This blog is reprinted from my Highland Park, Il website www.thinkbetterlife.com. Additional information is also available at www.IHateHeadaches.org (and on my blog of that site) and at www.delanydentalcare.com my Gurnee office website.
I am a firm believer in utilizing the concepts of Neuromuscular Dentistry. If you are not in my area and are looking for a neuromuscular dentist visit: http://occlusiontmjauthority.com
This is not meant specifically for my office but rather a guideline for how dentists should evaluate patients for TMJ disorders starting from the easiest night guards and moving to more complex treatment modalities.
The Best treatment for a TMJ disorder is very dependent on the exact symptoms and causes of the TMJ disorder in a particular patient. Determining the best treatment for an individual patient is usually done during a face to face visit but I can give several guidelines here.
Night Guard Treatment:
If you only have pain at night or just after awakening you are probably a good candidate for a Bruxism Appliance. These are designed to protect the teeth during nocturnal grind or bruxism.
This type of appliance is very effective for people who grind their teeth but can frequently cause more pain in patients who clench because it can createmore forces during clenching.
Clenching and grinding of the teeth during sleep is often associated with Sleep Disordered Breathing, including Snoring, RERA, UARS or Upper Airway Resistance Syndrome, Hypopnea or Apnea. These are dangerous conditions that can be made worse in some patients by a typical night guard.
Morning Frontal Headache and daytime tiredness are associated with sleep disordered breathing. Dentists trained in treating sleep disordered breathing can be found at AADSM.org .I have taught hundreds of dentists the basics of sleep apnea treatment. Ideally, a diplomate of the American Board of Dental Sleep Medicine is your first choice.
The NHLBI or National Heart Lung and Blood Institute considers Sleep Apnea to be a TMJ Disorder.
Patients who have an acute close-lock of one or both TMJoints are Emergency patients. The wrong treatment can lead to permanent disability and the development of chronic pain syndromes. Short term treatment is described below, long term stabilization will be discussed later.
An acute close-lock of one or both TMJoints can be evident upon wakening or may occur during the day. This is a type of Internal Derangement of the TMJoint. Patients who have chronic clicking or popping of one or both joints can have the disk get stuck anterior to the condyle of the mandible.
The symptoms for a unilateral close-lock of the TMJoint is reduced opening and sharp pain in the joint on the locked side. Attempting to open further gives increased pain and the jaw deviates to the side of the lock. If clicking was present previously it usually will be gone on the effected side.
The disk or meniscus is displaced and the condyle is pressing on the very delicate Retrodiscal Laminate. Trying to force the jaw open can permanently damage this important tissue.
Emergency Rooms are notorious for forcing the jaw open and causing increased pain and damage. For several years I taught emergency room physicians how to reduce close-lock dislocations. It is essential to support the jaw and prevent full closure or even a properly reduced joint can easily relock.
Many dentists and oral surgeons will place patients on a soft diet and prescribe non-steroidal anti-inflamatories such as Advil, Alieve or Aspirin. This is extremely risky approach to treating a close-lock. The longer the lock continues the more likelihood of permanent joint damage to the disk and retrodiscal lamina and the development of chronic pain.
The best approach is to reduce the dislocation as soon as possible and immediately supporting the bite with a temporary support to prevent recurrent locking. Unfortunately most dentists have no idea how to reduce a locked joint. The reduction can be done with jaw manipulation either awake or sedated. Acute close-lock can often be reduced easily by stimulation of specific reflexes in the jaw and pharynx.
Various appliances can be used to prevent damage and ease the reduction of more difficult locks these include unilateral pivotal splints for a lock in just one joint or a Rocobado spring loaded appliance for bilateral locks
Acute Open-Lock Dislocation or Subluxation
This is caused by a hyperextension of the jaw during opening. It can happen from a yawn or biting ito very thick sandwich. It can also occur immediately following a motor vehicle accident, usually being rear-ended. It can also happen after difficult dental procedures and/or extractions especially of lower molars.
The condyle of the mandible actually moves out of the norman joint position and extends past the eminence where it gets stuck. The patient will usually notice pain on the effected side and only 1 or 2 back teeth will touch on closing. This tends to be frightening initially.This is again an Emergency, however this is easily treated at the ER in the hospital.
Patients with open locks need to learn not to hyperextend and to control maximum opening. Prolotherapy can be used to tighten up the ligaments and tendons for a more stable joint that cannot hyperextend. Surgery is another option usually best avoided.
This is another condition that occurs frequently in cheerleaders, hence the name. Shouting and cheering for a long time hyperextends the joint and it can create an open lock situation described above. Sometime this will self reduce but there can be tremendous pain with jaw movement. This is primarily muscle overuse pain and rest, stretching and anti-inflammatory medications is the best road. It is vitally important to rule out close-lock and open lock conditions to avoid problems.
Post Dental Treatment: Medial Pterygoid Myositis, Myalgia/Myosits
These conditions can occur following dental work and can be secondary to injections, inflammation joint or muscle tearing or stretching etc.
There is very little opening similar to a close lock but this is due to tight shortened muscles. Time and anti-inflamatories can help. There are variations of what is the cause, Muscle Splinting is a normal physiologic process where the muscles tighten up to protect an injured area. Unfortunately, this can become chronic muscle shortening with muscle tightness, taut bands and trigger points. Muscle Spasm is usually very painful but short in duration. It is like a “Charlie Horse” of the jaw muscles. Myositis is the slowest to resolve and is related to inflammatory changes in the muscle and can be quite painful. Time, anti-inflamatories and stretching while icing helps.
FIBROMYALGIA AND MYOFASCIAL PAIN AND DYSFUNTION are two specific groups of muscle pain that must be included in this discussion of what is the best treatment.
All of the above conditions respond extremely well to Ultra Low Frequency TENS (ULF-TENS) There are two units available for ULF-TENS the Myomonitor from Myotronics and and the BioTens from BioResearch. No other TENS should be utilized.
These conditions also respond well to physical therapy, massage therapy and other manual techniques as well as ultrasound, interferential and micro current. An Aqualizer Appliance ™ can be excellent short term treatment.
It is essential to determine if a close-lock internal derangement is also present. Delay can lead to permanent damage.
Long-Term Chronic TMJ Dysfunction
TMJ is often called the Great Imposter due to the many associated symptoms that accompany the TMD
There are numerous types of appliances available including centric occlusion, centric relation and neuromuscular orthotics. There is a specialized type of appliance called an NTI which has specific though limited uses. Appliance can be made for the upper or lower arch. Ideally, an appliance should always look and feel comfortable for 24/7 wear including for using while eating even if it is not to be worn all the time. Frequently separate appliances are needed to treat sleep disorders breathing.
Doctors treating difficult cases should have additional training and expertise in a wide range of fields. I suggest visiting doctors who are a Diplomate of The American Academy of Pain Management and the American Board of Dental Sleep Medicine. Neuromuscular Dentists should be member of ICCMO, the International College of CranioMandibular Orthopedics. Centric relation dentists should belong to The American Equilibration Society though the best dentists belong to both groups and look at all aspects of treatment.
There are treatments that are often essential elements of complete treatment including management of trigger points with Spray and Stretch Techniques, Trigger Point Injections and /or manual techniques, Utilization of SPG or Sphenopalatine Ganglion Blocks, and coordination with Specialists in dealing with the Occipital-Atlas-Axis joints, usually Atlas-Orthoganol or NUCCA Chiropracters or Osteopaths.
Jaw problems are related to breathing, airway and posture so experience in DNA Appliances is very helpful for TMD dentists. Ideally, dentists treating TMJ disorders have a method of non-invasively seeing jaw function with computerized mandibular scans from Myotronics or BioResearch.
An absolute requirement of any doctor treating TMJ disorders is one who sets up time for a consultation reviewing your medical history, evaluating what has previously been done and how it worked. Your doctor should be able to clearly explain how all the different symptoms are related. The best TMJ doctors can usually relieve muscle and headache pain temporarily while you are in the office, welcome your questions make you feel comfortable and never talk down to you.
The best TMJ Dentists are people you feel comfortable talking to. The first visit will usually start in the consult room not the dental chair. Acute close locks will usually quickly move to treatment room. It is vitally important that you do not feel intimidated by your doctor, the best results occur when the patient and doctor work as a team to address problems.
Ideally, no permanent changes are made initially but rather treatment begins with a diagnostic orthotic. The goal of initial treatment is to relieve symptoms as quickly as possible and to understand the underlying etiology of the problem. Equilibration of the teeth is usually avoided until the patient is comfortable and a treatment plan is accepted. Wanton grinding on teeth can create new problems and it is hard to “ungrind a tooth” That said, brand new dental work that caused the problem sometime may need adjustment. The safest area of adjust is on the front teeth if they hit first but a diagnostic orthotic is still the best starting point.
Long term treatment should be discussed at the initial consultation but is only considered after resolution of pain and dysfunction.