Drawbridge Seminars -- Bringing Research to Practice

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• How would I know if I have a “TMJ” problem?

“TMJ” is not a single disorder but a group of disorders that tend to have a common constellation of symptoms. In other words, these disorders are not all alike. Some are relatively simple; others can be quite complex. Some individuals notice a change in their dental bite associated with the TMJ problem. The symptoms that might accompany a problem of this kind could include one or more of the following:

• Pain in the face or jaw
• Pain that seems to be in the ear (may be from the jaw joint)
• Headaches, particularly when they occur in the temples
• A feeling of tightness or pain in the jaw upon awakening from sleep
• Sounds from the jaw joints, such as clicking, popping, grating or grinding
• Difficulty with opening the jaw (tightness or pain) such as with yawning or at dental visits
• A sensation of catching or temporary locking of the jaw joint when opening the mouth for talking, yawning, singing or with eating.

An important thing to know is that the symptoms are typically not the problem but an expression of an underlying condition. Treatment that is focused only on relief of symptoms may not adequately address the underlying problem. If “treatment” of this kind should occur, in spite of achieving short-term relief, the actual problem may return, accompanied by the same group of symptoms. Definitive treatment will be focused on not only relieving symptoms but also on addressing the problem that is causing the symptoms. This approach to treatment will be more likely to keep the problem from reoccurring.

• What Causes TMJ?

Temporomandibular Disorders ("TMJ") represent a broad category of conditions with similar symptoms, not a single condition. These conditions are frequently a result of more than one factor, which may include hormonal, genetic, dental occlusal, and anatomical factors that may have predisposed the individual to developing a TMD. The actual onset of the symptoms may be insidious (not triggered by any obvious event) due to the presence of long-standing predisposing factors. However, onset can sometimes be precipitated by trauma, a bite change, or parafunction (clenching or grinding the teeth). There can also be factors that may prolong or perpetuate the condition, including parafunction, bite instability, systemic disease, and age-onset osteoarthritis.


• My jaw clicks and pops but I don’t have pain. Do I need treatment?

In the general population, 30 – 40% of people have clicking or popping sounds in one or both jaw joints. TMJ clicking is common, but it is not normal. Only one in five people will develop pain or other symptoms, such as catching or locking of the joints. If your jaw clicking/popping is not changing over time, you may not need treatment. But if clicking/popping is becoming louder or more frequent, or if you notice catching in the joint, you should seek knowledgeable help right away. Be sure to bring changes of this kind to the attention of your dentist. It is not always favorable that the joint sounds stop occurring, as this may be accompanied by pain and limited opening. If the clicking changes to a grinding or grating sound, you should seek advice from your dentist as this may be the start of osteoarthritis of the TMJ. Attempt to chew on the side that produces the least clicking and the least discomfort.

• What can I do myself that might relieve my “TMJ” symptoms?

The following are often helpful in temporarily relieving joint and muscle symptoms:

• Avoid wide or prolonged mouth opening.

• Eat a soft diet and be careful in other uses of your jaw. Avoid prolonged talking or singing.

• Take over-the-counter anti-inflammatory medications (maximum dose, if tolerated).

• Apply moist heat to your face and jaw (hot, moist wash cloths).

Although the symptoms may improve temporarily using these strategies, the underlying problem that is causing the symptoms is not being addressed by these measures. We strongly recommend that you seek knowledgeable help to diagnose and treat the condition that is causing these symptoms.

• Are my headaches related to my “TMJ” problem?

There are several types of headaches. A few occur relatively frequently. Others are less common. By far the most common type of headache is referred to as a “tension type” or “muscle contraction” headache. These headaches are characterized by a steady, dull, achy type of pain. They can be episodic or nearly constant. They can also be relatively mild to very intense. This type of headache can be related to jaw problems or “TMJ” and when they are, they most commonly occur in the temples. Other “muscle contraction” headaches may occur at other locations and may have other causes. For instance, headaches at the back of the head may be related to tight neck muscles because of poor posture, prior injury, or cervical misalignment. Patients who have “TMJ”-related headaches will very often, but not always, also have headaches at the back of the head.

Another relatively common type of headache is called “migraine” headache and these are typically characterized by a throbbing quality of pain that corresponds to the beating of the heart. For this reason, they are sometimes called “vascular” or "neurovascular" headaches. These can be very severe and debilitating. There are now a number of quite good medications that are effective against true migraine headaches.

Some patients will have a combination of muscle contraction and migraine headache. This is referred to as a “mixed” headache pattern. Each may have its own cause, so a patient with a mixed headache may have a muscle contraction headache that is related to a jaw problem but the migraine portion of the headache pattern may have an entirely different cause. Patients with a mixed headache pattern often can recognize the difference and can tell which one they are having at a given time.

A common misperception is that any headache that is very severe is a “migraine” headache. In spite of the headache being severe, if there is not a throbbing quality to the pain, it may not be a migraine headache. Muscle contraction headaches can also, at times, be quite severe. The primary distinguishing characteristic of a true migraine headache is the throbbing quality.

Headaches that occur in the temples and are of a steady, aching quality (no throbbing), regardless of the severity, may be related to problems with your bite or to a jaw problem. These can often be effectively managed by a dentist who is knowledgeable regarding this type of problem.

A more complete discussion regarding headaches can be found in the Education Materials —> Patient Education Pamphlets section.

• I grind my teeth. Can that be treated?

Clenching and grinding of the teeth is known as bruxism and because it can produce symptoms such as headache, jaw pain, “ear” pain, etc., as well as damage the teeth, management of bruxism is often indicated. There are several possible causes of bruxism, including inadequate restful sleep and excessive caffeine or alcohol. Many people who clench and grind their teeth when sleeping also clench or grind when awake. Medications used for improving sleep may reduce bruxism. However, occlusal appliances (“night guards”, “bruxism splints”, etc.) can be useful to prevent tooth damage and have been shown to reduce headaches and facial pain that is caused by the bruxism. Such an appliance will not, however, cause you to quit grinding or clenching. A properly designed occlusal appliance is particularly indicated when there is “ear” pain referred from the temporomandibular joints.

Tooth clenching and grinding has previously been attributed to stress and although stress can certainly be a compounding factor, it is probably not the only factor involved. Patients who carry tension in their jaws often also have neck stiffness and pain. Sometimes problems with the dental occlusion (bad bite) can also contribute to the clenching / grinding. Bite problems, like stress, may not be the sole cause but can certainly make the clenching and grinding worse. We recommend that you see a knowledgeable dentist to have this condition evaluated.

• Will an over-the-counter (drugstore) device help with my “TMJ” problem?

For uncomplicated jaw problems, some devices may relieve symptoms on a short-term basis. The style that requires you to bite firmly into heated material will hold your jaw in an unnatural, compressed position. Flexible devices can cause tooth movement. If the device is hard to keep in place at night, this can trigger tooth clenching in your sleep in an attempt to stabilize the device. If you have jaw catching or locking, the problem can be made worse by wearing one of these appliances.

• Can you recommend someone near me who I can see for my “TMJ” problem?

We are not in a position to refer you to someone in your area. Please go to the web site of the American Academy of Orofacial Pain, AAOP.org (link) and contact one of the people on their list who may be close to where you live. Often, if that person is not very close to you or for other reasons cannot see you, they will know someone in your area who is knowledgeable regarding “TMJ”.

Many dentists will advertise that they “treat TMJ”. This is not necessarily an indication that they are knowledgeable about such problems. There is very little training in dental school regarding these problems. It may be worthwhile to call a number of dental offices that do not advertise that they treat TMJ problems and ask them specifically who they consider to be the most knowledgeable person in your community. If the same name is mentioned by several offices, that may be the best person for you to see.

• Why do women seek “TMJ” treatment more than men?

Several studies, done in different countries, have clearly shown that women seek treatment for temporomandibular disorders at an average rate of about 7 times greater than men (these studies have varied from 3:1 to 9:1, women to men). However, in studies that have examined general populations groups (not patients), the prevalence of symptoms among women, compared to men, is about 2:1.

The occurrence of TMDs in women, based on age, parallels the child bearing years. This finding strongly suggests that hormonal factors may have a significant influence, perhaps related to an increased extensibility of ligamentous tissues that occur on a monthly basis with menses. Other possible hormonal effects include changes in pain perception related to the menstrual cycle have been proposed but at this time there are no firm conclusions to this intriguing question.

• What precautions are appropriate during routine dental visits for patients with known “TMJ” problems?

Routine screening of all dental patients can be incorporated into a dental practice fairly easily. We strongly recommend this. When this is the office procedure, the clinician will usually know if there is a TMJ problem with each patient being treated. It also allows the clinician to either treat or refer the “TMJ” patient in the early stages of the disorder before it becomes more of a problem.

With certain temporomandibular disorders, even routine dental care may exacerbate symptoms and/or precipitate progression of an underlying condition. For patients with pain on opening and/or limited range of motion, dental procedures of all kinds should be kept to a minimum until the cause has been thoroughly diagnosed and appropriate treatment undertaken. Elective treatment should be postponed and only critical dental care should take precedence until the TMD concerns have been stabilized. Provide support underneath the patient’s mandible during all procedures and keep the appointments short. For some patients, placing a small mouth prop that they can close against will reduce muscle fatigue.

• Does insurance cover “TMJ” diagnosis and treatment?

Insurance coverage for temporomandibular disorders varies from no coverage to modest coverage. If you have both medical and dental insurance, in the best of circumstances each may pay a portion of the expense. Because TMD treatment involves joints and muscles primarily, these disorders should be seen as medically comparable to the treatment of other orthopedic joint problems. In that sense, they are medical in nature, from an insurance perspective, rather than dental.

What kinds of treatment insurance companies cover can also vary greatly. Some will cover diagnostic procedures but nothing else. A few limit coverage to only surgical treatment. Others may cover appliance therapy but not physical therapy or surgical treatment. There does not seem to be any consistent logic behind decisions regarding benefits. One thing is very clear — decisions regarding insurance coverage are not based on the individual patient’s needs.



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