TMJ: Symptoms, Diagnosis, and Treatment
Temporomandibular joint disorder (TMJ or TMD) is a painful, common and often misdiagnosed condition concentrated in the intricate network of joints, muscles, nerves and bones where the lower jaw connects to the skull. Hence the name "Temporomandibular Disorder." It is the disrupted relationship between the temporal bone and the mandible. In other words, if the bite, or jaw position is out of alignment you may have a number of nagging symptoms that are missed your doctor. TMJ may be your problem, and treatment by a trained, Dentist may be your answer.
Different health care providers will recommend different treatment alternatives because, the truth is, most specialists look at a problem through the eyes with which they were trained. In other words, a chiropractor says it's because your joints are out of alignment. The physical therapist says your posture needs correcting. The surgeon wants to surgically correct the misplaced disc. Your dentist dismisses it or tells you not to worry. A family doctor doesn't know or prescribes medication. And a neurologist prescribes more medication.
However, If TMJ dysfunction results in the symptoms below, why not treat the disorder rather than masking it with medications? Why treat is surgically if it's a correction of posture rather than anatomical disease? Why re-align it chiropractically if it will only slip back out again? The idea is to correct the original SOURCE of the problem, and not just mask the symptoms.
THE VAST MAJORITY OF CONTEMPORARY EVIDENCE STATES THAT TMJ/TMD SYMTOMS ARE A RESULT OF A JAW MIS-ALIGNMNT OR BAD BITE.
When the jaw alignment is out, the muscles that brace and move the jaw, the joint or hinge that articulates the jaw along with the disk, and the nervous system that innervates the jaws go into disarray resulting in many of the following symptoms:
The chronic symptoms associated with TMJ can lead to depression and progressive dental problems. Over time, symptoms can worsen and may even become debilitating. Most people suffering from TMJ experience multiple symptoms that may seem unrelated. Your symptoms may include:
Migraine headaches are different than muscle-tension headaches. The medical definition of migraine is a severe headache lasting from a couple hours to a couple of days. Migraine is commonly accompanied with nausea or vomiting, visual disturbances, and extreme pain. Unfortunately, there is no medical test to diagnose whether someone is a migraine sufferer. A medical doctor simply asks a series of questions and based on the subjective report of the patient, a diagnosis is made. Furthermore, rarely are any follow-up questions as to why certain persons are prone to migraines and others not.
Migraines are a result of biochemical compounds called CGRP (Calcitonin Gene Related Peptide) and Serotonin. Disturbances in the major nerve (Trigeminal) responsible for the movement of the jaw can cause the release of CGRP at the nerve's nucleus.
Facial, neck, shoulder, and back pain
It is well accepted in the medical field that 80-90% of headaches are muscle-tension-related. Meaning, when the muscles are not in balance or torqued, this causes ischemia (lack of blood flow) and subsequent lactic acid and other metabolite build-up. This is similar to what is experienced after heavy exercise or weight lifting. A large percentage of headaches sufferers will feel headache pain around the temples and at the back of the head at the base of the skull. These two areas are major insertion points for two of the most common groups of muscles responsible for the position of the head and mandible. When these are constantly strained, or out of alignment, which is what occurs 24 hours a day, headache pain is inevitable in many patients.
Jaw tension and pain
Most pain, as reported in the medical literature and based on tens of thousands of cases, is from the muscles. As the position of the bite dictates the torque and strain of the muscles, decreased blood flow and waste bi-products including lactic acid accumulate causing pain. This is why it's so critical to establish a proper relaxed or tonus position of the muscles of the jaw and neck. Tonus is the ideal muscle length for optimum performance, corrected physiology, and even esthetics. Corrected muscle length via neuromuscular TMD treatment often and usually results in a more relaxed and balanced facial profile.
Clicking or popping of the jaw
Similar to other joints in the body, there exists a piece of cartilage between the bones of the jaw (mandible) and skull (temporal bone). A family dentist or doctor often dismisses the problem or tells you not to worry. Would you be concerned if the cartilage in your knee was slipping in an out of place every time you walked? While popping or clicking of the jaw may seem innocent, it can often become painful and debilitating as the cartilage dislocates day after day. Similar to hinges on a door, if the door is not shutting properly, the hinges may wear and tear. Fortunately, unlike door hinges, if the popping and clicking is treated early enough, and depending on the situation, many times the joint will "heal".
Sticking or locking of the jaw
Sticking or locking is usually the result of the cartilage disc being so far out of joint that it blocks the joint from opening; or the muscles that move the jaw are in such spasm (tight) due to continual jaw imbalance, that the jaw can no longer open or close properly. Over time this clicking may go away becoming a grating or scratching sound as the disc breaks down and arthritic changes occur. Many times, a bone on bone contact occurs further causing joint breakdown and sometimes pain.
Earaches or ringing ears
If an ENT (ear nose and throat physician) or family doctor cannot find a definitive diagnosis for ringing in the ears, sometimes this is a result of TMJ dysfunction or TMD.
When the jaw is out of alignment a couple things can happen: The jaw can pull on a tiny ligament that connects the disc to one of the bones of the inner ear. Similar to a guitar sting being wound too tight, this can cause a high-pitched frequency or ringing. Another cause may be the tension of the muscles of the back of the throat the wrap around the ear canal. Again, high tension can create high frequency resonance and be perceived as ringing.
Premature tooth wear or bone loss
Teeth are like the gears that align the mandible (lower jaw) to the maxilla (top jaw). If this relationship is not in balance, wear and tear of the gears is very likely. Just as a car's tires will wear and tear prematurely if the car is out of alignment, the relationship between the two jaws needs to be corrected in order to keep the teeth from wearing or breaking prematurely.
Difficulty chewing or swallowing
A mal-aligned jaw or bad bite immediately causes torque and strain on the upper muscles of the back of the throat. This is called the oropharynx. When one swallows, the constrictor (tightening) muscles of the oropharynx squeeze the food down into the esophagus. Now, imagine a garden hose that is already twisted. How much more difficult is it to pass water through it? It can often be done, but it's more difficult and more constricted. Muscles of the mandible join the muscles of the oropharynx via a connective band called the pterygomandibular raphe. If excess strain is placed on this junction, difficulty swallowing can be the result.
The lower jaw or mandible is the only jaw that moves. The mandible is connected to the upper jaw or skull via muscles. This is similar to strings coordinating and controlling a puppet. TMD causes the muscles (strings) to lose coordination due to torquing, fatigue and lack of balance. It therefore becomes difficult for the central nervous system to control the muscles and coordinate proper aligning of the teeth to chew.
Numbness and tingling in the hands and fingers
Up to a one third of all TMD sufferers can have tingling or other sensations in their hand or fingertips, and often report a weakened grip. These paresthesia-type sensations and lack of strength are a result of diminished control or pinching of the nerves under the arm pit. This branch of nerves is call the brachial plexus and exits the spinal column at C 4-6 passing between the scalene muscles. If the neck is twisted or tilted, a subsequent shoulder tilt results and the scalene muscles get pinched. This sends a tingling or weakening sensation to the hand and finger-tips.
Just has moving the top link of a chain causes the rest of the chain to compensate, distorations of the top "ling" or the TMJ can cause postural changes down the entire body. Imagine a sharp pebble in bottom of your shoe. This would cause you to avoid stepping on it and therefore walk funny with a raised hip on that side. Your body would compensate to stay balanced by twisting the spine. A similar phenomenon happens with the noxious interference or problem starts from the top and works its way down.
Because many TMJ symptoms are shared with other conditions such as migraines, arthritis, sinus ailments and gum disease, a consultation with a knowledgeable, experienced neuromuscular dentist like Dr. Satchwell is important to accurately diagnose whether TMJ is the source of your pain and develop a custom treatment plan to relieve your discomfort and improve your overall oral health.
Diagnosing and treating TMJ
TMJ symptoms are most often caused by bite conditions related to misaligned teeth. If a preliminary evaluation of your complaints and symptoms reveals that the most likely source of your pain is from a bad bite or TMD, then we will recommend the following:
Phase I TMD/TMJ therapy:
Phase I therapy consists of doing a very extensive review of your medical and dental history along with a review of your symptoms. We then take numerous posture photos and photos of your symptom areas. We palpate the muscles of the head and neck, and make models of your mouth. We then use a specialized diagnostic system (K-7 Image) to analyze readings of your muscles, your jaw joints, and track the movement of your jaw in three dimensions. This is analogous to an EKG (ECG) that a cardiologist uses if you're having heart problems. We also will take CT (attached image) "Cat Scan" images of your jaws.
Based on your history and our objective (real data) findings, we're able to make a diagnosis.
TMD is primarily a disorder of the bite. Therefore we fabricate an orthotic to align the bite. We use a highly trained laboratory to fabricate the orthotic precisely to the bite position that we have determined will be optimal for the patient's recovery. An orthotic is similar to a night-guard except it precisely puts the muscles, joints, and jaws to a correct position to allow healing. The orthotic will go over your lower teeth and only minimally, if at all, will affect speech. Because it places the jaw where it ought to go, many times it is unnoticeable to the public. When things are right, they look right.
The orthotic treatment typically lasts 3-6 months on average. This is longer with some patients and shorter with others depending on the severity of the disease and compliance of the patient. As healing progresses, the bite shifts and balances with healing as muscles relax, joints decompress, and things stabilize. This means that adjustments to and/or relining of the orthotic is necessary until maximum healing occurs. Once stable, phase II options are given.
Phase II, or permanent rehabilitation, is permanently putting the teeth into the correct position that the orthotic has established. The beauty of first doing Phase I treatment is that we can know that you will get better before we start anything irreversible. In other words, if the orthotic treatment doesn't work, you simply take it out. Nothing permanent has been done. However, the vast majority of cases are successful and we document this by taking scans (recordings of your jaw movement, jaw position, muscle activity, and joint health) and by a checklist you fill out at your visits telling us of your improvement.
One of the reasons we don't limit our practice to ONLY treating patients with TMD is this ability to offer Phase II. Once we know exactly where the level, corrected bite should be we offer the following options to permanently keep it there. This is done in the following way:
- Orthodontics (braces)
- Coronoplasty. Make minor adjustments to the chewing surfaces of your teeth to allow them to fit properly in the new bite
- Full Mouth Reconstruction Restore your worn teeth to a corrected position with porcelain veneers and crowns. Many times missing teeth are replaced with either permanent or removable bridges, or an implant.
- Long-term Orthotic. This orthotic is removable and is designed for long-term wear. It usually is selected in cases where braces or full mouth reconstruction is not a financial option for the patient. By offering Phase II options, we are able to ensure that what we've designed and worked for in the orthotic phase can be a permanent solution if the patient desires.
What's the difference between a night guard or an NTI that my dentist is recommending and the TMD Orthotic that you prescribe?
A night guard is a piece of plastic or acrylic that goes over the chewing surfaces of either your lower or upper teeth to prevent grinding (bruxism). It is not designed to orthopedically place the joints, jaws, or muscles in the correct position. Again, it is merely a protective surface to keep the jaws from moving around and wearing or chipping the teeth. An NTI (Nociceptive Trigeminal Inhibitor), which is fancy term meaning a piece of plastic that caused only the front teeth to hit and therefore diminishes the input of the nervous system, is a band-aid. No one was born to have only his or her front teeth hit.
Teeth are designed be nature to contact, especially the back teeth. One of the dangerous side-effects to long term NTI wear is the development of an anterior open bite. A phenomenon that develops due to the continuous pressure of the NTI on the front teeth only and lack of back tooth contact.
A custom-fitted TMD orthotic places all the teeth, muscles, and joints in exactly the position the body wants it to be. This allows for healing and not masking of the problem. Once the body has healed, which seems to average 3-6 months, we can move to phase II or permanent rehabilitation into that new bite position.
Do I treat this surgically?
In very rare cases surgical intervention may be necessary.
Each individual case is different, and Dr. Satchwell will develop a plan to correct your specific condition. Dr. Satchwell is the only neuromuscular dentist in the Pocatello, Idaho, area. He works with a team of neurologists, ear nose and throat specialists, chiropractors, and physical therapists to treat TMJ. He has a 95 percent success rate treating TMJ cases without surgery.
How Do I Choose a Doctor to treat my TMJ problem?
Because there is no Specialty for the treatment of TMJ, here are a few questions to consider asking your doctor:
- How long has the doctor been in practice?
- What areas of expertise does the doctor focus or specialize in?
- What type of continuing education has the doctor been through in this particular area of practice?
- How many hours of continuing education has the doctor had in this area?
- Do they have any Fellowships or Diplomates in this particular area?
- What is their definition of success in terms of therapy or treatment?
- How many patients have they treated for this problem?
- What is their success ratio?
- Are there any patients who have gone through this treatment that would be willing to talk to me before beginning treatment?
- Are all costs and timetables for this treatment clearly defined in writing?
If you live in the Pocatello, Jackson Hole or Idaho Falls, Idaho, areas and have questions about TMJ or would like to schedule a consultation to address symptoms affiliated with TMJ, please contact the Modern Smiles.
*The preceding was written personally by Dr. Satchwell. Please contact him at [email protected] for references.