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Temporomandibular (Jaw) Joint Disorders

Headaches have plagued mankind throughout recorded history. Over 50 million American annually have headaches so severe that they seek medical help. Most of these people state that their head pain is a major disruptive force in their daily lives. The majority of these patients suffer from Temporomandibular Joint Disorders (TMJ/TMD).

TMD is a group of separate, but related disorders of the temporomandibular joint and all the associated muscles, ligaments, nerves etc. Unfortunately, TMDs are the most frequently misdiagnosed of the medical/dental conditions. Two facts account for this sad state of affairs.

First, few doctors (physicians, dentists, chiropractor, osteopaths etc.) have proper training in the diagnosis and treatment of TMD. Secondly, these disorders have many overlapping symptoms, which mimics many other conditions. The most common symptoms are head pain (headache) and clicking or popping of the jaw joints, but the eyes, ears, neck and shoulders, the mouth, teeth and throat may be affected.

Temporomandibular Joint Anatomy:

The Temporomandibular Joint is the joint connecting the jaw (mandible) to the skull (temporal bone).

The two bones are held together and function via a complex group of muscles, ligaments and other soft tissues. The temporal bone has a concavity called the glenoid fossa in which the head of the jawbone (the condyle) sits. A cartilage disc called the articular disc separates the two bones. The articular disc slides in conjunction with the mandible to provide smooth movement and acts as a cushion against heavy forces generated by the strong jaw muscles. The right and left TMJ joints do not act as separate joints, but must move in coordination with one another.

The TMJoints are considered the most complex joints in the human body because they must provide for rotational movements, sliding movements and an infinite range of combined movements.

The nerve to the TMJoints called the trigeminal nerve because of its three branches. It is the largest of the 12 Cranial Nerves and makes up more nerve tissue than the other 11 combined. The trigeminal nerve plays a very important role in the brain’s identification and reaction, both physically and emotionally, to not only head pain, but for the rest of the body, too.

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. The trigeminal nerve cells group together in the brain stem to form the trigeminal nucleus (TN). The trigeminal nucleus gets branches sent to it from pain nerves originating in every part of the body.

When a patient feels chronic pain, the trigeminal nucleus gets "heated up". The TN also contains a structure known as the reticular activating system (RAS). The brain cells act as the awaking center of the brain. Patients with injured TMJoints will have the RAS become hyperactive. This accounts for the sleep disturbances suffered by chronic pain patients. The trigeminal nerve can also suffer injuries that create nerve pain (neuralgia). Trigeminal neuralgias are considered among the most pain afflictions in the history of mankind.

Movements of the TMJs are provided primarily by four pairs of muscles. These are the masseters, the temporalis, the lateral pterygoids and the medial pterygoids. All of the muscles of the neck and shoulder girdle are involved in jaw function such as jaw posturing and swallowing. The muscles are considered "accessory muscles" of TMJoint function. The need for all of these muscles to work in a coordinated manner is one of the keys to understanding TMJoint disorders. When the joints are injured, the ligaments rarely heal completely. A damaged TMJoint ligament can cause a dislocation of the articular disc and the condyle. The muscles that support the joint may become painful to touch and in function.

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The unique internal design of the joint is the reason that it is affected like no other joint in the body. Behind the condyle lie several structures. One is the posterior band, a loosely structured ligament that is highly elastic. It acts as a rubber band to pull the disc backward in jaw closing movements. Like all joints, the TMJoints contain a large, intricate complex of nerves telling the body, on a subconscious level, information about the position and condition of the joint. Surrounding the posterior band is a complex of blood vessels. When the jaw is closed, these vessels are compressed like a sponge. When the mouth opens and the condyle moves forward, the blood vessels expand to fill the vacated space. When the condyle is pushed to far backwards in the joint, it can slip off the cartilage disc and onto these nerves and blood vessels. This is a posteriorized condyle. Posteriorized condyles cause several bad things to happen in the joint.

1. The blood vessels and nerves are compressed with the constant movement of the jaw. This injures these delicate structures and causes inflammation and pain. This pain is signaled to the brain. Additionally, all blood vessels contain smooth muscle in their walls. All smooth muscles have nerves. These nerves are damaged by the constant grinding of the condyle. They send low level pain signals to the brain. These constant pain signals heat up the pain pathways in the central nervous system.
2. Posteriorized condyles function at the edge of the joint range of movement. It is at the extreme ranges of movement that all joints have pain nerves. This is nature’s way of telling the body that it is doing a bad thing to the joint. The TMJoints have these pain nerve cells like every other joint. With posteriorized condyles, every time the mouth is closed, low level pain signals are sent to the brain. With time, this constant barrage of pain signals sensitizes (heats up) these pathways and the brain becomes conscious of the pain.
3. Distalized condyles are an abnormal condition that throws the fine delicate relationships of the head and neck muscles out of balance. This leads to muscle tension, strain and fatigue.
4. Distalized condyles damage the disc itself. Improperly positioned condyles can even wear through the disc and the bones of the jaw and skull start to break down as they rub together. This causes an arthritic type of breakdown of the bones themselves.

Keep in mind the constant agitation of the central nervous and the strain on the muscles controlling the joint as you read the symptoms below. The connection between the physical strains of the joints and the symptoms starts to become apparent.

The most common symptoms are clicking/popping or grating sounds from the joints. This clicking is the condyle slipping on an off the dislocated articular disc. The grating sound is called crepitus and is often the sound of bone rubbing against bone when the disc is dislocated. The jaw may also lock open or closed.

A second common symptom is headache or head pain. TMJ head pain is most often felt in the temples, around the eyes, in the back of the head and the neck, or in the shoulders. TMJ headaches are often described like "wearing a hat two sizes too small", for the pain rings the head.

Clenching or grinding of the teeth (bruxism) is a common symptom of TMJ. The abnormal forces and strain produced by tired, spastic muscles can refer pain into the neck, face or head. These muscle tension headaches can be so severe that they are confused with migraine headaches. Unfortunately, the patients are often not examined for TMJ and the "migraine" treatment works poorly. Further, the teeth themselves may become sensitive or painful due to TMJ and/or bruxism. The teeth may be cold sensitive or painful upon chewing. The pain will most commonly be diffuse, but may feel to be in a single tooth. Too often, this tooth pain resulted in unnecessary root canals or extraction of teeth.

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Ear problems without an identifiable source are often symptoms of TMJ. The common ear problems associated with TMJ are ringing/buzzing, fullness or a stuffy feeling. There may even appear to be a hearing loss in an otherwise normal appearing ear. Patients may feel dizzy or disoriented when suffering from TMJ.

Depression and sleep disturbances are common with TMJ. These two symptoms are the result of chronic painful nervous input to the CNS from TMJoints, ligaments and muscles. A stated before, this bombardment of the brain with pain signals heats up the reticular activating system, the "sentinel" of the brain. Because the aroused brain does not allow the body to reach the deeper stages of sleep, the patient will awaken often at night. The patient then feels tired or listless in the morning instead of the refreshing feeling of good nights’ sleep. The depression is commonly the result of two mechanisms. Again, the trigeminal nerve plays a major role in chronic pain from anywhere in the body. With TMJ, the trigeminal nucleus processes the pain information carried by the nerves. The TN then relays the pain signals to the thalamus of the brain. The thalamus acts a sorting mechanism to route the signals to the proper areas of the cerebral cortex for interpretation and reaction. This is like mail coming into the central post office, being sorted and then delivered to the right addresses. The thalamus acts like the central post office. The thalamus also relays signals to the limbic system. The limbic system is in control of emotions. The chronic pain signals cause the depression in the emotions. The second mechanism for depression involves the depletion of neurotransmitters in the brain. When the brain is subjected to chronic painful impulses, it will attempt to dull or stop those impulses using the Descending Inhibitory System (DIS). The DIS works overtime to control the pain until the signaling chemicals, the neurotransmitters, are depleted. The flood gates are now opened for more noxious signals to get through not only to the conscious level of the brain, but also into the limbic system enhancing the depression and other emotional aspects of pain.

As you can see there are many possible symptoms associated with TMJ. The head and neck are the most complicated parts of the body. Other health problems can present some of the same symptoms as TMJ. TMJ is called the Great Imposter because of the overlapping symptoms. Therefore, it is especially important to have a proper diagnosis made before beginning treatment.

Self-assessment Test for TMJ:

If you think that you may have TMJ, answer the following questions:

1. Do your TMJoints click, pop or make a grating sound?
2. Do your jaws ever lock?
3. Do you have frequent headaches?
4. Do your headaches involve the temples, around the eyes and/or the back of the head?
5. Do you clench or grind your teeth?
6. Are your teeth sensitive to temperature changes or chewing.
7. Have you had unexplained toothaches?
8. Is it painful to open widely or to move your jaw from side to side?
9. Do your neck and shoulder muscles ache or are tender to pressure?
10. Do you have a ringing or buzzing in your ears?
11. Do you frequently feel dizzy?
12. Do you have trouble sleeping through the night?
13. Do you have trouble falling asleep?
14. Is it had to get back to sleep once you awaken?
15. Do you wake up tired and/or with sore jaw muscles?

The more the above answers are "yes", the greater the chance that you have TMJ. On the page below, chart the symptoms that you have. A copy of the form may be printed. Go to the printable form. Again, the greater the number of symptoms that you have, the greater the chance that you have a TMJ problem. This section is not meant to provide a diagnosis. If you are concerned and wish to be examined, please contact our office or a qualified dentist in your area. Few physicians or dentists are trained to treat TMJ. Be certain to see a doctor both knowledgeable and experienced in the treatment of TMJ and has credentials in the field.

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Symptom Chart:

Diagnosis of TMJ:

A proper diagnosis always begins with a thorough examination. This is especially true in TMJ. Often patients suffering from the "Great Imposter" wander from office to office seeking help for their problems. The most severe case that I have found in the medical/dental literature is a lady who had seen 103 different doctors including 32 dentists, 20 neurologists and 15 family physicians. She also was admitted to the hospital 12 times for testing. Her documented medical bills exceeded $300,000! Today she is living pain-free because a proper examination and diagnosis was made.

Detailed Medical/Dental History:

A proper medical history should include all past medical dental problems and treatments, any history of trauma, especially to the head and neck region, specific questions about your symptoms and the nature and duration of any pain and jaw problems.

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This consists of several parts and may take up to two hours to complete. A complete exam should include the following (see text below the images provided by Dr. James E. Carlson and the Acculiner Corp):

This consists of several parts and may take up to two hours to complete. A complete exam should include the following:

1. Postural exam to discover any musculoskeletal problems that either contribute to or are the result of TMJ problems. This includes scoliosis, lower back pain, and short leg syndrome among others. The human body functions best when aligned at right angles to the center of gravity.
2. A cranial examination will evaluate the planes of the skull including the dental plane of occlusion.
   
3. Dental Examination to evaluate the shape of the dental arches, swallowing patterns, wear or fractures of teeth, missing teeth and existing dental restorations and numerous other clues to what is happening in the patients body. The dentist will usually make models of the mouth so that the teeth and the dental arches may be more closely examined.
4. Neurologic examination to test for nerve or brain damage that may cause symptoms of TMJ. Certain brain tumors will mimic TMJ symptoms.
5. TMJ Examination to look at the ranges of motion, gait, speed and smoothness of jaw movements. The TMJoints will be palpated to check for internal joint inflammation, pain and the presence of joint sounds.
6. Joint Vibrational Analysis records the vibrations made by joint tissues during movement. JVA technology, based on that used in US Navy submarines, records vibrations, not sounds. All sounds are vibrations, but not all vibrations are sounds. The JVA is much more accurate than palpation, a stethoscope or even the patient self-reports, when it comes to recording vibration in the joints. The patterns and the electronic signature of your joints are compared to known standards for healthy joints. This technology also provides important objective (factual) documentation so vitally important in personal injury lawsuits and for filing insurance claims.

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7. Radiographic (x-ray) Examination of the joints allows the doctor to see many important structures and conditions hidden from view. Common x-rays are a panoramic x-ray that is useful only for screening for fractures, tumors and severe breakdown of the joints. Tomographs provide the best view of the TMJoints. Tomographs are x-ray slices of structures in the body. This technique allows the doctor to look at specific structures in great detail. The TMJoint tomographs accurately depict the position of the condyle in the fossa, and show degenerative and traumatic changes in the bones of the joints.

8. Other special tests include electromyography, which is a cousin of the electrocardiogram. As the electrocardiogram measures the muscular activity of dysfunctions of the heart muscle, electromyography measures the activity and dysfunction of head and neck muscles. This information is important in treatment planning and for documentation purposes. Computerized jaw tracking is another important diagnostic and treatment tool. Using a small, powerful magnet stuck to the gums below the lower front teeth, movements of the jaw can be measured with unprecedented accuracy. The jaw tracker can be combined with the JVA to provide the most comprehensive diagnostic and treatment information available today.

9. Psychometric tests are standardized questionnaires that compare patient’s response to questions about their condition. This information is very helpful to the doctor in the evaluation of the severity and chronicity of TMJ problems. The most common and accurate test is the TMJ Scale.

Every patient does not necessarily need all of these tests, but more information makes possible an accurate assessment, diagnosis and treatment plan for patients.

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Treatment of TMJ

The subject of "Treatment for TMJoint Problems" covers a wide range of treatments and a variety of practitioners. Dentists are the most common and most logical Doctors to treat TMJ. Only properly trained Dentists can provide the comprehensive treatment and case management needed to help patients suffering from TMJ. Since most TMJ patients have musculoskeletal problems too, the Dentist may work with massage therapists, chiropractors, physical therapists and physicians to treat the areas of the body that are outside of the realm of dentistry. Our goal is to get the body as pain-free and healthy as possible. It is important to remember that 100% relief of discomfort may not be possible. Just as with the person who has torn up a knee (like me), a TMJ patient may have some occasional flare-ups of their symptoms or can be prone to re-injury. Soft tissues never "heal" as completely back to their original condition.

Treatment of TMJ is divided into three phases, Phases I, II and III. The Phase I goal is to reduce and eliminate joint and muscle pain, addressing structural problems throughout the body, and by educating the patient as to how to help themselves. The most common form of treatment is with a splint. A splint is a custom designed and fitted plastic mouthpiece. Splints come in a variety of shapes and designs. However, all splints fall into three main categories. The first type is a Nightguard. A nightguard is commonly an upper appliance designed only to prevent damage to teeth from nocturnal grinding. It can also be worn during the day if the patient is experiencing severe stress. Nightguards are not normally helpful in treating TMJ.

The second type of appliance is a Superior Repositioning Appliance. The purpose of this splint is to allow muscle relaxation and to decompress the TMJoints. This appliance is usually helpful when the TMJ problem is of recent origin and muscular in nature. These appliances are generally worn for 6-12 months to allow healing of the TMJoint tissues. If the patient improves well on this appliance, then a gradually weaning off the appliance may be attempted. These appliances can also be useful if the internal dislocation or Internal Derangement is slight in nature. With slight dislocations, almost any type of appliance can help some people. This has been the cause of great controversy throughout the TMJ community over the years. The success of these appliances led to confusion among many practitioners as to the cause and mechanisms of TMJ. Since most TMJoint problems are cause by posteriorly displaced condyles, any type of splint might help a slightly displaced condyle.

The third type of TMJ appliance, and usually the most effective, is the Anterior Repositioning Appliance. This appliance brings the lower jaw forward; recapturing the articular disc and preventing repeated dislocations. The appliance is worn 24 hours daily to prevent more damage and to allow maximum healing of the damaged joint tissues. By preventing the crushing of the retro-discal tissues, the anterior repositioning appliance allows "hot" nerve pathways to calm and the central nervous system aspects of chronic pain to cool down. The inflamed joint tissues can now heal. Our office takes the anterior repositioning appliance further. We use our BioResearch jaw tracking and electromyographic equipment to find the most neuromuscularly compatible jaw position. This jaw position is most in harmony with the patient’s own muscle and joint structures. Only the use of neuromuscular techniques can determine the most stable and stress free jaw position. Patients employing neuromuscular techniques routinely achieve the fastest and best results. Phase I is also where associated musculoskeletal problems are addressed. Many patients have postural distortions that left untreated will limit the success of TMJ treatment. We work with chiropractors, physical therapists, neuromuscular (medical) massage therapists and acupuncturists to improve the overall health of the patient. It is essential to the long-term success and stability of treatment that any postural distortions be addressed.

Once the patient has reached the point of maximum improvement and is stable and pain-free, Phase II can begin. The goal of Phase II therapy is to maintain the support of the TMJoints by the teeth in a pain-free position. Depending on where the pain-free position of the jaw lies, several different types of therapy are available for Phase II treatment. The vast majority of symptoms must be resolved before Phase II therapy can commence.

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Some patients may be able to be weaned from full-time use of the splint. Often, these patients have suffered a traumatic injury to the TMJoints and had few or no previous symptoms of TMJ. The patient will stop wearing the appliance for increasing periods daily. If no symptoms return, then the patient will wear the splint at night or during periods of severe stress.

If the patient can not be weaned off the splint, then long-term splint wear is an option. The splint will last 2-3 years but will slowly wear, risking bite closing and a return of symptoms. A semi-permanent splint can be made with a metal framework. This can last many years with minimum maintenance.

For many years, there was a philosophy that adjusting the bite to remove tooth structure that was interfering with the smooth movement of the jaws could solve TMJ problems. Sometimes this was the first choice of treatment, instead of the use of a splint. In some cases, this can be helpful. However, some patients have had this treatment done excessively and have ended up worse than they started. When only a limited amount of tooth structure is causing the distalizing force on the jaw, bite adjustments are sometimes used. This treatment is not reversible and should be considered only after the symptoms have been resolved through use of a splint. Bite adjustment is helpful only in specific cases.

Orthodontics is the treatment of choice for many TMJ patients. Because the prime underlying factor with TMJ is distalized condyles grinding on the nerves and blood vessel complex at the back of the TMJoints, treatment usually brings the mandible forward to relieve pressure on these delicate tissues. Orthodontic treatment brings the teeth together in a position that supports the pain-free jaw position.

Some patients may not want, or be good candidates for orthodontics. Another option is to use crowns, bridges and other dental restorations to provide support for the jaw in the pain-free position. The skill level required to restore a mouth to this new jaw position is very high. Be certain that the dentist has a very strong background in reconstructive dentistry and understands the special needs of a TMJ patient.

TMJoint surgery should be the last resort for treatment! A very high percentage of TMJoint surgeries are failures. In his outstanding book, TMJ: Its Many Faces, Dr. Wesley Shankland, President of the American Academy of Head, Neck and Facial Pain recommends three criteria be satisfied before TMJoint surgery is tried. The criteria are:

1. All conservative treatment was a failure. If splint therapy is a failure once, it should be repeated, with a different splint design, or by a different doctor.
2. There has to be a demonstrable physical or structural explanation for the patient’s complaints. A physical problem can be seen with an MRI, x-rays, or with dye injections into the joint (arthograms). Make certain that this is not an exploratory surgery or that the surgeon "thinks" this surgery will help.
3. Patients must be suffering so much that they must take strong pain medication, and their life-style is greatly altered. In other words, the patient must be desperate and at the "end of their rope" before surgery is attempted.

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Many patients suffering from TMJ problems have been told things like "It’s all in your head." or "You’re depressed and need medications". Other patients have been put on migraine medications without much success. Still others have shuffled from office to office looking for relief without success. We welcome those patients who are in pain. We provide a supportive and understanding environment. Our guiding principles are best stated in two quotes from Albert Schweizer:

"We must all die. But if I can save a [person] from days of torture that is what I feel is my great or even new privilege. Pain is a greater lord over mankind than even death itself."

Since I recovered from TMJ and chronic pain, I have taken this as my personal motto:

"Those who bear the mark of pain are never really free, for they owe a debt to those who still suffer!"

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David B. Miller, D.D.S. 1269 Pleasant Grove Blvd. #100
Roseville, CA. 95747

 
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Date this page was last edited: 06/30/01