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The Treatment
of TMD
If you have managed to read through all 6 of the
preceding pages, you probably realize that there is a stark difference between the diagnosis of the
two broad categories of TMD.
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The majority of TMD patients (I like to refer
to them as TMJ Lite) have the muscle related symptoms of headache,
ear ache, neckache, jaw pain and inability to remain open for long periods,
or tooth related symptoms of sensitivity to cold, a tendency to bony
destruction in periodontal disease, an increase in the decay caused by sugar
habits, along with some difficulty in chewing hard foods.
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The minority of patients (heavy duty TMJ)
have organic problems with the joint itself caused by external trauma or by
the constant trauma to the joints produced by the parafunctional habits.
The trick is to differentiate between the two categories, and at times the
difference is not always especially obvious. The good news is that
conservative treatment usually works well on both categories of patients,
and so differentiation between the the two categories is not always
necessary.
The treatment of TMD Lite
The Bruxing Guard
The key to treating these patients is to reduce
the patient's tendency to clench and grind her teeth. Even if, when the
teeth are closed together, and the joints do not line up properly, all
the symptoms tend to fade away if the patient does not tend to keep the teeth
together with the forces characteristic of bruxing. The most common, and
least expensive treatment for TMD is the construction of a hard acrylic
bruxing guard (and now flexible plastics are being used as well).
These are horseshoe shaped plastic appliances which fit over (usually) the top
teeth and have a smooth surface on the underside so the lower teeth can slide
over the plastic without resistance. This prevents the teeth from locking
together, and relieves a lot of the force placed on the teeth and joints. If an
appliance like this is worn long enough, the bruxing habit may eventually
disappear altogether, which would be the ideal treatment goal if it always
happened. Unfortunately, bruxing guards still allow the patient to
clench against the guard. Since clenching is associated with overuse
of the temporalis muscle, patients may still experience tension headaches even
though they wear their guard religiously.
The
bite adjusted (deprogrammed) Bruxing guard
Bruxing guards work even better if they are built
so that when the lower teeth contact the plastic, the joints are forced to sit
in their most relaxed positions in the most superior part of the
socket. This position can be
determined quite easily by a simple trick called
deprogramming in which a piece of plastic is inserted over the top front
teeth that does not allow the posterior teeth to make any contact.
Usually, within an hour or so of wearing one, the jaw has "dropped" into a
relaxed position with the joints in a more desirable position. A bite
registration is taken with the deprogramming device (deprogrammer) in
place so the new bruxing guard can be built to the new bite-adjusted jaw
position which corresponds to a more physiologically acceptable joint position.
Deprogramming has an additional advantage in that if it works, it will relieve
the symptoms very quickly and can be worn until the deprogrammed bruxing guard
can be built.
The main disadvantage with this treatment
modality is that your teeth do not look any better after you have cured the pain
associated with TMD, and if the bruxing habits do not disappear on their own,
the patient is stuck wearing a bruxing guard whenever he is likely to be
bruxing. In addition, patients still can clench against any bruxing guard.
Thus, even a properly balanced deprogrammed bruxing guard will not reliably
relieve all tension or migraine headaches, although it generally will reduce
their frequency. The major advantage to this treatment modality is
that it is not expensive
and can often relieve long standing pain that has been a major hindrance to a
normal lifestyle for years!
 Deprogrammers
The concept of deprogramming is based on the
reflexive relaxation of the lower jaw when the back teeth are not permitted to
engage. The various muscles that open and close the jaw learn and remember
the level of contraction needed to perform their movements in a coordinated,
comfortable way. They learn which positions of these muscles cause pain,
and which don't, and store all the information in your brain in the form of "engrams"
which are similar to automatic, unconscious computer programs that your body
uses each time you open or close your mouth. In persons with TMJ, these
movements can be quite complex.
Deprogramming may be done with any number of
devices.
The butterfly deprogrammer
(seen in the image immediately above) is my own design. It takes about 20
minutes to fabricate in the chair and can be worn during the bite registration
process, which takes all the guesswork out of getting a functional relaxed
centric relation. For those interested, I have provided the original
paper (written in 1986), never published, on the fabrication and use of this simple appliance.
 Another
device which has recently come onto the market is called the NTI (for
Nocireceptive Trigeminal Inhibition). It is a proprietary device which
fits over the top front teeth and accomplishes the same thing as the butterfly
deprogrammer. Many dental offices are now beginning to treat TMJ using
this deprogrammer. Many dental labs now make these devices and any dentist
wishing to use deprogramming to treat TMD should check with their lab to see if
they fabricate them. Click on the image to go to the inventor's site.
A third device is called a Lucia Jig.
It fits over the two top front teeth like the NTI. It is fabricated
"freehand" by the dentist out of cold cured acrylic or light cured composite.
Lucia jigs have been in use by dentists for treating TMJ for a very long time.
Deprogrammers have become more and more accepted as a permanent
treatment modality for TMD. The main advantage of a deprogrammer over a
bruxing guard is that the patient is unable to clench the teeth against a
deprogrammer. Thus tension headaches are effectively treated with a
deprogrammer while bruxing guards are not as reliable for this purpose since the
patient can still clench the teeth against a bruxing guard. For the same
reason, deprogramming has been accepted by the medical community as an
acceptable treatment modality for many cases of
migraine headache. The main
disadvantage of a deprogrammer as a permanent treatment modality is the
appearance of the teeth while wearing one.
A
couple of notes to dentists
- Originally, I believed that a deprogrammer, if worn
continuously, could cause intrusion of the lower incisors.
Over the years, I have noticed that this has not happened as I
expected, even in those patients who continue to wear the
deprogrammer for years on end. This may be due to the fact that
the deprogrammer is rarely worn during the day when the patient
is talking or otherwise in contact with other people. It
may also be due to the fact that the deprogrammer is really
accomplishing the what its name implies; actually deprogramming
the patient and stopping bruxing, even when the patient stops
wearing it.
- It becomes easier to visualize the relationship between
bruxing or clenching and tooth movement when you think about
patients who lose a temporary crown prior to insertion of the
final restoration. These patients fall into two
categories. Some present with fairly rapid drifting
of the prepared tooth (or the adjacent teeth) while others seem
to suffer very little tooth movement. The difference
between patients in these two categories results from their
bruxing habits. Bruxing seems to mobilize the bone to
allow for rapid drifting of teeth, even if the tooth in question
is not in occlusion.
- I have built flat plane bruxing guards for patients, and
then discovered that they did not prevent the symptoms of
headache or jaw aching. When this happens, I can often
bring about relief by placing a small anterior discluding element on the
bruxing guard using light cured composite.
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How to
find a dentist who treats TMD using deprogramming techniques
At present it can be difficult to find dentists who
treat TemperoMandibular joint Disfunction using this fairly simple
and effective approach. Since the advent of the NTI device,
and its easy availability through dental laboratories, many dentists
are using this device for their TMD patients. In some cases,
patients may find a dentist simply by calling different offices to
see who is using the NTI.
There is a "central registry" on the web named "HeadAchePrevention.com".
This website has a central search function whixh
allows patients to find a local dentist who treats patients using
the NTI. The search is dependent on dentists who
register with the website, so the database will not contain all the
dentists who provide the service. Click
here to go to their home page and click on the "NTI
Provider List" link at the top of the page. If you are a
dentist wishing to be listed, simply go to the above link and
register. |
The Prosthodontic solution
If you are rather well off financially, you
can have a dentist rebuild all your teeth so that their new positions guide the
joints into the proper alignment. This is called the prosthodontic
solution because the dentists most likely to recommend this treatment are
specialists called prosthodontists who make a lot of crowns, bridges and
implants. The proper alignment is determined mechanically in these cases, and
with the joint discrepancy corrected, there is less of a tendency on the part of
the patient to brux the teeth. The main disadvantage to this form of
treatment, is that the new teeth will still tend to lock together, and if the
bruxing habits continue, as they frequently do, the patient may still have all
the muscular symptoms he started with. The advantage is that now the
joints are in a more correct alignment so the joint damaging process may be
halted, and the teeth usually look great. It seems to have worked
splendidly for Burt Reynolds.
The
Orthodontic solution
A third treatment modality is orthodontics.
In this case, the natural teeth are moved into a correct position that allows
the joints to sit correctly in their sockets. The correct position is
determined by a science called cephalometrics which is a subcategory of
diagnostic x-rays. This treatment has the same advantages and
disadvantages as noted in the discussion of the prosthodontic solution above.
It has the further advantage of leaving you with all-natural teeth that are nice
and straight, but it has the added disadvantage of taking a long time to
accomplish. (Interestingly, in the long run, this treatment modality is much
less expensive than the prosthodontic solution, and is more likely to break the
bruxing habits.)
The use of drugs in the
treatment of TMD
Two types of drugs are generally of use in the treatment of TMD.
Pain medications are useful to the extent that the drugs
are used to reduce pain in acute situations. The most useful drugs for TMD
pain are non-steroidal-anti-inflammatories (NSAIDS) such as Advil or Motrin
combined with Tylenol. These drugs are freely available over the counter
and are non addictive. Prescription versions such as Lodine are often
longer lasting and better for chronic situations. Narcotics are never
indicated for use in the treatment of TMJ for more than 24 hours. The
addicting properties of narcotics combined with the intense personality types
associated with TMD make make them a dangerous choice for long term use!!!
Muscle relaxants such as Flexaril, Parafon and Robaxin
are often used to relieve the muscle tension that leads to bruxing, especially
for nighttime use. More addicting varieties of muscle relaxants such as
Valium are useful for nighttime use only for limited periods of acute muscular
activity.
In the past, injections of corticosteroids
directly into the affected joint have been used to bring about relief.
This does, in fact, appear to work for fairly prolonged periods.
Unfortunately, these injections tend to produce degenerative changes in the
structures within the joint, and ultimately cause more problems than they cure.
The
"all-natural" cures
In the final analysis, no matter what the
physical parameters of the joints, teeth and muscles happen to be, the "root
cause" of most TMD pain involves the bad habits of bruxing (grinding and
clenching the teeth). Even severe TMD produced by traumatic events are
generally temporary unless the patient grinds and clenches, in which case the damage is
made worse, and the pain persists. If you can find any method of stopping
the habits, you can stop the disease, and this includes anything that can work
on the mind as well as on the body. It is a very rare person indeed who
can simply stop by sheer force of will power. These habits have deep
psychological roots, and are done unconsciously anyways. In the past,
psychoanalysis, group therapy and even past life therapy have been known to
bring about relief.
When real pain and physical damage to the body
are caused by habits which have a psychological basis (and stress is ultimately
a psychological reaction to the strain of everyday living) the disease is said
the have "psychosomatic" origins. This term is vastly misunderstood by the
public at large. It does NOT mean that the problem is "all in your mind".
It means that your body is connected to your brain, and the way your body reacts
to the various stimuli it encounters daily depends to a large extent on the way
your mind chooses to direct it.
The
treatment of severe TMD and internal joint deterioration
| Dental students, hygiene students and
assistants who want to know more about the technical aspects of
occlusion should also see my companion page on
occlusion
and the internal arrangement of the TMJ. |
Actually, the same treatments that are used for
the treatment of the less severe forms of TMD often work quite well for patients
with real organic joint damage. In general, forcing the joints into a
physiologically correct position when the teeth are together, as discussed
above, frequently stops the deterioration cold, and sometimes allows for
healing of the damage already done, provided that the patient's bruxing habits
are under control. (See
deprogramming above.) It doesn't work
for everyone. Here, nature sometimes needs an assist from an oral
surgeon who may be able actually to correct the anatomy of the joint itself.
This is always a last resort, and even most surgeons are not especially keen on
performing this type of surgery. This is frequently because the correction
of the physical deformity does not usually halt the bruxing habits, and these
may cause relapse of the surgery.
Arthroscopy
Patients who have disc displacement may benefit
from arthroscopy. Arthroscopy is preformed in a surgical suite and only takes
about one hour per joint. An arthroscope is placed into the joint in front of
the ear. By arthroscopy, the surgeon is able to visualize the entire joint space
and remove pathology. This often allows the meniscus to move more freely and
function better. There is very little postoperative discomfort and the
patient is able to eat and drink immediately after the procedure. This
type of surgery generally involves reshaping bone and cartilage elements, and
sometimes the complete removal of the meniscus. Simple arthroscopies are
relatively safe procedures.
Open surgical
procedures
While arthroscopy is a procedure that
requires two or three small incisions in order to allow the insertion of a
fiber-optic instrument for visualizing the joint space, as well as small
openings for instrumentation, open procedures require a complete incision to
allow complete visualization of the joint. The advantage to open
procedures is that they allow the surgeon more room, so more complex replacement
procedures can be accomplished. This means that the surgeon can insert
implants as well as remove and remodel joint components.
Meniscus and whole joint replacements
Joint implants and replacements have
begun to come into their own in recent years. These procedures are
very expensive, and a good deal more risky than arthroscopy procedures, but
if done by experienced, skilled surgeons, they may bring about relief when
nothing else does.
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The image below shows a panoramic x-ray of a
patient of mine who had serious long term pain from
deterioration of the TM Joints. She had whole joint
replacement surgery combined with surgery to correct a seriously
underdeveloped lower jaw. The surgery involved
removal of both condyles (the ball of the joint) as well as both
fossas (the sockets) and their replacement with titanium
implants. See the diagram above
to get your bearings. Titanium is a metal which allows for
osseous integration (bone will actually attach to it naturally).
The surgery did relieve the patients pain on opening and closing
the jaw, but was not without its negative after effects, as
there was residual neuralgia (nerve hypersensitivity) which must
be treated separately. Click the image below to see larger
images of this film, as well as before and after images of the
patient herself.
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The TMJ section used to occupy a single page on this website,
but due to its extreme length, it has been broken up into seven separate pages.
A good understanding of the Temperomandibular joint, occlusion and their
associated disorders may be gained by reading them in order.
TMJ Pages
1,
2,
3,
4,
5,
6,
7
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