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TMJ

TMJ Overview

Temporomandibular joint (TMJ) syndrome or TMJ joint disorders are medical problems related to the jaw joint. The TMJ connects the lower jaw to the skull (temporal bone) under your ear. Certain facial muscles control chewing. Problems in this area can cause head and neck pain, a jaw that is locked in position or difficult to open, problems biting, and popping sounds when you bite.

TMJ Causes

TMJ can be caused by trauma, disease, wear due to aging and/or habits.

Trauma: Trauma is divided to microtrauma and macrotrauma. Microtrauma is internal, such as bruxism (grinding the teeth) and clenching (jaw tightening). This continual trauma to the temporomandibular joint can change the alignment of the teeth and jaws. Muscle involvement causes inflammation of the capsular membranes surrounding the joint. Teeth grinding (bruxism) and clenching are habits that may be contributing factors or symptoms in people who complain of pain in the temporomandibular joint or have facial pain that includes the muscles involved in chewing (myofascial pain). Macrotrauma, such as a punch to the jaw or impact/whiplash in an accident, can break the jawbone or damage the disc.
  • Bruxism: Teeth grinding as a habit can result in muscle spasm and inflammatory reactions, thus causing the initial pain. Changes in the normal stimuli or height of the teeth, misalignment of the teeth, and changes in the chewing muscles may cause temporomandibular joint changes. Generally, someone who has a habit of grinding his or her teeth will do so mostly during sleep. In some cases, the grinding may be so loud that it disturbs others.
  • Clenching: Someone who clenches continually bites on things while awake. This might be chewing gum, a pen or pencil, or fingernails. The constant pounding on the joint causes the pain. Stress is often blamed for tension in the jaw, leading to a clenched jaw.

Osteoarthritis: Like other joints in the body, the jaw joint is prone to have arthritic changes. These changes are sometimes caused by breakdown of the joint (degeneration) or normal aging. Degenerative joint disease causes a slow progressive loss of cartilage and formation of new bone at the surface of the joint. Cartilage destruction is a result of several mechanical and biological factors rather than a single entity. Its prevalence increases with repetitive microtrauma or macrotrauma, as well as with normal aging. Immunologic and inflammatory diseases contribute to the progress of the disease.

Rheumatoid arthritis: Rheumatoid arthritis causes inflammation. As it progresses, the disease can cause destruction of cartilage and erode bone, deforming joints. It is an autoimmune disease involving the antibody factor against immunoglobulin G (IgG). Chronic rheumatoid arthritis is a multisystem inflammatory disorder with a persistent symmetric joint involvement. Certain infectious diseases may be the cause of rheumatoid arthritis.

TMJ Symptoms

  • Pain in the facial muscles and jaw joints may radiate to the neck or shoulders. In addition, you may experience referred pain or trigger points distant to the affected jaw joints. Joint muscles and/or ligaments and/or tendons may be overstretched. You may experience muscle spasms from TMJ. You may feel pain every time you talk, chew, or yawn. Pain usually appears in the joint itself, in front of the ear, but it may move elsewhere in the skull, face, or jaw.
  • TMJ can cause ear pain, ringing in the ears (tinnitus), fullness in the ears and hearing loss. Sometimes people mistake TMJ pain for an ear problem, such as an ear infection, when the ear is not the problem at all. To formulate a correct diagnosis, a referral to an ENT (Ear, Nose and Throat doctor) may be necessary.
  • When the joints move, you may hear sounds, such as clicking, grating, and/or popping. Others may also be able to hear the sounds. Clicking and popping sounds are often common. This could mean that your temporomandibular disc may be in an abnormal position. Sometimes no treatment is needed if the sounds give you no pain.
  • Your face and mouth may swell on the affected side.
  • The jaw may lock wide open (dislocate), or it may not open fully at all. Also, upon opening, the lower jaw may deviate to one side. You may find yourself favoring one painful side or the other by opening your jaw awkwardly. These changes could occur suddenly and without warning. Your teeth may not fit properly together, and your bite may feel odd.
  • Due to muscle spasms, you may experience trouble swallowing.
  • Headache and dizziness may be caused by TMJ/TMD. You may even feel nauseous or vomit as a result.

DIAGNOSIS

It is necessary to have a knowledgeable clinician perform a complete diagnosis before a successful treatment program can begin. This diagnosis may include the following:
     A complete medical and dental history.
     A complete clinical examination including:

Exams and Tests

Medical history

In diagnosing your jaw problem, the doctor will ask the following questions:
  • What kind of pain do you have?
  • Is it an ache or a throbbing pain or a sharp stabbing pain?
  • Is the pain continuous or intermittent?
  • Can you outline the area of pain on your face with your finger?
  • What helps to alleviate the pain? What aggravates the pain?
  • Do you grind or clench your teeth? Do you bite your nails or chew on any objects, such as pens or pencils?
  • Do you hold the telephone with your shoulder against your ear for a long time?
  • Do you chew gum often? For how long?
  • Do you have any oral habits that you have not mentioned?

Physical examination

During the physical examination, the doctor will examine your head, neck, face, and temporomandibular joints, noting any of the following:
  • Tenderness (pain) and its location
  • Sounds, such as clicking, popping, grating
  • The mandible (lower jaw) range of motion and whether it is easy to open and close and can move from side to side and forward-backward without any pain
  • Your assessment of pain on a scale from 0 (no pain) to 10
  • Wear on buccal cusps of the mandibular teeth, especially the canine
  • The rigidity and or tenderness of the chewing muscles
  • How your teeth fit together: normal, open bite, crossbite, overbite, dental restorations, or skeletal deformity

  1. Transcranial Lateral Oblique X-Rays (8-view), Tomograms (3 cuts), CT and/or MRI procedures may be necessary to evaluate the condition and shape and/or position of the joint bones and meniscus of the TMJ.
  2. Electromyographic evaluation of the tension (hyperactivity) in the jaw and facial muscles surrounding the joint.
  3. Range-of-motion studies and jaw tracking tests to determine the condition of the joint during function and at rest. (Myotronics, Seattle, Washington)
  4. Examination of posture and body symmetry.
  5. In some cases, the clinician may request a MMPI (Minnesota Multiphsic Personality Inventory) to evaluate possible psychogenic factors.

In addition, the examination or referrals may include:
  • Ear, nose and throat examination to rule out other conditions when necessary (acoustic neuroma).
  • Neurological examination when necessary.
  • Orthodonic examination when necessary.
  • General internal medical examination when necessary.

TREATMENT


Non-surgical treatment

The diagnostic procedures enable the clinician to assess the severity and the cause(s) of the condition. In many cases, the symptoms are related to muscle hyperactivity and/or dental and skeletal mal-relationships with minimal joint damage. In these cases, successful treatment options are non-surgical, and may include:
  1. Application of moist heat and cold spray.
  2. Injections of a local anesthetic into muscle trigger points.
  3. Physical therapy (passive and active jaw exercises).
  4. Medication (muscle relaxants, anti-anxiety medication, anti-depressants, anti-inflamatories, and pain relieving medication)
  5. Multivitamins, minerals, and natural enzymes.
  6. Neuro-muscular orthotics to restore the proper vertical, lateral, anterior-posterior muscle resting length and the most comfortable physiologic position of the condyle to the eminence-fossa-meniscal complex.
  7. Biofeedback and acupuncture.
  8. TENS (transcutaneous electrical neural simulation) Myomonitor.
  9. Coronoplasty (reshaping anatomy of tooth structures)
  10. Orthodontics to restore proper relationship between the upper and lower jaw and teeth; after this relationship has been established by use of a neuro-muscular orthotic.
  11. General dentistry to restore missing teeth and maintain proper relationship of the maxilla and mandible by use of partial and complete dentures, crowns, bridgework, and dental implants after this relationship has been established with a neuro-muscular orthotic.
  12. Local anesthetic and cortisone injections into the joint to relieve pain and swelling.

Surgical treatment

treatment In other, more severe cases, surgery is necessary to correct bone and tissue damage caused by disease, trauma, chronic dysfunction, and iatrogenic causes, i.e., Proplast. These may include:
  1. Arthroscopic examination (lysis and lavage) and arthroscopic surgery to treat early and less severe damage to the joint.
  2. Surgery to repair damaged bony joint and meniscal surfaces due to osteoarthritis. This is a wear and tear arthritis. This is done by use of a Vitallium articular eminence device. The device has been used over 30 years. There have been multiple long-term studies of its bio-compatibility and efficacy.
  3. Total jaw joint implants are needed to restore extensively damaged joint surfaces. These devices are a Vitallium ramus and acrylic condylar head functioning against a Vitallium articular eminence device. This system has been in use for 30 years.

If you wish to be seen as a TMJ patient at Mid-Valley Dental Care, please download and complete the following form: TMJ Form 402A

TMJ and Whiplash

(Various articles intended for attorneys)
For specific articles please contact: Terence Lau, D.D.S., F.I.C.O.I., F.A.A.C.P.

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