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TMJ Disorder: An Overview
“What is TMJ Disorder and What is the temporomandibular joint?”
The temporomandibular joints, or TMJs in humans are complex sliding ball joints that attach the mandible (lower jaw) to the skull (specifically the temporal bone). These joints are located just in front of the ears and you can feel them if you press your fingers to the area just in front of your ears and open and close your mouth. The TMJs enable the jaw to open and close, move forwards and backwards, left and right and various combinations of these movements. For more on anatomy of the joint, we will be putting out an article on anatomy soon. In the meantime, The American Academy of Facial Pain has a helpful site on TMJ anatomy, available on their TMJ AnatomyLink
“What causes temporomandibular joint disorder?”
(grinding or clenching of the teeth) (coming soon: an article on bruxism)
(rheumatoid arthritis or osteoarthritis) and other degenerative conditions
Trauma or injury
Dental work (orthodontia, wisdom teeth, dental prosthesis, malocclusion)
Postural factors (disorders of the support structures and musculature of the head and neck)
One thing to note is that many patients do not have one clear event that causes their problems, it is usually a combination of several, which may include but are not limited to the above list.
“What are the symptoms?”
It should be considered that there are many symptoms of TMJ disorder and everyone is different, therefore the disorder can and does manifest itself in a variety of ways.
Here are some of the common symptoms:HeadachesEar painRinging in the earsLimited mouth openingPain when chewing, yawning, or moving the TMJClicking, popping or grating sounds when opening (with or without pain)Tooth painSwellingDifficulty chewing or uncomfortable biteDizzinessHearing problemsRadiating pain in the face, neck, shoulders, back and arms
“How is it diagnosed?”
TMJ disorder has many symptoms, some of which can mimic other disorders. It has been called “The Great Imposter” by many physicians, and because of this, diagnosis should be done by a physician. The most common method of diagnosing TMJ disorder (TMJD or TMD) is by visiting a dentist and having a physical exam and history performed. The dentist will examine your face and jaw for pain and tenderness, listen to your joint for noises, check your bite, and measure your opening. He or she will most likely take x-rays of your joints which will enable the bones and surrounding teeth to be seen and make sure that no other problems affecting these structures are causing your symptoms. Sometimes, other tests are ordered, such as CT scans, which are used to view the bony detail of the joint. MRI’s can also be ordered to view the soft tissues of the joint, including the disc.
“What is the treatment?”
Treatment can vary from simple, self-care to complicated surgical procedures. It is very important when seeking TMD treatment that the patient exhausts all conservative options before moving on to invasive treatments.When you first believe that you may have a temporomandibular joint problem, there are ”’things that you can do at home to relieve your pain”’, such as:Eating soft foods such as yogurt, eggs, cereal, oatmeal, etc (we will have an article on nutrition soon) to give your joints a rest. Avoid hard, crunchy foods (raw vegetables, chips, nuts), chewy foods (hard rolls, gum), and large foods that force you to open your mouth wide (hamburgers, big sandwiches, hot dogs, etc).Moist heat or cold packs if both are used, apply ice first, then do gentle stretching as directed by your physician, and apply heat. You can make your own heating pack by either wetting a washcloth or towel and microwaving it, or putting rice in a tube sock and microwave that.Take Medications Try over-the-counter medications such as Ibuprofen or Naproxen. Your physician might prescribe other medications such as anti-anxiety medications, muscle relaxants, narcotics, non-steroidal anti-inflammatories, and anti-depressants. (PLEASE NOTE: Most, if not all medications have the potential to produce side-effects. Please ensure you exercise caution when taking any medication and if you experience any side effects, you should stop taking the medication immediately and seek professional help. Always read the label and use medication only as directed.)Avoid yawning widely, resting your chin on your hand, resting the phone on your shoulder, or excessive talking. Try and practice good posture.Be aware of clenching and grinding: try to keep your lips together and teeth apart. If necessary, set an alarm for every ten to fifteen minutes and check to make sure you are not clenching or grinding. This will become a habit.Try and avoid situations which are known to cause you to feel stressed or emotionally traumatized because this can cause an excacerbation of symptoms (many people clench or grind their teeth when stressed). Some people go through stressful situations prior to developing TMJ disorder, but there is definitely a physiological factor involved as well. This point has been debated by patients and physicians for many years. Some patients do not believe that emotional factors play a large part in their disorder, while others do. More research needs to be completed regarding issue.
“What if self-care treatments fail?”
If Self Care Fails and self care techniques, like mentioned above, do not relieve your pain, your physician might recommend moving forward with more than self care treatment. This can include:
MRI, CT, X-Rays (Panorex, Tomogram, etc) and other imaging can be used to determine the state of the joints and surrounding tissues as well as determine what treatment may be the most appropriate. MRI’s are primarily used for visualizing soft tissue such as discs, muscles, etc where as CT scans show bone in great detail. X-Rays give a basic look at the joints and their relationship with your occlusion (the way your teeth fit together).
Splints, nightguards, biteplates and NTI’s (all words for similar devices) are the most common treatment for jaw related pain and muscle disorders. There will be an upcoming article going into more depth about this subject.
Trigger point injections are injections to address knots in muscles that cause pain.. they can be done with anesthetic only, ie: no epinephrine and no anti-inflammatory. After having these injections, your physician will direct you to use some sort of coolant such as spray and stretch or ice and do stretching exercises to avoid discomfort. Some physicians may choose to do a type of injections called “dry needling” which involves no anesthetic or steroid. Anti-inflammatory injections are given with anesthetic followed by either a steroid or serapin, which is a type of anti-inflammatory derived from a natural plant source. The amount of steroid injections are limited because the structure of muscles can be compromised if given too much.
Some doctors will send you to physical therapy, others will perform it in their offices, and others will have you do it at home. The most common modalities performed in physical therapy are TENS, ultrasound, infared, iontophoresis, stretching exercises, hot and cold packs, massage, and evaluation of posture, ergonomics, and sleeping positions.
Some doctors will refer you to chiropractors, massage therapists, accupuncturists, biofeedback therapists or nutrionists. One doctor, an osteopath, is trained to perform all of these functions. An osteopath is a doctor who has different medical training than an MD. As with any medical procedure, one must do their homework and be comfortable both with the modality and the practioner for it to be successful.
There are many medicines used to treat TMJ disorders depending upon your symptoms. These include muscles relaxants to relax muscles around the joint, pain medications to help with daily function, anti-depressants such as SSRI’s and tri-cyclics for pain and depression, non-steroidal anti-inflammatory drugs (NSAIDs) to assist with pain relief and inflammation, sleeping medication to assist with sleep disruption that often accompanies pain, anti-seizure medication used for nerve pain and sometimes headaches, headache abortives as many TMJ patients respond positively migraine or headache medicines for head pain. Sometimes medication management gets complicated and patients are referred to pain clinics or specialists such as neurologists. These physicans will take care to ensure that there are not interactions between medications and the medication and side effects of these medications are not exacerbating symptoms.
Referral to Specialists:
Many of the symptoms of TMJ disorder can be complicated and require referral to specialists. These specialists will work with your general physician or dentist to form a team. This can include neurologists for migraines, headaches, and nerve pain, pain specialists for pain management, medicication management, and neck and back pain, rheumatologist for arthritis, fibromyalgia or other related diseases and disorders, or ear nose and throat doctor for ear and hearing related symptoms. Depending on who is originally treating you, you might be referrred to a “TMJ specialist” or oral surgeon.
More Advanced Treatment:
If conservative treatments fail after a period of time, then more invasive treatments may be considered depending on your particular situation. Some of these treatments will be discussed in the next article, TMJ Surgery: An Overview. Any invasive treatments should only be considered after exhausting extensive conservative, non-invasive therapies and receiving multiple opinions from independent physicians.
Please keep in mind that there are no board certifications, no standard of care, and very little conclusive research on TMJ disorders and their treatment. Dentists, surgeons, and medical doctors do not agree on a treatment protocol that is effective for the majority of patients, therefore, we recommend that as with any medical treatment, you proceed carefully and do extensive research. Reprinted with permission from TMJ Friends, a support group run by patients, for patients.