“I want my life back!”
There is Spectrum of TMJ Disorders from mild to life destroying symptoms. Severe symptoms should be treated more aggressively before an acute problem becomes a chronic pain condition.
DOCTORS DO NOT HEAL PATIENTS, RATHER THEY REMOVE THE IMPEDIMENTS TO HEALING, THE BODY HEALS ITSELF!
Mild TMJ disorders are easily solved with a grinding appliance worn at night or by changing habits that exacerbate the system. Clicking and Popping in the absence of pain can be watched and never treated. Treatment for mild, short-term discomfort include moist heat, soft diet, over the counter analgesics, jaw exercises, relaxation techniques, adjusting posture during day and night avtivities, elimination of habits like chewing gum, nail biting and pen or pencil chewing.
Early acute problems often turn into chronic life destroying chronic pain syndromes. Early treatment can prevent exacerbation.
The first type of severe TMJ problem is an acute close-lock of one or both Temporomandibular joints. Close-Lock refers to displacement of the disc inside the TMJoint off the head of the condyle. This is a type of Internal Derangement of the TMJoint. An open lock or subluxation is a very different disorder.
The most common type close lock is unilateral or one sided. When the patient tries to open they can seperate their front teeth about 15-40 mm with minimal pain but additional opening cause sharp pain on the side of the lock. Watching how the jaw moves is important to identifying there serious problem. Opening is usually straight for the first 25 mm but the there is tightness and/or pain in the locked joint and the jaw deviates to the side of the dislocation.
If the right joint is locked the jaw will move to the right with additional opening. The patient can move their jaw sideways toward the locked side but cannot move far io the opposite side without sharp pain. This is because the disc is displaced medially anteriorly and the disc prevents translation or sliding movement of the jaw on the locked side only. Rotation occurs around the locked jointwith additional opening.
This is an emergeny conditon that is often mistreated by dentists. Moist heat, watchful waiting and analgesics do not unlock the disc. The disc is normally held in place by the Retrodiscal Lamina which is filled with blood vessels, nerves and elastic tissue. This delicate tissue that is meant to stretch and tether the disc gets shredded between two bones. The tearing and damage to this tissue is what causes severe pain on opening. Forceful opening of the jaw incorrectly can permenantly destroy this tissue and lead to severe future problems. Healing back to normal physiology is impossibe when the disc is displaced.
An acute close-lock can become a chronic lock and the tissue gradually stretches and the acute pain diminishes but the body is now unbalances. There is a change in how the muscles, nerves and brain must adapt for function. These changes require muscle adaptation or chronic muscle repetitive strain movements to balance the loss of joint support.
The important point is that prompt treatment to reduce the dislocation is indicated to prevent permanent degenerative changes. that can lead to Chronic TMJ Dysfunction Syndrome.
A second type of acute disorder is Trismus. Trismus is often called “lock Jaw” and it is the inability to open due to muscle spasm or muscle tightness, myalgia or myositis. The net result is severely limited opening. Trismus may be related to muscle injury, long dental treatment, secondary to anaesthetic injections, infection, or other types of trauma.
Unfortunately for patients Trismus can also occur in conjunction with an acute close-lock. Most physicians and dentists are not good at defining the cause of decreased opening and/or muscle spasm.
Muscles are a frequent culprit in long term TMJ problems and must be addressed to allow the body to heal. 90-95% of all pain patients experience is muscular in nature contrary to the patients perception. This is because of pain referral from muscles to other structures. TMJ Disorders are often called “The Great Imposter” because symptoms masquerade as other problems and the proper diagnosis is missed or misdiagnosed.
Muscle Spasm is not the same as Muscle Splinting which is very different from Myositis.
Myofascial Pain and Dysfunction results from acute conditions and repetitive strains leading to chronic muscle shortenis with taut band and trigger points.
I will briefly define many types of muscle issues briefly. Please understand that volumes could be written on each issue.
Muscle Splinting is not a disorder or a disease state but rather a healthy physiologic occurence where following injury the muscles tighten and shorten to protect the injured area. This is positive during the acute phase of injury but can lead to chronic problems if the underlying condition is not corrected. An example would be an acute close-lock ot the TMJoint that is not reduced. Muscle splinting prevents additonal damage but also makes it harder to reduce the dislocation.
Muscle Spasm is an acute and sudden involuntary contraction of muscle tissue.. This spasm may be instantly sharp and painful or almost imperceptibe. A cramp is a type of short term acute spasm that usually relaxes quickly but the terms are not interchangeable. Muscle Spasm may occur due to electrolyte imbalance leading to changes in physiologic function. Nerve dysfunction or inapproriate nerve signaling can also cause spasm. Acute Muscle spasm may occur as the first step after an injury to accomodate rapid slinting of the injured area.
Myalgia is a more general term and it refers to muscle pain or pain originating in muscles from any cause. Myalgia can be a symptom of many divesre disorders and diseases.
Myositis is an inflammation of the muscles and can have many causes from injury, metaboloic causes, viral infection, immune disorders. A temporary myositis can occur in the medial pterygoid muscle following dental anaesthesia (block) and wisdom tooth removal from trauma. This will present as Trismus but it is distinct and different that a close-lock joint. A myositis and a close -lock joint can happen simultaneously from a common injury.
Post exercise or overuse muscle pain is frequent in TMJ patients who excessively chew gum, clench or grind their teeth or have other noxius habits that affect the muscles. Cheerleaders joint is a condition usualy associated with young girls screaming and shouting for long times overdoing function leading to injury. Post exercise pain may be due to build up of lactic acid and can present as myosits , muscle spasm or muscle splinting. Overuse of muscle or joints can lead to acute pain and loss of function but is usually self limiting. Cheerleader Joint can also present as an open-lock. This is a condition where the condyle of the mandible has hyperextended over the eminence (subluxation) and is mechanically stuck on the other side of the eminence. This can be accompanied by many muscle issues which can make reducing the dislocation more difficult. This patient will usually have a wide open bite with only one or two back teeth touching.
Myofascial Pain and Dysfunction (MPD) is different than the previous problems. It is a long-term problem from chronic muscle misuse over an extended period of time. It isactually the physiologic systems of the brain, nervous system and muscles to effectively function in an injured or out of balance state. The muscles that are chronically misused shorten. Their are changes to the muscle spindle a special physiologic organ within the muscle that regulates muscle length. Development of chronic problems are a combination of muscle splinting continuing too long and physiologic changes within the muscle. MPD is considered a regional condition.
Fibromyalgia is in many ways similar to Myofascial Pain and Dysfunction but is widespread muscle disorder often considered to be an imune or biochemical problem. It is associated with rheumatic diseases and chronic fatigue. It can be initiated by Lyme diease or viral infection. It is often treated with Neurontin or Lyrica. There are many who believe that Myofascial Pain and Dysfunction are variations of the same condition. Chronic pain can cause development of either problem.
Research has shown that disrupted sleep can create fibromyalgia symptoms. A study by Moldofsky actuall showed that young health college students who had their Delta sleep and Slow wave sleep deliberately disrupted developed fibromyalgia symptoms. When the experiment ended many of these students continued to experience the fibrimyalgia like pain. They also developed Alpha-Intrusion into Delta sleep a marker for fibromyalgia. Patient s with TMJ disorders frequently have sleep disordered breathing. Sleep Apnea, Snoring and upper airway resistance syndrome can all lead to fibromyalgia.
HEALING TMJ DISORDERS MUST ADDRESS underlying problems and initiating causes but sometimes there is ongoing muscle issues after the initiating problem has healed. These muscle problems can become ongoing due to changes in the function of patients.
NEUROMUSCULAR DENTISTRY CREATES A STAGE FOR HEALING. The ultra-low frequency TENS allows muscles to heal naturally by pumping out waste products from the muscle tissues and bringing in nutriton from the blood due to increased blood flow. The relxed muscles are then used in creation of a diagnostic physiologic orthotic. As the muscles heal and the posture self corrects the orthotic is adjusted to continually balance the system.
Underlying structural issues still need to be addressed. Postural conditions, airway and breathing, sleep and many other issues are dealt with. The impediments to healing are identified and removed so healing can occur. Chronic muscle pain sometimes must be treated with physical therapy, spray and stretch, trigger point injectios, stretching and/or massage. The muscle problems may have reached the point where they need to be aggressively treated to return them to normal homeostasis.
The most basic concept of TMJ treatment is a return to homeostasis. Creating a landing point for the jaws to close where there is little to no pathologic muscle adaptation. Breathing and swallowing are the two most important fuctions of the jaw healing requires care attention to airway issues. Swallowing occurs 2000 time a day and is the only time we fully occlude our teeth completely in the absence of pathological parafuction. Swallowing to ideal physiologic occlusion is a reset mechanism for our nervous system, our muscles, the combined physiologic function controls posture.
Healing requires a healthy healing space, that is what the physiologic diagnostic orthotic give the patient. The built up problems often just dissipate on their own but in others must be addressed iitem by item on the path to health.
Surgical treatment is best avoided when possible but is occasionally required .