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April 20, 2017
It’s not unusual for patients to tell us they “have TMJ.” The correct response to this would be: “Yes, indeed, you have two of them.”
“TMJ” is an acronym, for Temporomandibular Joint; these are the two jaw joint bones, known as the temporal and mandible bones. What these patients are actually referring to are abnormalities in the head, neck, jaws, ears, sinuses, throat, jaw joints and teeth. There may also be clicking and popping in the jaw joints on opening, closing and chewing; lock jaw (inability to open) or migraines. Pain involving the muscles of the face, head and neck may also be present. The proper diagnostic term for these conditions is Temporomandibular Disorder or “TMD.”
Often patients with a history of these symptoms have sought relief from their family doctor. They may have been prescribed pain pills or muscle relaxants, with little or no improvement. If there are ear problems, such as ringing or pressure in the ears, patients may also have been referred to ENT specialists or neurologists, also without resolution. After a while patients start to feel frustrated, perhaps even questioning the reality of their symptoms.
It should be stated that it is entirely appropriate for your dentist to address these issues. The right approach is for a thorough evaluation of the patient’s intraoral and extraoral situations, and asking the right questions about their condition to determine an accurate diagnosis. An explanation to understand the cause of this pain should follow.
TMD is multifactorial and typically there is a definite cause and effect relationship between the painful symptoms and an imbalance in the function of one or more of the structures of the head and neck: teeth, bones, jaw joints, muscles, ligaments. The undiagnosed pain causes stress, emotional issues, and worry, which then in turn, makes the clinical condition worse, often resulting in a vicious cycle.
Depending on how long the symptoms have been present, most are readily treatable or manageable with time. However, occasionally, clinical conditions require referrals to specialists within the professional dental community.
Often there is visible relief in a patient’s face when they learn that the condition is relatively common. And, as the findings are explained, they are reassured that we can help. Often they say “when do we start?”
Part 2: TMD – Temporomandibular Disorders
Recently I attended a seminar on TM Disorders entitled “TMD patients are ‘NUTS'” – an acronym for “Not Understanding Their Symptoms.” What followed was a breakdown of the reasons this is occurring.
In chronic low grade pain situations, patients may be tolerating pain without even realizing anything is wrong. Provided the overall body pain stays below a certain threshold, minor injuries are tolerated. If an accident or pain situation occurs, which in and of itself may not be severe, the result can be a raising of the cumulative pain levels in the body, to over their threshold, and then everything hurts. This is also typical of patients diagnosed with Fibromyalgia. Treatment of the precipitating event results in a return to normal pain levels.
TMD patients typically present facing one or more of the following symptoms:
1. Headache pain in the base of the neck; a squeezing pain like a vice on one or both the sides of temple areas of their head; frontal pain in the forehead area and behind their eyes or pain in and around both jaw joints on opening or closing; with or without clicking.
2. Pain starts in one area and radiate to make other areas hurt, or even make it feel like specific teeth hurt, when in fact they healthy.
3. Pain is worse when they awaken and gradually subside, as the day goes on. Or pain starts slowly and progresses to peak later in the day.
4. Pains can be vague and diffuse or very localized to a specific firm and hard to touch muscle area.
5. Ear pain, with or without ringing.
6. Throat pain present on one side or both sides. There may be fullness and pressure in their ears and inability to clear and pop their ears.
7. Cheek or Side Facial Pain, getting worse during chewing or clenching. Specific teeth may also be very tender to touch or when chewing.
Treating TMD patients is a balancing act. Some books suggest that there might be a TMD personality and these can vary as well. For example, a very precise patient may be unable to tolerate the smallest abnormality while a more relaxed personality is able to tolerate a higher level.
Patients dispositions vary on any given day too. An example of this is when a “bad bite” condition (teeth, bone and muscle imbalances) can be tolerated when someone is on holidays and relaxed. A change occurs when the same person returns to a daily routine of high stress. That is when the increased pressure on the “bad bite” can be overwhelming and cause pain.
Part 3: How is Facial Pain Managed?
Because there are so many interrelationships between the various TM disorders, every aspect must be considered in the evaluation, diagnosis and treatment of patients. Often it is difficult to identify which disorder came first.
Pain in the TMJs can lead to pain in the muscles, because they are “tightening and splinting” to try and protect the painful movement of the jaw. With time, this can lead to muscle spasms in the opening and closing jaw muscles. This increases pressure on the joint discs, and causes pressure on the bony surfaces of the joint. This in turn can cause a decrease in the mobility of the joint; affecting the patient’s ability to open. In this scenario, the question should be asked: “Is there history of trauma to the face and the joints?” Often the patient will tell us: “Yes, but I didn’t come to the dentist because I thought the pain would go away.” Therefore trauma is the cause of the problem. Had this been diagnosed early and treated, it could have alleviated the subsequent ongoing issues.
If the cause of muscle pain is due to a poorly fitting bite, refinement of the bite by the minor reshaping of the teeth permits the teeth to fit together more accurately, and allow the symptoms to subside. Alternately, for serious bite discrepancies, treating with orthodontic braces may be the more appropriate solution to moving the teeth into proper position.
Fabricating a plastic bite splint is another option to relieve the muscle spasms and protect the teeth from poor biting forces. These splints also allow muscles in spasm to return to normal. The splint is adjusted to allow all the teeth to bite on it as evenly as possible, with the TMJs in their most comfortable position possible. These splints are particularly indicated for patients who are known to be clenchers and grinders. Often, these will promote the retraining needed for the patient to eliminate their grinding/clenching action. Further, the splint protects the teeth by decreasing the grinding forces on opposing teeth. Grinding patients often indicate that “I’ve become accustomed to the splint, so having it in my mouth at night helps me get a good night’s sleep.”
Emotional stress therapy may be indicated. There is evidence that increased levels of anxiety, fear and stress can create increased frequency of grinding and clenching of teeth. These abnormal activities stretch the thin ligament that attaches each tooth to the bone, causing significant pain.
With TMJ disorders, as with all medical conditions, proper evaluation is the key. Asking all the right questions leads to an accurate diagnosis and the appropriate treatment.
This multi-part series addressing TMD has been prepared by Santé – Highbury Dental’s Dr. Clarence Cormier.