A technical understanding of TMD / TMJ

TMD X-Ray and Tomography

Temporomandibular joint tomographic x-rays play a valuable role in diagnosis and treatment. Recent studies have concluded that a fairly high rate of unexpected new osseous and positional findings support the need for tomograms in patients with a clinical diagnosis of derangement or joint pathology. Approximately forty to fifty percent of tomographic radiographic examinations produced a change in diagnosis.

Tomography is medically necessary to evaluate bony changes in the condyle and temporal bone such as flattening, erosion, and sclerosis. Condylar position and asymmetries of mandibular anatomy can be most clearly evaluated with the exacting multiple slice technology of tomography. Additionally, the ability to screen for additional abnormalities such as tumors or cysts is provided by tomographic radiography.

References:

Efficacy of TMJ radiographs in terms of expected versus actual findings, UCLA, Oral Surgery, Oral Medicine, Oral Pathology 1995;79:367-81

Care for Temporomandibular Disorder Cervical and Facial Myositis and Cephalgia

Treatment consisted of maxillary and mandibular orthopedic repositioning appliances to recapture the displaced discs. The maxillary appliance serves as a stabilizer for sleeping and reclining to offset gravitational forces. This appliance is very bulky in the anterior area and would greatly impede mastication and speaking.

The mandibular appliance was fabricated and is intended for daytime use and can be used for mastication and usual daily activities.

TMD Trauma

A study in the Journal of Oral Rehabilitation in 1996 titled “Trauma in Patients with Temporomandibular Disorders: frequency and treatment outcome” was to assess the incidence of jaw injury in TMD patients and to compare the severity of the symptoms, the clinical characteristics and the treatment outcome in TMD patients with or without a history of trauma to the head and neck region directly linked to the onset of symptoms. The study sample included 400 consecutive TMD clinical patients. In 24.5% of patients the onset of the pain and dysfunction could be linked directly to the trauma, mainly whiplash accidents.

No significant differences could be found between the two groups in daily recurrent headache, dizziness, neck pain, joint crepitation and pain in the joints. Maximal mouth opening was less than 2-0 mm in 14.3% of patient with a history of trauma and in 4.1% of those without such a history. According to the Helkimo dysfunction index (DI), more trauma than non-trauma TMD patients belonged to the severe dysfunction groups (DI 4 and 5) at first examination.

The outcome of a conservative treatment procedure (counseling, occlusal splint, physiotherapy, occasionally occlusal therapy and non-steroidal antiinflammation drugs was not different between the two groups at the 1 year evaluation. The degree of maximal opening was similar: less than 20 mm in 3.7% and 2.2% in trauma and non-trauma patients respectively.

Forty percent and 41% respectively were symptom free or had DU = 1. The results suggest that external trauma to the joint or to the jaw in general is an important initiating factor in the etiology of TMD and also that the prognosis is favorable.

Treating for a Temporomandibular Disorder and Cephalgia

The necessity for range of motion movements is as follows:

Taking range of motion movements is an accepted test for diagnosis and treatment of temporomandibular disorders. The measurements are a tool to evaluate progress and assist in treatment decisions. Normal range of motion for mandibular opening is approximately 50 mm with 12 mm being the norm for right and left lateral excursions. A reduced opening with difficult excursion may indicate a severe trismus or a closed lock of the temporomandibular joint. An opening much above the norm may indicate hypermobility and stretched ligaments in the jaw joint.

A Clinical Outline of Temporomandibular Joint Diagnosis and Treatment, by Dr. William B. Farrar and Dr. William L. McCarty examines in detail the necessity for various range of motion measurements and is suggested reading.

TMJ Treatment / Restorative

Surgical procedures and/or an orthopedic repositioning appliance were provided to reposition the mandible, relieve muscle pain, edema, nerve impingement and recapture the displaced articular disc.

Restorative procedures are necessary to complete orthopedic stability of the mandible and maintain the current jaw position. A specific court ruling regarding insurance cases states:

Goss v. Medical Service of the District of Columbia, DC Court of Appeals, No. 81 1276, 13 June 1983.

The medical insurer’s position was that restorative bridge work is considered dentistry. The patient’s position was that the crowns were medically necessary to correct a malpositioned jaw.

Court results: “There was no need for the crown and bridge work independent of the jaw. In fact the crowns were directly related to and required by the medical condition affecting the jaw. The treatment did not treat the teeth or tooth relationship as the patient’s teeth were used only to support the devices required to stabilize the jaw position.”

A Medical Necessity

Clinical examination revealed: articular disk disorder, muscle spasm, and cephalgia.
An orthopedic jaw stabilization orthotic was placed to position the condyles in the fossa in a more true anatomical position, reduce stress to the jaw joint, increase joint space, allow remodeling of the condyle, heal retrodiscal tissue, capture the dislocated articular disc, provide proper alignment of the mandible to the skull, reduce myospasm and pain, and maintain the muscles of mastication in proper physiologic resting length.

This appliance is orthopedic and neuromuscular treatment and should be considered as a medical necessity by the insurer.

TMJ and Otrthodontics

Post Surgical Orthotic / Medical Necessity

A post-surgical orthotic device is designed to allow healing of the retrodiscal tissue and stabilize the mechanism of the temporomandibular joint. The orthotic is important for rehabilitation. Without it, extreme pressure and intra-articular edema could result. Postsurgical orthotic therapy is used to position the jaw in a similar fashion as if a stabilization splint or cast were used post-operatively on a knee, hip or any other joint. The orthotic therapy is treatment to bone, cartilage, ligaments, and muscles and should be handled as a medical necessity by insurance carriers.

Orthodontics

Symptoms of headaches, facial pain, and dizziness. Objective findings included limited range of motion, muscle tenderness upon palpation (masseter, temporalis, bilateral), crepitus of the temporomandibular joint, and deviation of the jaw upon opening and closing. Maxillary and mandibular interdental fixation devices (CPT 21110) were placed to provide a stable jaw position. Treatment was not to the teeth but was orthopedic and neuromuscular in nature. Courts have ruled on similar insurance claims sent to medical insurance that “devices used to treat the patient’s condition were intended to relieve pain from the mandibular joint rather than to correct dental problems. Reasonable minds would not inevitably conclude that, as a matter of law, procedures performed were “dental services” excluded from coverage under health policy”. Because of the medical nature of the diagnosis, treatment should be considered as a medical necessity.

Agony of the daily grind…

DO YOU wake up in the morning with an aching jaw, headache, and difficulty opening your mouth? You have probably been grinding your teeth.

Regular grinding, known as bruxism, can wear teeth away and almost rivals snoring on the annoyance scale.

- Stress is believed to be a major role in the condition and it is also linked to the non-alignment of the top and bottom teeth.

- The mind subconsciously tries to correct the position during sleep, triggering the grinding.

- Other causes include snoring and sleep apnoea, where the upper airway relaxes during sleep causing blockage of airflow.

- Drinking tea and coffee or alcohol before going to bed can also increase the chance of tooth grinding.

- Some may be unaware they are grinding away so it’s worth asking the dentist for a check-up.

- Damage to teeth can often be repaired and there are mouth-guards available to help protect from further damage.

You may have to wear this mouth-guard for life and it’s worth finding out if it needs to be renewed as your teeth change.

- If the grinding is due to misalignment you should talk to your dentist about a brace.

- Other possible remedies include hypnosis and behavioural therapy to allow you relax.

- Avoid chewing gum: the repetitive action of chewing is almost identical to the motion of the jaw during bruxism.

- Hold a warm, damp cloth to your face before bedtime to relax the jaw.

Painful Headaches And Jaw Pain?

Do you clench and grind your teeth? Are you waking up with painful headaches that radiate from your temples, ears or jaw? Do you have limited mouth opening? Do you have sensitive teeth, loose teeth or toothaches in the absence of tooth decay? Do you have crowns or cosmetic veneers that constantly come off and need to be re-cemented periodically? Do you have clicking or popping of your jaw joint?

If you answered yes to any of these questions, then you may be suffering from a common problem known as TMJ Disorder, an often misunderstood or misdiagnosed condition. In our 18 years of experience Downtown, we have successfully treated thousands of patients for this problem. Our experience has led us to believe that TMJ Disorder is prevalent in the Downtown population.

The Downtown patient works on average more than 40 hours per week and shoulders most of the responsibilities in the household. This results in high levels of stress due to the high pressures of daily life. There is no doubt that stress is a major factor in increasing the symptoms of TMJ, but contrary to what most people believe, it’s not the primary cause. The primary causes are reflexes that are triggered by the teeth that cause spasms of the numerous muscles of the jaw, neck and face.

Most joints of the body are fixed in a hinge axis. This is the same movement a door makes when it’s opening and closing from its hinge. The jaw joint is the only joint in the body that is able to slide out of its socket. Because it can do this, it’s able to deviate from its hinge axis and do the complex motion of chewing, an ability we all take for granted.

If teeth occlude (come together) at the hinge axis position of the jaw, most people would be fine. However, if the teeth developed in a position where the bite occludes outside this hinge axis, where the jaw is slightly protruded from the socket, then there is a potential for TMJ symptoms. The average person cannot tell if their bite comes together forward of this hinge axis, only observing that their jaw is intermittently sore or they have a sudden, uncontrollable urge to clench and grind their teeth. Only a properly trained dental professional can diagnose if the teeth are occluding outside of this hinge axis position.

The initial treatment for TMJ Disorder is relatively simple and noninvasive. However, it does require thorough care by a dental professional. We simply make a custom TMJ splint, adjusting it meticulously at several appointments so that the patient’s teeth come together on the device in the ideal hinge axis position. After achieving proper adjustment the splint will eventually neutralize the harmful reflexes. A mouth guard from a drugstore or by mail order will not resolve TMJ Disorder because it will be arbitrarily set to a bite position. After wearing a proper TMJ splint for only 48 hours, the TMJ patient will notice a difference. They will find that their jaw feels more rested, headaches occur less frequently and teeth sensitivity is resolved.

For the most part, TMJ Disorder can be managed with splint therapy. But fixing the bite itself could be required if an individual cannot wear a splint indefinitely, by either re-contouring certain teeth, doing crowns and/or veneers, doing orthodontic treatment or a combination of any of these treatments. But contrary to what most people have heard, there is an effective treatment for this disorder. At the same time, if not treated and ignored, it will worsen, resulting in breaking teeth, worsening gum disease and/or severe jaw joint damage requiring painful surgeries.

About Temporomandibular Joint Disorder

TMD is difficult to diagnose because the symptoms of TMD can mimic those of many other conditions. If you are suffering from jaw pain, you may have TMD.

Is your jaw giving you pain?

If so, you may have TMD. Tempomandibular jaw disease, or TMD, is a broad term for a collection of jaw conditions characterized by problems such as:

• Unexplained pain in the face, jaw or teeth
• Limitations in jaw movement

How is TMD diagnosed?

TMD is difficult to diagnose because the symptoms of TMD can mimic those of many other conditions. For example, facial pain can be a symptom of a sinus or ear infection, abscessed tooth, migraine or any type of nerve related facial condition. A dentist experienced in diagnosing and treating TMD, such as those at the Art of Smile Making, will perform a complete medical evaluation including a detailed medical history and physical examination of your face, head, neck and jaw areas before making a diagnosis and recommending a course of treatment for TMD.

What are the symptoms of TMD?

While symptoms of TMD vary, the most common symptoms include:

• Dull pain in the jaw joint or surrounding areas
• Problems using the jaw or inability to open the mouth comfortably
• Clicking, popping or grating sounds from the jaw joint
• Locking of the jaw upon opening the mouth
• A bite that feels uncomfortable, painful or misaligned
• Headache or migraine
• Neck, shoulder or back pain
• Swelling of the jaw or on the side of the face
• Dizziness
• Ringing in ears or hearing loss

How is TMD treated?

Treatment for TMD involves relaxation of the jaw muscles and restoration of the jaw joint back to its unstrained position. This can involve the utilization of plastic appliances or other adjustment of the teeth to correct any misalignments of the bite.

If TMD has been present a long time or if the patient is suffering severe trauma, more involved medical or dental procedures may be required. Because untreated TMD may result in increasing discomfort or arthritis of the jaw joint, early detection is the goal.

Who suffers from TMD?

It is estimated that over 10 million people in the United States currently suffer from TMD. Significantly, while both men and women experience TMD, approximately 90 percent of the patients seeking treatment for TMD are women in their childbearing years. Research indicates that women seek treatment for TMD at a higher rate than men and that women are more likely than men to report ongoing pain associated with TMD. Also, research performed by the NIDCR has documented a correlation between hormone replacement therapy and oral contraceptive therapy with pain treatment. This may explain why more women tend to suffer symptoms and seek help for TMD pain.

Can TMJ Cause Arthritis?

TMJ or temporomandibular joint is located right in front of the ears, right on the spot where the lower jaw and upper jaw meet. Open your mouth and feel the ball and socket joints in front of your ears. Close your mouth. The bones that are moving there are your temporomandibular joints. You see, these joints are used several times in a day. You use it when you eat, speak, yawn, and bite. Indeed, it is one of the most used joints in your body. The TMJ is a very complex joint. It is composed of a complicated array of muscles, bones, and tendons.

TMJ disorders or problems of these joints do occur. When that happens, stiffness, ear pain, headaches, clicking sounds, bite problems, and locked jaws can be expected. In worse cases, arthritis may also occur. TMJ can cause arthritis if not treated right away. The most usual underlying conditions of TMJ disorders are teeth grinding problems, habitual fingernail biting, too much gum chewing, dental problems, teeth misalignment, jaw trauma, and stress. It is very important that these conditions are addressed right away so that they won’t evolve into arthritis.
TMJ disorders have a set of symptoms. You know you have it if you experience recurring headaches. You would also feel facial pains from time to time. The pain may start on the joints and spread over the head and the face. It could get worse as you open and close your jaw. The contraction of the jaws is painful, more so if you’re exposed to the cold weather or relatively cold surroundings.

Patients of TMJ disorders would also experience ear pain. Half of the people with TMJ will have ear pain without any signs of infection. The pain is usually associated to the joints and it can be felt somewhere below or in front of the ears. If there were no ear drainage or hearing loss associated with the ear pain you’re feeling, then TMJ is the most likely culprit.

TMJ patients can expect to hear clicking, crunching, grinding, or popping sounds when they open and close their mouth. Pain may accompany these sounds too. Dizziness is also likely. People suffering from TMJ may experience balance problems and vague dizziness from time to time.

Tinnitus and fullness of the ear may also occur to people with TMJ disorders. Their ears may feel clogged or muffled. This feeling is compounded during airplane landings and takeoffs. Ear fullness is associated with the dysfunction of the Eustachian tube. Because of the hyperactive muscles in that part on people with TMJ, this symptom becomes almost natural. On the other hand, patients with tinnitus due to TMJ would experience relief from their condition once the joint disorder is resolved.