Drawbridge Seminars -- Bringing Research to Practice

Guidance For Patients Trying to Understand Appropriate Treatment for a "TMJ" Disorder.

The acronym "TMJ" is a broad, umbrella term that covers a wide range of disorders and "TMJ" is not a specific, well defined condition that is the same for every patient. TMJ-related problems can vary from fairly simple, straightforward conditions to conditions that are quite complex. Confusion arises because the symptoms produced by all of these variations are fairly similar, although the severity of the symptoms may vary. As a result, the distinctly different TMJ-related conditions are often grouped together because of their overlapping symptoms. However, the symptoms are not the disorder, they are an expression of the individual disorder. Treatment, whatever it may be, should address the underlying disorder that produces the symptoms. Symptomatic treatment, alone, is likely to leave a patient predisposed to return of the symptoms.

There is no single, universal treatment that is appropriate for all of these variations. Treatment of a temporomandibular disorder should always be based on a biologically-specific diagnosis. Arriving at a specific diagnosis requires completing a thorough history and a thorough exam. Only after taking the history and doing the exam can the treating individual accurately categorize the underlying condition. The treating clinician should be able to describe to the patient the nature of thier problem and explain the treatment objectives that will hopefully resolve the actual condition, not just the symptoms.

If a biologically-specific diagnosis cannot be defined and described to the patient, it may indicate that the clinician has only a limited understanding of the specific temporomandibular disorder, and the proposed treatment may only address the symptoms. The patient should not be reluctant to ask the clinician if the proposed treatment addresses only the symptoms or if it is focused on treating the condition that is producing the symptoms. If the patient feels uncomfortable with the response to this question, they should continue to seek a more in-depth understanding of their problem.

Described below are several examples of overlapping conditions that may have no distinct demarcations of signs and symptoms. These conditions may be better understood by also reviewing the illustrations and accompanying text provided in “TMJ Anatomy”. See "TMJ Anatomy" in the navigation sidebar.
 

1. Facial Pain with No History of Sounds (clicking/popping) From the Jaw Joints (TMJs)

The symptom of facial pain, alone, is not sufficient to make a biologically-specific diagnosis. To arrive at a diagnosis requires taking a history and doing an examination. When this has been done in a thorough manner, the clinician should be able to explain what is producing the pain. But more than that, the clinician should be able to describe what would be required to address the underlying cause of the symptoms. If the patient is simply told that they have “TMJ”, it should be apparent that the clinician has a limited understanding of these conditions and the patient would be well-advised to seek an opinion from a clinician who can describe the patient’s condition in more specific terms, as well as what would be necessary to address the underlying cause.

2. Jaw Joint (TMJ) Sounds with No Pain or Limited Opening

Sounds such a clicking and popping from the jaw joints (TMJs) are common in the general population. Several studies done in various countries have generally agreed that with examination, alone, 30-40% of the general population demonstrate these sounds. Most of these individuals seem to go through life without any adverse result. However, for a small portion of this group, problems can develop, including pain and other “dysfunction” of the jaw joints. There is currently no means of identifying which of these individuals with clicking or popping will develop further problems. However, it needs to be said that if the individual notices a change in the nature of the clicking and popping, particularly if the popping becomes louder or more frequent, or if catching of the joint is noticed, it is advisable for the individual to seek knowledgeable help as soon as possible. The same would be true if pain develops associated with these sounds or if the popping stops and there is then a limited ability to open the mouth all the way. There are a limited number of dentists who have taken a special interest in these conditions and have sufficient knowledge and experience to provide good advice and treatment. If possible, try to find a dentist for whom a substantial portion of his/her practice involves treatment of TMJ related conditions.

3. Recent Onset of Jaw Joint (TMJ) Click/Pop with Associated Facial Pain

This would be an indication that a thorough history and examination should be done to determine exactly the nature of the condition that is producing the pain; i.e. a biologically-specific diagnosis, not just “TMJ” which is not biologically-specific. Based on the information gathered from the history and examination, a knowledgeable dentist with experience treating these condition should be able to clearly describe the condition that is producing the pain and treatment that would be appropriate.

One of the most important things that should come from the history and exam is to determine whether the pain is entirely from muscles or whether there is pain also coming from the jaw joints (TMJs). Muscle pain comes from excessive, prolonged contraction of the muscles. There are a variety of things that can contribute to this excessive muscle activity. One of these is pain coming from other sources, such as joint pain. When there is pain coming from the joints, some of the muscle pain is likely to be a response of the muscles in an attempt to protect the joint from painful movement. this is analogous to limping when leg muscles tighten to protect a painful knee, hip, or ankle. Treatment should be directed at the underlying source of the pain, not simply at reducing the symptoms.

4. Prior TMJ Click/Pop That Has Now Progressed to Intermittent Catching or Locking

Whether or not there is pain associated with this condition, at the earliest sign of catching or intermittent locking of the jaw joint (TMJ) the patient should seek immediate help from a knowledgeable and experienced dentist. When catching and intermittent locking begins, there is an increased potential for this to progress to persistent locking of the joint. If locking of the joint should occur, effective treatment becomes more difficult, less predictable, and often more costly.

5. Persistent Limited Opening (Locking), Facial Pain, Prior History of TMJ Click/Pop,
Now Absent

Frequently, when a patient has had a jaw joint that clicks or pops and, suddenly, the clicking or popping stops, they may interpret this as a good thing – assuming perhaps that the problem has resolved itself. Although it is easy to see how someone might come to that conclusion, nothing could be further from the truth. Very often when this happens, there will be a noticeable change in the patient’s ability to open their mouth – typically they can open less, something significantly less, than they had previously when the jaw was still popping. What has happened is that the jaw joint has “locked". (To understand what this means, anatomically, read the description of locking in “TMJ Anatomy”.) This does not mean that the locking prevents mouth opening, but the result is that, to some degree, the ability of the locked joint to move has been restricted.

If there is pain accompanying the locking, initial treatment should first be focused on relief of symptoms. This will involve addressing unfavorable loading of the locked joint. Appropriately managing the loading of the joint will also improve the potential for adaptation of the tissues within the joint. The most effective means of doing this is with the use of an appropriately designed, and appropriately adjusted, occlusal appliance. However, this alone will seldom cause the joint to spontaneously unlock. Often physical therapy (by a therapist who has significant knowledge and experience with “TMJ” patients) will facilitate a reduction in symptoms. In some instances of locking, TMJ surgery may be appropriate. However, because of the variability of conditions from one patient to another, as well as the variety of types of TMJ surgery, it is usually best to attempt to manage this type of condition non-surgically prior to consideration of surgery. Surgeons who do TMJ surgery (many do not) typically do not provide non-surgical treatment. However, if non-surgical treatment with an occlusal appliance and physical therapy proves inadequate, this may be the appropriate time to consider a surgical consultation. The dentist who has provided the non-surgical treatment should coordinate additional care with a surgeon who does TMJ surgery.

 

6. Long-Standing Limited Opening with Facial Pain & Grating/Grinding Sounds from TMJs

Patients with a longstanding limited ability to fully open their mouth may at some point in the past, have had one of their jaw joints (TMJ) lock. (To understand what this means, anatomically, read the description of locking in “TMJ Anatomy”.) It is not uncommon for jaw locking to occur without pain and the patient may have simply accommodated to this limited opening. However, at some point in time, pain and/or grating/grinding sounds may develop in the locked joint. The grating/grinding sounds usually are indicative of a breakdown of the tissues within the joint, which may not necessarily lead to immediate pain. However, pain can occur long after the original locking of the joint and the subsequent tissue breakdown. The pain may occur as a result of some triggering mechanism, such as trauma to the jaw.

Appropriate treatment for this condition should first be focused on management of the pain. This will involve addressing unfavorable loading of the locked joint. Appropriately managing the loading of the joint will also improve the potential for adaptation of the tissues within the joint. The most effective means of doing this is with the use of an appropriately designed, and appropriately adjusted, occlusal appliance. Often physical therapy (by a therapist who has significant knowledge and experience with “TMJ” patients) will facilitate a reduction in symptoms. Non-surgical treatment (appropriate use of an occlusal appliance, together with knowledgeable physical therapy) will frequently be an effective means of managing the symptoms. However, if there is a progression of tissue breakdown, and/or significant pain persists, TMJ surgery may be an appropriate option. Surgeons who do TMJ surgery (many do not) typically do not provide non-surgical treatment. Therefore, if non-surgical treatment with an occlusal appliance and physical therapy proves inadequate, this may be the appropriate time to consider a surgical consultation. The dentist who has provided the non-surgical treatment should coordinate additional care with a surgeon who does TMJ surgery.

7. Age-Related Onset of Grating/Grinding Sounds from TMJs

Grating/grinding sounds from the jaw joint (TMJ) is usually indicative of a breakdown of the tissues within the joint. This breakdown of tissues may not necessarily lead to pain. Not uncommonly this type of change may lead to a shortening of the joint, resulting in a change in the bite. (This is addressed below) When this occurs in an older person, particularly if there is no limitation of opening, and there is no accompanying pain, it is usually best to initially do nothing other than manage the symptoms. Treatment will involve addressing loading of the joint. This will also improve the potential for adaptation of the tissues within the joint. The most effective means of doing this is with the use of an appropriately designed, and appropriately adjusted, occlusal appliance. Often physical therapy (by a therapist who has significant knowledge and experience with “TMJ” patients) will facilitate a reduction in symptoms.

As mentioned above, when there has been significant breakdown of the bony parts of the joint, it is not uncommon for this to be accompanied by a change in the patient’s bite. This breakdown of the bony part of the joint may occur slowly and may not be recognized by the patient until a significant change has occurred. When this is first recognized by the patient, they may think that it has occurred suddenly when, in fact, it more likely has slowely progressed. (Precaution: Dentists who do not fully appreciate the nature of such a change may be tempted to immediately alter the bite, such as grinding on the “high” teeth, as a direct means of “solving” this problem. This is not recommended as the first means of managing the bite change.) Such a change in the bite should initially be managed by the use of the occlusal appliance, and may be adequately managed on a long-term basis in an older person by the use of the occlusal appliance, simply having them continue wearing it on a limited basis, such as during sleep. However, particularly if this should occur in a somewhat younger patient, there may be reasons to consider making permanent dental alteration in the bite. If this is to be considered, it is always advisable to be reasonably certain that the changes within the joint that have led to this bite change are not progressing. When the need for a more permanent bite correction is anticipated, it is usually advisable to obtain quality imaging of the joints early in treatment, to be used as a baseline representation of the affected joint at that point in time. Later, when the symptoms have resolved and sufficient time has passed to allow for “healing” of the affected joint, comparing the initial imaging with a second imaging study will provide evidence as to whether the degenerative changes within the joint have stabilized. Only if there is a clear indication that the degenerative changes have “healed” should any permanent dental correction of the bite be undertaken.

8. TMJ Sounds & Facial Pain in Patient with Chronic Tooth Grinding (Bruxism)

Before any treatment is undertaken to treat either the pain or the tooth grinding, a thorough history and examination should be done to determine exactly the nature of the condition that is producing the pain; i.e. a biologically-specific diagnosis, not just “TMJ”, which is not biologically-specific. Based on the information gathered from the history and examination, a knowledgeable dentist with experience treating these condition should be able to clearly describe the condition that is producing the pain and to also recommend treatment that would be appropriate.

One of the most important things that should come from the history and exam is to determine whether the pain is entirely from muscles or whether there is pain also coming from the jaw joints (TMJs). Muscle pain usually results from excessive, prolonged contraction of the muscles. There are a variety of things that can contribute to this excessive muscle activity, including bruxism. One of these is pain coming from other sources, such as joint pain. When there is pain coming from the jaw joints, some of the muscle pain is likely to be a response of the muscles in an attempt to protect to the joint from painful movement. Jaw joints that are healthy and structurally intact can be loaded during normal function without any pain. Pain from the jaw joints typically is the result of loading of tissues that are not able to tolerate frequent or prolonged loading, such as would occur with clenching or grinding of the teeth.

Clenching and/or grinding of the teeth is one of several contributors to excessive muscle activity that can lead to muscle pain. In a patient who has both muscle pain and jaw joint pain, one of the objectives of treatment would be to manage the load on the jaw joints, as well as to minimize the activity of the muscles involved in clenching and grinding. This can be accomplished by the use of an appropriately designed occlusal appliance that will require adjustment over time, as changes will occur on the appliance secondary to altered muscle activity, changes in the TMJs and bruxism-related wear on the appliance. Treatment with an occlusal appliance will involve more than fitting it to the patient’s teeth and telling the patient to wear it when they sleep. Even the most effective occlusal appliances do not usually eliminate tooth clenching or grinding but when properly designed and adjusted they can provide better support for the joint during sleep, manage the forces applied to the teeth and joints during bruxism, and help create an awareness by the patient of bruxism activity.

9. Locking Open When Yawning or Other Wide Opening (Dental Visits)

Locking open of the jaw joints is an entirely different phenomenon than locking closed, which has been mentioned above and in the section of this website called “TMJ Anatomy”. When the jaw locks open, it is referred to as “subluxation”, meaning that the ball part of the joint (the condyle) moves too far forward during opening and gets “stuck” ahead of a normal boney bump at the front of the joint called the articular eminence. Usually this subluxation occurs in a person who has excessively limber or hypermobile joints. Such persons my know that they are more limber than other people or may have been called “double jointed”. They can often do things with their joints that the average person can’t do. There is a simple test that would indicate this kind of flexibility. If you bend your hand at the wrist and then try to bend your thumb back to touch your wrist, you may find that you can do this or can almost do it. This joint hypermobility is more common in females and is usually easier to do in a younger person than an adult.

If you have had your jaw “lock open”, you may have felt a bit panicked, not knowing what to do about it. Getting it to unlock is fairly easy. The person with the locked joint should sit in a chair with their head braced against a hard surface, such as a wall. Another person (with clean hands) should put their thumbs on the biting surfaces of the lower teeth, as far back as possible and should push down first, and then back. This will usually cause the condyle to go back to its normal position, allowing the jaw to close. Once locking open has occurred, it may happen more easily in the future. So the person whose jaw had locked should be careful from that point forward to not open widely. When there is a need to yawn, it is a good idea to put your fist under your chin and prevent the jaw from opening as widely as it might have otherwise or to place the tip of the tongue against the roof of the mouth during the yawn.

10. Onset of TMJ Pain & Click/Pop During Orthodontic Treatment

Because clicking and popping occurs fairly commonly in the general population, the appearance of joint sounds alone may not be a reason for concern. However, if that clicking and popping has been accompanied by the onset of pain, it will be important to determine the source of that pain. It may be entirely muscular in nature or it may be arising from the jaw joints. By all means, this should be brought to the attention of the orthodontist. Don’t let the orthodontist be dismissive about the onset of jaw joint sounds, as it is not normal. A proper evaluation of the nature of this condition should be done. [Please read #8, above, re. the sources and cause of pain in the jaw.]

Carefully consider whether there might have been a triggering event that caused this change. For instance, trauma to the jaw or biting on something hard, etc. might have been a trigger. Having your mouth open for a prolonged time might be a trigger. You should also note whether the clicking and pain occurs fairly frequently or whether it occurs only at certain times or when associated with certain activities of the jaw, such as which side of your mouth you are chewing on when it occurs. If this clicking and pain began following some change that was done to your braces, this may be an important clue. For instance, the use of elastics of a certain kind to activate tooth movement will sometime lead to a change of this kind. Any of these may be important and should be reported to the orthodontist.

The significance of such a change may have different implications depending on whether you are fairly early in your orthodontic treatment or whether, perhaps, you are nearing completion. Until your orthodontist has had a chance to evaluate these changes, certain precautions are in order. It is usually preferable that you try to limit wide opening of your mouth and you should avoid biting anything with your front teeth as this may require wide opening. If the clicking and pain is increased by chewing on one side of your mouth, try to avoid this by chewing on the other side.

There is sometimes a need to make changes in the orthodontic treatment plan because of the development of pain that is accompanied by the onset of jaw clicking/popping. However, your orthodontist will only be able to determine whether this is necessary and exactly what changes should be made if you report the onset of the joint sounds.

11. Jaw Soreness on Awakening in a Child Who Grinds Their Teeth

It should be appreciated that grinding of the teeth (bruxism) is common in children. Unless there are significant symptoms associated with this, seldom is there an indication to provide treatment. Wear that occurs on the baby teeth, that will be lost when the permanent teeth come in, should be of little concern. However, children who have persistent headaches, “ear” aches or jaw pain that have not responded to other attempts at treatment should be considered for treatment that will minimize the the adverse effects of tooth grinding. The most effective treatment is likely to be a removable appliance that fits over the teeth. However, because of the continuing growth and development of the child’s mouth and the loss of baby teeth and eruption of permanent teeth, it may be necessary to make a new appliance perhaps as often as every 6 - 10 months.

It is known that certain drugs used in the treatment of attention deficit disorder (ADD/ADHD) and autism spectrum disorders may have a side effect of increased bruxism.

12. Arthritic Changes in the TMJs in a Child

Most TMJ arthritic changes that are seen in children are related to a systemic inflammatory disease process. The most common is idiopathic arthritis, commonly known as juvenile rheumatoid arthritis (JRA). Typically both jaw joints are involved and result in an altered growth pattern of the mandible resulting in characteristic occlusal changes including an anterior open bite.

Trauma-induced arthritis in children is more typically occurs on only one side and the impact on the dental occlusion is less noticeable but it may lead to asymmetric growth patterns. Sophisticated imaging can differentiate these conditions.

 

 

 
   
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