. The sounds produced by this dysfunction are usually described as a “click” or a “pop” when a single sound is heard and as “crepitation” or “crepitus” when there are multiple, rough sounds. Teeth
Disorders of the teeth can contribute to TMJ dysfunction. Impaired tooth mobility and tooth loss can be caused by destruction of the supporting bone and by heavy forces being placed on teeth. The movement of the teeth affects how they contact one another when the mouth closes, and the overall relationship between the teeth, muscles, and joints can be altered. Pulpitis, inflammation of the dental pulp, is another symptom that may result from excessive surface erosion. Maybe the most important factor is the way the teeth meet together: the equilibration of forces of mastication and therefore the displacements of the condyle.
There are many external factors that place undue strain on the TMJ. These include but are not limited to the following:
Over-opening the jaw beyond its range for the individual or unusually aggressive or repetitive sliding of the jaw sideways (laterally) or forward (protrusive). These movements may also be due to parafunctional habits or a malalignment of the jaw or dentition. This may be due to:
Repetitive unconscious jaw movements called bruxing.
Malalignment of the occlusal surfaces of the teeth due to dental defect or neglect.
Jaw thrusting (causing unusual speech and chewing habits).
Excessive gum chewing or nail biting.
Size of foods eaten.
Degenerative joint disease, such as osteoarthritis or organic degeneration of the articular surfaces, recurrent fibrous and/or bony ankylosis, developmental abnormality, or pathologic lesions within the TMJ
Myofascial pain dysfunction syndrome
Lack of overbite
Expression of too much JAW Micro RNA due to a genetic variation. Treatment
If the occlusal surfaces of the teeth or the supporting structures have been damaged due to dental neglect, periodontal diseases or trauma, the proper occlusion should be restored. Pain relief
While conventional analgesic pain killers such as paracetamol (acetaminophen) or NSAIDs provide initial relief for some sufferers, the pain is often more neuralgic in nature, which often does not respond well to these drugs. An alternative approach is for pain modification, for which off-label use of low-doses of Tricyclic antidepressant that have anti-muscarinic properties (e.g. Amitriptyline or the less sedative Nortriptyline) generally prove more effective. Long-term approach
It is suggested that before the attending dentist commences any plan or approach utilizing medications or surgery, a thorough search for inciting para-functional jaw habits must be performed. Correction of any discrepancies from normal can then be the primary goal.
An approach to eliminating para-functional habits involves the taking of a detailed history and careful physical examination. The medical history should be designed to reveal duration of illness and symptoms, previous treatment and effects, contributing medical findings, history of facial trauma, and a search for habits that may have produced or enhanced symptoms. Particular attention should be directed in identifying perverse jaw habits, such as clenching or teeth grinding, lip or cheek biting, or positioning of the lower jaw in an edge-to-edge bite. All of the above strain the muscles of mastication (chewing) and results in jaw pain. Palpation of these muscles will cause a painful response.
Treatment is oriented to eliminating oral habits, physical therapy to the masticatory muscles, and alleviating bad posture of the head and neck. A flat-plane full-coverage oral appliance, e.g. a non-repositioning stabilization splint, often is helpful to control bruxism and take stress off the temporomandibular joint, although some individuals may bite harder on it, resulting in a worsening of their conditions. The anterior splint, with contact at the front teeth only, may then prove helpful. This method of treatment is often referred to as “splint therapy.”
According to the National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH), TMJ treatments should be reversible whenever possible. That means that the treatment should not cause permanent changes to the jaw or teeth. Examples of reversible treatments are:
Over-the-counter pain medications, used according to manufacturers’ instructions.
Prescription medications prescribed by a healthcare provider.
Gentle jaw stretching and relaxation exercises you can do at home. Your healthcare provider can recommend exercises for your particular condition, if appropriate.
Feldenkrais TMJ Program, uses a unique understanding of human neurology to reduce chronic tension in the jaw, face, neck, and upper back, and to reverse long-standing movement habits responsible for the original TMJ symptoms.
Stabilization splint (biteplate, nightguard) is the most widely used treatment for TMJ and jaw muscle problems; however, the actual effectiveness of these splints is unclear. If an oral splint is recommended, it should be used only for a short time and should not cause permanent changes in the bite. If a splint causes or increases pain, stop using it and tell your healthcare provider. Avoid using over-the-counter mouthguards for TMJ treatment. If a splint is not properly fitted, the teeth may shift and worsen the condition.
Mandibular Repositioning (MORA) Devices can be worn for a short time to help alleviate symptoms related to painful clicking when opening the mouth wide, but 24-hour wear for the long term may lead to changes in the position of the teeth that can complicate treatment. A typical long-term permanent treatment (if the device is proven to work especially well for the situation) would be to convert the device to a flat-plane bite plate fully covering either the upper or lower teeth and to be used only at night. According to an article on Quackwatch.org, MORA devices are considered the most widley used option although the scientific validity has not been proven.
What may be concluded is that there are various treatment modalities which a well-trained experienced dentist may employ to relieve symptoms and improve joint function. They include :
Manual adjustment of the bite by grinding the teeth (occlusal adjustment). This, too, is not a widly accepted practice and should be avoided as it is irreversible.
Mandibular repositioning splints which move the jaw, ligaments and muscles into a new position and myofunctional therapy
Arthrocentesis (joint irrigation)
Surgical repositoning of jaws to correct congenital jaw malformations such as prognathism and retrognathia
Replacement of the jaw joint(s) or disc(s) with TMJ implants (This should be considered only as a treatment of last resort.)
Attempts in the last decade to develop surgical treatments based on MRI and CAT scans now receive less attention. These techniques are reserved for the most recalcitrant cases where other therapeutic modalities have changed. Exercise protocols, habit control, and splinting should be the first line of approach, leaving oral surgery as a last resort. Certainly a focus on other possible causes of facial pain and jaw immobility and dysfunction should be the initial consideration of the examining oral-facial pain specialist, oral surgeon or health professional. One option for oral surgery, is to manipulate the jaw under general anaesthetic and wash out the joint with a saline and anti-inflammatory solution in a procedure known as arthrocentesis. In some cases, this will reduce the inflammatory process.””
Clin J Pain. 2010 Feb;26(2):116-20.
Development of temporomandibular disorders is associated with greater bodily pain experience.
Lim PF, Smith S, Bhalang K, Slade GD, Maixner W.
Center for Neurosensory Disorders, School of Dentistry, University of North Carolina at Chapel Hill, NC 27599-7455, USA. firstname.lastname@example.org
OBJECTIVES: The aim of this study is to examine the difference in the report of bodily pain experienced by patients who develop temporomandibular disorders (TMD) and by those who do not develop TMD over a 3-year observation period. METHODS: This is a 3-year prospective study of 266 females aged 18 to 34 years initially free of TMD pain. All patients completed the Symptom Report Questionnaire (SRQ) at baseline and yearly intervals, and at the time they developed TMD (if applicable). The SRQ is a self-report instrument evaluating the extent and location of pain experienced in the earlier 6 months. Statistical analysis was carried out using repeated measures ANOVA. RESULTS: Over the 3-year period, 16 patients developed TMD based on the Research Diagnostic Criteria for TMD. Participants who developed TMD reported more headaches (P=0.0089), muscle soreness or pain (P=0.005), joint soreness or pain (P=0.0012), back pain (P=0.0001), chest pain (P=0.0004), abdominal pain (P=0.0021), and menstrual pain (P=0.0036) than Participants who did not develop TMD at both the baseline and final visits. Participants who developed TMD also reported significantly more headache (P=0.0006), muscle soreness or pain (P=0.0059), and other pains (P=0.0188) when they were diagnosed with TMD compared with the baseline visit. DISCUSSION: The development of TMD was accompanied by increases in headaches, muscle soreness or pain, and other pains that were not observed in the Participants who did not develop TMD. Participants who developed TMD also report higher experience of joint, back, chest, and menstrual pain at baseline.
The following information about Neuromuscular Dentistry is reproduced from Wikpedia:
“”Neuromuscular dentistry is a dental treatment philosophy in which temporomandibular joints, masticatory muscles and central nervous system mechanisms are claimed to follow generic physiologic and anatomic laws applicable to all musculoskeletal systems. It is a treatment modality of dentistry that focuses on correcting “misalignment” of the jaw at the temporomandibular joint (TMJ). Neuromuscular dentistry acknowledges the multi-facted musculoskeletal occlusal signs and symptoms as they relate to postural problems involving the lower jaw and cervical region. Neuromuscular dentistry claims that “misalignment problem(s)” can be corrected by understanding the relationships of the tissues involved, which include muscles, teeth, temporomandibular joints, and nerves. In short, proponents of neuromuscular dentistry claim that it adds objective data and understanding to previous mechanical models of occlusion.
Symptoms of temporomandibular joint disorder (TMD) are claimed to include :
Headaches / migraines
Back, neck and shoulder pain
Tinnitus (ringing in the ears)
Trigeminal neuralgia (tic douloureux), a neuropathic pain disorder unrelated to TMD
Bell’s Palsy, a nerve disorder unrelated to TMD
Sensitive and sore teeth
Limited jaw movement or locking jaw
Numbness in the fingers and arms (related to the cervical musculature and nerves, not to TMD)
Worn or cracked teeth
Clicking or popping in the jaw joints
Jaw joint pain
Tender sensitive teeth
A limited opening or inability to open the mouth comfortably
Deviation of the jaw to one side
The jaw locking open or closed
Postural problems (forward head posture)
Pain in the joint(s) or face when opening or closing the mouth, yawning, or chewing
Pain in the muscles surrounding the temporomandibular joints
Pain in the occipital (back), temporal (side), frontal (front), or infra-orbital (below the eyes) portions of the head
Pain behind the eyes
Swelling on the side of the face and/or mouth
A bite that feels uncomfortable, “off,” or as if it is continually changing
Older Bells palsy
Neuromuscular dentistry uses computerized instrumentation to measure the patient’s jaw movements via Computerized Mandibular Scanning (CMS) or Jaw Motion Analysis (JMA), muscle activity via electromyography (EMG) and temporomandibular joint sounds via Electro-Sonography (ESG) or Joint Vibration Analysis (JVA) to assist in identifying joint derangements. Surface EMG’s are used to verify pre-, mid- and post-treatment conditions before and after ultra-low frequency Transcutaneous Electrical Nerve Stimulator (TENS). By combining both computerized mandibular scanning (CMS) or jaw motion analysis (JMA) with ultra-low frequency TENS, the dentist is able to locate a “physiological rest” position as a starting reference position to find a relationship between the upper and lower jaw along an isotonic path of closure up from the physiologic rest position in order to establish a bite position. Electromyography can be used to confirm rested/homeostatic muscle activity of the jaw prior to taking a bite recording. Once a physiologic rest position is found, the doctor can determine the optimal positioning of the lower jaw to the upper jaw. An orthotic is commonly worn for 3-6 months (24 hours per day) to realign the jaw, at which point orthodontic treatment, use of the orthotic as a “orthopedical realigning appliance”, overlay partial, or orthodontic treatment and/or rehabilitation of the teeth is recommended to correct teeth and jaw position.
Because of the additional training needed and the complex computer systems and hardware required, neuromuscular dentistry is more expensive than conventional dentistry. The costs can range from $3,500 to $25,000 for usually four to six months, and up to one year or more of treatment for complex cases. (This does not include any additional orthodontics or restorative treatment).”” The Las Vegas Institue of Advanced Dental Studies or LVI has endorsed Neuromuscular Dentistry and is one of the major organizations teaching Neuromuscular Dentistry. Dr Norman Thomas has taken the realm as head of research at LVI and together they are advancing the science. LVI has a leading Dentist wegsite that lists neuromuscular dentists as does ICCMO. Dr Shapira has founded http://www.ihateheadaches and hopes that he will soon have doctors across the country listed who can treat headaches, migraines and TMJ disorders with neuromuscular dental techniques
There is no current TMJ specialty or TMD specialty recognized by the American Dental Association (ADA) Dental specialists include Orthodontists and Oral and Maxilofacial surgeons who occasionally treat TMJ disorders but most dentists who treat TMJ disorders are licensed general dentists. Oral surgeons are usually only involved in surgical treatments. Dr Shapira treats patients from across Illinois and Wisconsin and sees patients from Gurnee, Libertyville, Vernon Hills, Schaumburg, Barrington, Lake Forest, Palatine,Highland Park, Deerfield, Lake Bluff, Kenosha, Milwaukee, Racine, Madison, Rockford, Chicago and Southern Illinois. He has patients who have come from Texas, Colorado, Florida and New York and makes special arrangements for their stays at a local hotel and country club where he hold his courses on Dental Sleep Medicine for dentists from across the U.S.
Addition information on Neuromuscular Dentistry,TMJ,TMD,TMJD,Migraines ,Tension Headaches, Fibromyalgi, Sleep Apnea, obstructive sleep apnea, snoring and chronic pain can be found at the links provided above.