Jaw Joint and Muscle Sprain/Strain: JAMSS

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A new article in Inside Dentistry (reference below) reveals research that 50% of patients with TMJ disorders (TMDs) the initial onset was a result of Dental Care.
These problems may occur due to direct trauma to the jaw muscles or joints, sustained contractions of jaw muscles, and/or prolonged stretching of the masticatory muscles and joints, ligaments and tendons.
In my experience, this is especially true with procedures like lower molar extractions when bite blocks are not used, root canal therapy on second and third molars and other long appointments.
It is likely that most patients experiencing this were predisposed in some fashion to having jaw issues.

There are many things that can be done to help prevent these problems:
1. The judicious use of Travell Spray and Stretch technique following a long dental appointment can often relax the muscles and allow healing especially if done early. I frequently do this immediately after an appointment and before and/or aftyer on patients with pre-existing issues. Most pain related to TMJ dysfunction is actually Myofascial Pain and Dysfuntion or MPD.

2.Ice and or heat packs over jaw and neck muscles. This is similr to a post exercise muscle pain. Moist heat or heat alternated with ice can be extremely helpful.

3. I am an enormous advocate of the Aqualizer, an oral appliance that utilizes hydraulics to equalize the bite and relax musles. It has been shown to relax not just the jaw muscles but also neck, shoulder and back muscles over a couple of hours.

The use of ULF-TENS is amazing for preventing and allowing rapid healing of this type of problem. the ULF-TENS preconditions the muscles for their “Work Out” and afterward gentle pulsing helps relax muscles by increasing blood flow and pumping out waste products, such as lactic acid.

The Myomonitor is the original ULF-TENS and has an exceptional 50 year safety record. It has been show to be extremely efficient at relaxing muscles physiologically and this has beeen confirmed by surface EMG. The Myomonitor has a second aspect that is also very important, it acts as a SphenoPalatine Ganglion Stimulator and prevents onset of Axis two issues related to stress, anxiety and pain.

Axis two is H-P-A action or Hypothalamus-Pituitary-Adrenal System. This has been known since the work of Hans Selye first opened the medical communities eye to the effect of stress on the human body. SPG Blocks or Sphenopalatine Ganglion Blocks are also amazing at treating many TMJ issues as well as migraines, cluster headaches, anxiety and other pain issues.

It effectively helps turn off sympathetic overload and allow the parasympathetic system to predominate to allow healing.

Most TMJ disorders whether intracapsular or extracapsular are the result of repetitive strain injuries due to bit issues or patient behavior, ie cheerleaders joint or gum chewing. Adding a long dental procedure , trauma of extraction or injection thru muscle can be a significant factor in devloping long term problems.

Reference. Post Operative Jaw and Muscle Pain, a gGuide to Risk Assessment, Prevention and Treatment. Inside Dentistry April 2017 69-76
Brady LA, Fricton J, Eli B

J Am Dent Assoc. 2016 Dec;147(12):979-986. doi: 10.1016/j.adaj.2016.06.017. Epub 2016 Aug 31. Preventing chronic pain after acute jaw sprain or strain.
Fricton J, Eli B, Gupta A, Johnson N.…

What Is The Best TMJ Treatment in Chicago?

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The Best treatment for a TMJ disorder is very dependent on the exact symptoms and causes of the TMJ disorder in a particular patient. Determining the best treatment for an individual patient is usually done during a face to face visit but I can give several guidelines here.

Link to over 100 patient video testimonials: https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos

Night Guard Treatment:

If you only have pain at night or just after awakening you are probably a good candidate for a Bruxism Appliance. These are designed to protect the teeth during nocturnal grind or bruxism.

This type of appliance is very effective for people who grind their teeth but can frequently cause more pain in patients who clench because it can createmore forces during clenching.

Clenching and grinding of the teeth during sleep is often associated with Sleep Disordered Breathing, including Snoring, RERA, UARS or Upper Airway Resistance Syndrome, Hypopnea or Apnea. These are dangerous conditions that can be made worse in some patients by a typical night guard.

Morning Frontal Headache and daytime tiredness are associated with sleep disordered breathing. Dentists trained in treating sleep disordered breathing can be found at AADSM.org .I have taught hundreds of dentists the basics of sleep apnea treatment.  Ideally, a diplomate of the American Board of Dental Sleep Medicine is your first choice.

The NHLBI or National Heart Lung and Blood Institute considers Sleep Apnea to be a TMJ Disorder.

Patients who have an acute close-lock of one or both TMJoints are Emergency patients. The wrong treatment can lead to permanent disability and the development of chronic pain syndromes.  Short term treatment is described below, long term stabilization will be discussed later.

An acute close-lock of one or both TMJoints can be evident upon wakening or may occur during the day. This is a type of Internal Derangement of the TMJoint. Patients who have chronic clicking or popping of one or both joints can have the disk get stuck anterior to the condyle of the mandible.

The symptoms for a unilateral close-lock of the TMJoint is reduced opening and sharp pain in the joint on the locked side. Attempting to open further gives increased pain and the jaw deviates to the side of the lock. If clicking was present previously it usually will be gone on the effected side.

The disk or meniscus is displaced and the condyle is pressing on the very delicate Retrodiscal Laminate. Trying to force the jaw open can permanently damage this important tissue.

Emergency Rooms are notorious for forcing the jaw open and causing increased pain and damage. For several years I taught emergency room physicians how to reduce close-lock dislocations. It is essential to support the jaw and prevent full closure or even a properly reduced joint can easily relock.

Many dentists and oral surgeons will place patients on a soft diet and prescribe non-steroidal anti-inflamatories such as Advil, Alieve or Aspirin. This is extremely risky approach to treating a close-lock. The longer the lock continues the more likelihood of permanent joint damage to the disk and retrodiscal lamina and the development of chronic pain.

The best approach is to reduce the dislocation as soon as possible and immediately supporting the bite with a temporary support to prevent recurrent locking. Unfortunately most dentists have no idea how to reduce a locked joint.  The reduction can be done with jaw manipulation either awake or sedated.  Acute close-lock can often be reduced easily by stimulation of specific reflexes in the jaw and pharynx.

Various appliances can be used to prevent damage and ease the reduction of more difficult locks these include unilateral pivotal splints for a lock in just one joint or a Rocobado spring loaded appliance for bilateral locks

Acute Open-Lock Dislocation or Subluxation

This is caused by a hyperextension of the jaw during opening.  It can happen from a yawn or biting ito very thick sandwich.  It can also occur immediately following a motor vehicle accident, usually being rear-ended.  It can also happen after difficult dental procedures and/or extractions especially of lower molars.

The condyle of the mandible actually moves out of the norman joint position and extends past the eminence where it gets stuck.  The patient will usually notice pain on the effected side and only 1 or 2 back teeth will touch on closing.  This tends to be frightening initially.This is again an Emergency, however this is easily treated at the ER in the hospital.

Patients with open locks need to learn not to hyperextend and to control maximum opening.  Prolotherapy can be used to tighten up the ligaments and tendons for a more stable joint that cannot hyperextend.  Surgery is another option usually best avoided.

Cheerleaders Joint

This is another condition that occurs frequently in cheerleaders, hence the name.  Shouting and cheering for a long time hyperextends the joint and it can create an open lock situation described above.  Sometime this will self reduce but there can be tremendous pain with jaw movement.  This is primarily muscle overuse pain and rest, stretching and anti-inflammatory medications is the best road.  It is vitally important to rule out close-lock and open lock conditions to avoid problems.

Post Dental Treatment:  Medial Pterygoid Myositis, Myalgia/Myosits

These conditions can occur following dental work and can be secondary to injections, inflammation joint or muscle tearing or stretching etc.

There is very little opening similar to a close lock but this is due to tight shortened muscles.  Time and anti-inflamatories can help.    There are variations of what is the cause, Muscle Splinting is a normal physiologic process where the muscles tighten up to protect an injured area.  Unfortunately, this can become chronic muscle shortening with muscle tightness, taut bands and trigger points.   Muscle Spasm is usually very painful but short in duration.  It is like a “Charlie Horse” of the jaw muscles.  Myositis is the slowest to resolve and is related to inflammatory changes in the muscle and can be quite painful.  Time, anti-inflamatories and stretching while icing helps.

FIBROMYALGIA AND MYOFASCIAL PAIN AND DYSFUNTION are two specific groups of muscle pain that must be included in this discussion of what is the best treatment.

All of the above conditions respond extremely well to Ultra Low Frequency TENS (ULF-TENS)  There are two units available for ULF-TENS the Myomonitor from Myotronics and and the BioTens from BioResearch.  No other TENS should be utilized.

These conditions also respond well to physical therapy, massage therapy and other manual techniques as well as ultrasound, interferential and micro current.  An Aqualizer Appliance ™ can be excellent short term treatment.

It is essential to determine if a close-lock internal derangement is also present.  Delay can lead to permanent damage.

Long-Term Chronic TMJ Dysfunction

TMJ is often called the Great Imposter due to the many associated symptoms that accompany the TMD

There are numerous types of appliances available including centric occlusion, centric relation and physiologic orthotics.  There is a specialized type of appliance called an NTI which has specific though limited uses.  Appliance can be made for the upper or lower arch.  Ideally, an appliance should always look and feel comfortable for 24/7 wear including for using while eating even if it is not to be worn all the time.  Frequently separate appliances are needed to treat sleep disorders breathing.

Doctors treating difficult cases should have additional training and expertise in a wide range of fields.  I suggest visiting doctors who are a Diplomate of The  American Academy of Pain Management and the American Board of Dental Sleep Medicine.  Physiologic Dentists should be member of ICCMO, the International College of CranioMandibular Orthopedics.  Centric relation dentists should belong to The American Equilibration Society though the best dentists belong to both groups and look at all aspects of treatment.

There are treatments that are often essential elements of complete treatment including management of trigger points with Spray and Stretch Techniques, Trigger Point Injections and /or manual techniques, Utilization of SPG or Sphenopalatine Ganglion  Blocks, and coordination with Specialists in dealing with the Occipital-Atlas-Axis joints, usually Atlas-Orthoganol or NUCCA Chiropracters or Osteopaths.

Jaw problems are related to breathing, airway and posture so experience in DNA Appliances is very helpful for TMD dentists.  Ideally, dentists treating TMJ disorders have a method of non-invasively seeing jaw function with computerized mandibular scans from Myotronics or BioResearch.

An absolute requirement of any doctor treating TMJ disorders is one who sets up time for  a consultation reviewing your medical history, evaluating what has previously been done and how it worked.  Your doctor should be able to clearly explain how all the different symptoms are related.  The best TMJ doctors can usually relieve muscle and headache pain temporarily while you are in the office, welcome your questions make you feel comfortable and never talk down to you.

The best TMJ Dentists are people you feel comfortable talking to.  The first visit will usually start in the consult room not the dental chair.  Acute close locks will usually quickly move to treatment room.  It is vitally important that you do not feel intimidated by your doctor, the best results occur when the patient and doctor work as a team to address problems.

Ideally, no permanent changes are made initially but rather treatment begins with a diagnostic orthotic. The goal of initial treatment is to relieve symptoms as quickly as possible and to understand the underlying etiology of the problem.  Equilibration of the teeth is usually avoided until the patient is comfortable and a treatment plan is accepted.  Wanton grinding on teeth can create new problems and it is hard to “ungrind a tooth”  That said, brand new dental work that caused the problem sometime may need adjustment.  The safest area of adjust is on the front teeth if they hit first but a diagnostic orthotic is still the best starting point.

Long term treatment should be discussed at the initial consultation but is only considered after resolution of pain and dysfunction.



Myofascial Pain And Dysfunction: MPD, The Muscular Component of TMJ Disorders

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Muscle pain and stiffness can be caused by Myofascial Pain Syndrome

myofascial-pain-chicagoMyofascial Pain Syndrome (MPD) is a chronic pain disorder that puts a lot of pressure on certain points in your muscles, which tends to cause pain in other parts of your body that are not directly related to where this pain began. These pressure points, which are located  in taut bands within the muscle, are often called ‘trigger points’ because they’re responsible for the ‘triggering’ of muscle pain that can be felt in other seemingly unrelated parts of your body (also known as referred pain).

When someone is diagnosed with Myofacial Pain Syndrome, their main complaint is feeling muscle pain in their lower back,head,  neck, shoulders and chest area. This pain can range from being very mild to being very extreme, with those diagnosed often feeling a mild aching or burning up to an intense stinging sensation. If you’re someone who’s been recently diagnosis with Myofacial Pain Syndrome, we understand how it can be difficult to get through the day due to your feeling this pain.

There’s a relationship between Myofascial Pain and TMJ as both syndromes directly affect the jaw area. TMJ is an actual disorder of the jaw that directly affects the jaw, jaw joints and the adjoining facial muscles, which in turn causes muscle pain and soreness. Although Myofascial Pain Syndrome is also commonly experienced in the jaw area, it doesn’t stem from any previous disorder.

TMJ and MPD are both frequently caused by repetitive motion injuries.  A motion that is totally comfortable when done once or a few times a day can cause serious problems when it is repeated thousands of time a day.  An example would be a deviate swallow.  We swallow 2000 times a day and doing it incorrectly thousands of times a day for weeks, months or years can create very painful trigger points of MPD.

There’s also a difference between Myofascial Pain Syndrome and Fibromyalgia. Any pain and discomfort felt by those who have been diagnosed with Fibromyalgia tends to be located in one area, with those with a Myofacial Pain Syndrome diagnosis experiencing pain in many areas of their body.

Painful Spots and Trigger Points in MPD

Trigger points refer to certain areas located within a particular muscle that are more sensitive. When this sensitive area experiences any type of pressure, this pressure can easily cause muscle pain to spread to other parts of the body. Some of the more common trigger points affect the head and jaw include:

  • Temporalis Muscle (chewing muscle)
  • Masseter Muscle (facial muscle)
  • Medial Pterygoid Muscle (sinuses)
  • Lateral Pterygoid Muscle (cheeks and joint)
  • Trapezius (neck, shoulders, back)
  • Posterior Cervical Muscle Group (neck)
  • Splenius Capitis (neck, head)
  • Occipital Muscles (neck)

Stop the Muscle Pain

beautiful young woman has a pain in the neckCurrent treatments for Myofascial Pain include Trigger Point Injections, Dry Needling, Spray and Stretch, massage, accupressure, myotherapy  and an Occipital Nerve Block. Trigger Point Injections can help relieve your pain quickly and works by having a small needle containing a numbing ingredient inserted directly into a trigger point.  The trigger point actuall will disappear after the injection, often permanently.  Dry Needling is a method that uses acupuncture needles in order to puncture a trigger point, which helps the muscles to relax. The Spray and Stretch treatment option works by spraying a vapocoolant directly on the trigger point, which is going to relieve pain by acting as a counter-irritant. The use of an Occipital Nerve Block is also an option and works by using a local anesthetic in order to temporarily freeze the part of the body that’s experiencing pain.

Because Myofacial Pain is often experienced in the jaw area, it’s definitely worth your time to see how dental treatments may be able to help alleviate any of your current muscle pain by using highly beneficial TMJ treatments.  Physiologic Dentistry utilizes ULF-TENS that can help eliminate MPD.

Find Out What’s Right For You

In order for you to figure out what the best treatment is going to be for you, you’re going to need a full evaluation in order to determine the exact cause of your pain. Be sure to contact us today so we can work directly with you in order to determine what treatment is going to ultimately work best for you.