Temporo Mandibular (JAW) Joint Disorders (TMD)

Chronic recurrent headaches, neck aches and facial pain are a common occurrence in millions of Australians.

Also people frequently suffer from ear symptoms like pain, ringing, buzzing, loss of hearing or chewing or locking of the jaw which can make chewing speaking or moving the jaw painful or difficult. Many people have worn sensitive teeth and unexplained toothache.

Until recently these symptoms appeared unrelated and were frequently undiagnosed or misdiagnosed as migraine, tension headaches, neuritis, neuralgia or stress. Standard treatment remedies for these types of disorders were unsuccessful.

Today it is well recognised that these often unexplained, undiagnosed and therefore untreated symptoms are related to a group of problems called Temporo Mandibular Disorders (TMD)

Temporo Mandibular Disorders (TMD) are often called "TMJ" by doctors, chiropractors, physiotherapists, patients and even insurance companies although the term TMJ actually only refers to Temporo Mandibular joints (TMJ) themselves. TMD is much broader than that for it is a group of maladies which not only affects the TMJ’s but associated muscles of the jaw, face and neck as well as related neurological and vascular structures.

It is estimated that one in every 4 people suffers from one or more TMD symptoms.

TMD is known as the "great impostor" because these disorders have many overlapping symptoms which mimic many other conditions.

It is difficult to diagnose without the knowledge of how the jaw joints, muscles, bones and teeth work together.

Sadly many people suffer from these pains through out their lives and never understand what is causing it and accept it as being normal or part of their life.

Now, through proper training and diagnostic skills, using state of the art computerised techniques we are able to pinpoint the cause of these symptoms and provide relief of the symptoms and restoration of proper function in TMD patients.

TMD is also known as TMJ Disorder or syndrome (Cranio-Mandibular Dysfunction) or Myofascial Pain Dysfunction (MPD)

WHAT IS TMD?

TMD or Temporo Mandibular Disorder is a group of separate but related disorders of the temporo mandibular joints (the jaw joints located immediately in front of the ears) as well as the associated muscles of the jaw, face and neck and related ligaments, nerves and blood vessels.

Problems within this complex can produce a myriad of symptoms which at first glance, might appear to be totally unrelated to the jaw complex.

The structures that make it possible to open and close your mouth include the facial bones, temporo mandibular joints and muscles. These are very specialised and must work together whenever you chew, speak or swallow. Your teeth and especially the way your teeth fit together or “bite” form part of this jaw complex. The major nerve supply is the trigeminal nerve which has three branches and is the largest of the twelve cranial nerves by far. The area of the brain that interprets information from the trigeminal nerve is called the trigeminal nucleus which also receives pain nerves from every part of the body. Everything is related.

Any problem which causes an imbalance in the delicate working relationship of the jaw and skull with the muscles that attach and move the jaw as well as the nervous system associated with these systems may result in TMJ Dysfunction (TMD)

How?

Your lower jaw is attached to the head and neck by numerous muscles.

If the muscles and joints do not work together correctly the muscles have to work harder, they become overactive and consequently will tire and fatigue. Eventually they become shorter, stiff and go into spasm producing pain, muscle tenderness and tissue damage.

A vicious cycle characteristic of TMJ disorders is triggered; disharmony leads to muscle spasm producing pain, muscle tenderness and tissue damage.

The pain makes you feel tense and uptight. This worsens the muscle spasm, which in turn increases the pain.

CYCLE OF TMJ DISORDER

The end result is the balance of the head, neck and shoulders is affected, which in turn alters the posture and function of the rest of the body.

Anatomy of TMJ

In a normal TMJ anatomy the articular disc is placed between the condyle (lower jaw) and the skull (temporal bone).

Disc in correct place

Disc and condyle together

The muscles controlling the jaw joint may be painful and strained resulting in the displacement of the jaw joints. The patient may demonstrate clicking, grating, snapping or popping sounds in the joint. The TMJ’s dysfunction, there are changes to the teeth and as a result we see a variety of symptoms unique to each person.

Disc between jaw and bone

Disc slightly forward

Disc much further forward

The problems become far reaching as the other muscle that have the same nerve supply may also go into spasm. The central nervous system is constantly agitated with the potential for pain to radiate or be referred throughout the head, neck and back.

TMD's are physical disorders that may take years to develop. There are many ways that the harmony of the jaw complex can be disrupted but the most common relates to your teeth and especially to your bite.

SIGNS AND SYMPTOMS OF TMJ DISORDER

• Clicking, popping, grating sounds in the ear or joint
• Limited opening of the mouth
• Locked jaw
• Pain or soreness around the jaw joint
• Headaches
• Neck, shoulder or back pain
• Facial pain especially in the temples around the eyes
• Clenching or grinding of the teeth (bruxism)
• Sensitive and sore teeth
• Unexplained loose teeth
• Worn chipping or cracked teeth
• Cracking, chipping or breaking dental restorations
• Ringing in the ears
• Ear congestion or stuffiness
• Numbness, tingling in the fingers or arms

As you see there are many signs and possible symptoms associated with TMD. The head and neck are the most complicated parts of the body. Other health problems can present some of the same symptoms as TMD, therefore it is especially important to have a proper diagnosis for successful treatment.

SELF ASSESSSMENT TEST FOR TMD

If you think you may have TMD, answer the following questions.

1. Are you aware of grinding or clenching your teeth?
2. Do you wake up with some stiff muscles around your jaws?
3. Do you have frequent headaches?
4. Does your jaw click, pop, grate, catch or lock when you open your mouth?
5. It is difficult or painful to open widely, to move your jaw from side to side, eat or yawn?
6. Are your neck and shoulder muscles stiff, sore or tender to pressure?
7. Are your teeth sensitive, loose, broken or worn?
8. Do your teeth meet differently from time to time?
9. Have you had unexplained toothaches!
10. Is it hard to use your front teeth to bite or tear food?
11. Does stress make your clenching and pain worse?
12. Do you have ringing or buzzing in your ears?
13. Do you frequently feel dizzy?
14. Do you have trouble sleeping through the night?
15. Do you have trouble falling asleep?
16. Have you injured your neck, head or jaws?

The more times you answered "yes" the more likely it is that you have a TMD disorder. Since some types of TMD problems can lead to more serious conditions early detection and treatment are important.

WHAT CAUSES TMD DISORDERS?

Temporo mandibular disorders rarely have a single cause. It is important to recognize anything that alters the relationship between the lower jaw (mandible) and the upper jaw (maxilla) has the potential to cause TMD.

The lower jaw may be overclosed (too close to the upper jaw) and/or distally placed (too far back in the joint or socket). Also the lower jaw may deviate to one side due to interfering tooth cusps.

Anyone of the following factors may contribute to TMD.

• Acute Trauma
  TMD disorder can come from a single traumatic event such as whiplash injury, which traumatizes the jaw or skull.
  "Whiplash" injuries can result from car accidents, a fall or a blow to the head that wrenches the jaw out of position. Such a force may exceed the body's physical limits causing injury to both hard and soft tissue.
  Sometimes trauma to the joint can cause chronic damage, which may eventually contribute to TMD problem, at a later time.
• Opening Too Wide
  All joints have limitations to movements and the TMJ is no exception. If you open wide for a long time, or if your mouth is forced open, ligaments will be torn.
• Chronic Causes
  More frequently the underlying conditions that cause these signs and symptoms and structural, biochemical and emotional that develop over the years and finally manifests into one or more of the signs and symptoms.
  The structural problem is almost always present and leads to over activation of the jaw, head and neck muscles.Factors related to the teeth and bite are among the most common causes of TMD Disorders.
• Bruxism
  Bruxism refers to a non-functional grinding and clenching of the teeth. Some people do this while awake but, more often bruxing is done while sleeping. That is why so many people do not realize that they are bruxers.
  One indication that a person is a bruxer is sore, tired jaw muscles in the morning. Some researchers feel that the constant grinding of the teeth causing pressure on the TMJ's may injure the ligaments, thus allowing the disc to dislocate. At the very least bruxism produces muscle pain and sensitive, worn teeth. Bruxism is the most common factor found in TMD.
• Malocclusion
  This term means "bad bite". When the teeth do not fit together in harmony with the shape and position of the joints, pressure can be placed on the joints. Furthermore, improperly aligned teeth can place the chewing muscles under stress and cause them to tire and eventually go into spasm. The spasm causes pain and tissue damage which in term causes more spasm. The end result of this spasm - pain - spasm cycle may eventually become a TMD disorder.
  Malocclusion may also be produced by.
  • Distorted development of one or both jaws
  • Underdevelopment of one or both jaws
  • Loss of teeth without replacement
  • Over closed bite
  • High dental restorations
  • Poor fitting denture or partial denture
  • Loss of bone in denture patients
  • Tongue habits
  • Orthodontics
• Orthodontics
  Whilst orthodontics can significantly improve ones appearance and correct factors leading to TMD some researchers also feel that orthodontic treatment may produce TMJ problems. Orthodontics treatment should take into consideration the correct position of the TMJ's and the skeletal structures as well as the alignment of teeth.
• Ligament Laxity
  People who appear to be double jointed actually suffer from a problem termed ligament laxity. If this occurs elsewhere in the body there is a strong chance that the TMJ will also be loose causing excessive movement. This is fairly common in active young women who suffer from TMD.
• Stress
  Emotional stress often plays an integral role in the development of TMD. Stress increases both the severity and duration of bruxism whilst asleep. Also many will subconsciously clench and/or grind their teeth more while awake during times of stress. In times of stress our adaptability goes down. As a result you are more likely to experience symptoms of TMD if other factors already exist (bruxing, joint damage, poor bite etc)
  Stress is like throwing petrol onto an existing fire: the fire is a TMJ problem and the petrol is stress. The petrol causes the fire to flair up and burn wildly for a time but the petrol did not produce the fire (or TMJ) it just made it worse.
  Muscles tighten, teeth clench, abnormal pressure is forced against the TMJ disc and TMD problems start.
• Systemic Diseases
  Various diseases can cause or aggravate TMJ problems. Immune disorders such as rheumatoid arthritis, psoriatic arthritis and systemic Lupus erythematous can produce inflammation in the TMJ. In addition, viral infections such as mononucleosis, mumps, and measles can cause damage to the surface of the TMJ, which ultimately can lead to an internal derangement.
• Nutrition
  We are just starting to understand the critical role proper nutrition plays in the optimal functioning of our body, our resistance to stressful situations and insults and our ability to adapt to the challenges of our lives.
• Postural Distortions
  We live in a gravity-based world. The muscles and nerves of our body are designed to keep our head, pelvis and feet level with the ground when standing still and working in balance when under motion. The human body functions best when the skeletal structures are parallel or at right angles to the centre of gravity.
  If an area of the system is faulty or injured the body will shift or "compensate" from its normal balanced posture. This spreads out the forces and allows the injured area to avoid any extra stress on that area. But this compensation now places stress on other, more remote areas to the body and often pain is experienced in these areas. When these postural planes are not level we have what is termed a postural distortion. These distortions can either contribute to or are the result of TMD problems.
  We need to look at the entire system and try to maximize the function of the whole body. If we only treat the "complaint' area, rarely will the real cause be found.
• Ergonomics
  Any activity that causes the head to be held in an unnatural way may intensify TMD problems. Particularly troublesome habits including cradling a telephone between the ear and the shoulders, carrying a heavy shoulder bag and slumping over a desk to read or type. Playing certain musical instruments and surgery can exacerbate TMD symptoms.
  There are many people who have no pain but still have occlusal bite disease". Worn, chipped or broken teeth, broken fillings, changing position or shape of one's skull are all indications of TMD disorder and these patients should address these problems sooner rather than later.

BIO-INSTRUMENTATION = COMPUTERIZED DIAGNOSTICS

Since TMD is often misdiagnosed, we have invested in the most state of the art technology and equipment to allow us to diagnose, treat and monitor TMD. These sophisticated instruments have been used by medical specialists for years and are now being used in dentistry to objectively collect data that is proving invaluable in helping many patients that have been previously unable to find relief.

The technology includes...

• Joint Vibration Analysis
• Jaw Tracking (Electrognathography)
• EMG ( Electromyography)
• BioTens

Treatment

The treatment of each person suffering from TMD must be tailored to the particular needs of the individual. We recommend that you first consult with a medical doctor to rule out any medical disease that may be causing your symptoms.

Successful treatment for TMD problems will involve a wide range of treatments and a variety of health practitioners since the TMJ and the dental structures are interconnected and interrelated to the overall body alignment and function and visa versa.

Rebalancing body structures and functions may be appropriate during treatment since most TMJ patients have musculoskeletal problems as well.

Treatment of TMJ is divided into three phases

• Phase 1
  
  
  
  
  The goal of this phase is to reduce and eliminate joint and muscle pain, address structural problems throughout the body and educate the patient as to how to help themselves. The most common form of treatment at this stage is a splint or orthotic appliance.
  Treatment also usually includes exercises, medications, lifestyle changes and stress management.
  The following steps are normally taken...
  1. Construct an occlusal splint, using the relaxed position of the muscles of the head and neck to place the lower jaw in an optimum physiological rest position
  2. Reduce and eliminate TMJ problems
  3. Correct postural distortions
  4. Educate the patient as to how to help themselves
  There are many types of occlusal splints or orthotics. We will advise you what is the most appropriate splint for your particular needs.
• Phase 2
  This stage involves correcting body irregularities.
• Phase 3
  The goal of this phase is to maintain the support of the TMJ joint 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 in phase3 including...
  1. Long term splint use
  2. Bite adjustment
  3. Dental reconstruction
  4. Orthodontics
  5. TMJ surgery
  Often treatment will include a combination of these therapies.

THE CORRECT BITE

Traditionally, to find the correct bite dentists would focus on the teeth and TMJ joints ignoring the role of the muscles and associated structures. It was believed that there is an ideal reproducible position for the TMJ Joints that the dentist could guide the patient into and then treat the teeth to produce an “ideal bite.” All other components of the system, the ligaments, muscles and nerves would accommodate and adapt to this new correct bite.

Now there is a better way called Neuromuscular Dentistry that emphasises the need to establish a bite based on the muscles that move the jaw rather than the position of the teeth as they come together. Neuromuscular Dentistry recognizes that the muscles that move the jaw must be in a comfortable, relaxed position so that they don't conflict with the teeth and temporo mandibular joints.

The first step in Neuoromuscular Dentistry is to find the optimal position of the jaw where the muscles of the neck and head are relaxed and at rest. In this position, the muscles will heal , pain trigger points will go away and joint capsules will heal.

Once the temporo mandibular joints are in physiologically comfortable, resting position, the interrelationship and function of the joints, muscles, bones and teeth is at its best.

This comfortable position of the TMJ is guided by the muscles and stablized by the biting position of the upper and lower teeth.

Harmony of the teeth, the facial, head and neck muscles and the TMJ is restored.