Temporomandibular Disorders
Temporomandibular disorders (TMD) occur as a result of problems with the
occlusion,
jaw joint (called the temporomandibular joint, or TMJ), and surrounding facial
muscles that control chewing and moving the jaw.
What is the temporomandibular joint?
The temporomandibular joint is the hinge joint that connects the lower jaw
(mandible) to the temporal bone of the skull, which is immediately in front of
the ear on each side of your head. The joints move smoothly up and down and side to side and enabling you to talk, chew, and
yawn. Muscles attached to and surrounding the jaw joint control its position and
movement.
What causes TMD?
The cause of TMD is not clear, but dentists believe that symptoms arise from
problems with the muscles of the occlusion and/or with the parts of the joint itself.
Injury to the jaw, temporomandibular joint, or muscles of the head and neck, such as from a heavy blow, can cause TMD. Other possible causes
include:
- Grinding or clenching the teeth, which puts a lot of pressure on the
TMJ
- Dislocation of the soft cushion or disc between the ball and socket
- Presence of osteoarthritis or rheumatoid arthritis in the TMJ
- Stress, which can cause a person to tighten facial and jaw muscles or
clench the teeth
What are the symptoms of TMD?
People with TMD can experience severe pain and discomfort that can be
temporary or last for many years. TMD is seen most commonly in people between
the ages of 20 and 40, and occurs more often in women than in men.
Common symptoms of TMD include:
- Pain or tenderness in the face, jaw joint area, neck and shoulders,
and in or around the ear when you chew, speak, or open your mouth wide
- Limited ability to open the mouth very wide
- Jaws that get "stuck" or "lock" in the open- or
closed-mouth position
- Clicking, popping, or grating sounds in the jaw joint when opening or
closing the mouth (which may or may not be accompanied by pain)
- A tired feeling in the face
- Difficulty chewing or a sudden uncomfortable bite – as if the upper
and lower teeth are not fitting together properly
- Swelling on the side of the face
Other common symptoms include toothaches, headaches, neckaches, dizziness,
and earaches and hearing problems.
How is TMD diagnosed?
Because many other conditions can cause similar symptoms -- including a
toothache, sinus problems, arthritis, or gum disease -- your dentist will
conduct a careful patient history and clinical examination to determine the
cause of your symptoms. He or she will examine your temporomandibular joints for pain or tenderness;
listen for clicking, popping, or grating sounds during jaw movement; look for
limited motion or locking of the jaw while opening or closing the mouth; and
examine bite and facial muscle function.
Sometimes panoramic x-rays will be
taken. These full face x-rays allow your dentist to view the entire jaws, TMJ,
and teeth to make sure other problems aren’t causing the symptoms. Sometimes
other imaging tests, such as magnetic resonance imaging (MRI) or computed
tomography (CT), are needed. The MRI views the soft tissue such as the TMJ disc
to see if it is in the proper position as the jaw moves. A CT scan helps view
the bony detail of the joint.
Your dentist may decide to send you to an oral surgeon (also called an oral
and maxillofacial surgeon) for further care and treatment. This healthcare
professional specializes in surgical procedures in and about the entire face,
mouth, and jaw area.
What treatments are available for TMD?
Treatments range from simple self-care practices and conservative treatments
to injections and open surgery. Most experts agree that treatment should begin
with conservative, nonsurgical therapies first, with surgery left as the last
resort. Many of the treatments listed below often work best when used in
combination.
Basic treatments
- Apply moist heat or cold packs – Apply an ice pack to the side of
your face and temple area for about 10 minutes. Do a few simple stretching
exercises for your jaw (as instructed by your dentist or physical therapist).
After exercising, apply a warm towel or washcloth to the side of your face for
about 5 minutes. Perform this routine a few times each day.
- Eat soft foods – Eat soft foods such as yogurt, mashed potatoes,
cottage cheese, soup, scrambled eggs, fish, cooked fruits and vegetables, beans,
and grains. In addition, cut foods into small pieces to decrease the amount of
chewing required. Avoid hard and crunchy foods (like hard rolls, pretzels, raw
carrots), chewy foods (like caramels and taffy) and thick and large foods that
require your mouth to open wide to fit.
- Take medications – To relieve muscle pain and swelling, try
nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen
(Advil, Motrin, Aleve), which can be bought over-the-counter. Your dentist can
prescribe higher doses of these or other NSAIDs, or other drugs for pain such as
narcotic analgesics. Muscle relaxants, especially for people who grind or clench
their teeth, can help relax tight jaw muscles. Anti-anxiety medications can help
relieve stress that is sometimes thought to aggravate TMD. Antidepressants, when
used in low doses, can also help reduce or control pain. Muscle relaxants,
anti-anxiety drugs, and antidepressants are available by prescription only.
- Wear a splint or night guard -- Splints and night guards are plastic
mouthpieces that fit over the upper and lower teeth. They prevent the upper and
lower teeth from coming together, lessening the effects of clenching or grinding
the teeth. They also correct the bite by positioning the teeth in their most
correct and least traumatic position. The main difference between splints and
night guards is that night guards are only worn at night and splints are worn
full time (24 hours a day for 7 days). Your dentist will discuss with you what
type of mouth guard appliance you may need.
- Undergo corrective dental treatments – Replace missing teeth;
use
crowns, bridges, or braces to balance the biting surfaces of your
teeth or to correct a bite problem.
- Avoid extreme jaw movements:
- Keep yawning and chewing (especially
gum or ice) to a minimum and avoid extreme jaw movements such as yelling or
singing.
- Don’t rest your chin on your hand or hold the telephone between your shoulder
and ear. Practice good posture to reduce neck and facial pain.
- Keep your teeth slightly apart as often as you can to relieve pressure on the
jaw. To control clenching or grinding during the day, place your tongue between
your teeth.
- Learning relaxation techniques to help control muscle tension in the jaw. Ask
your dentist about the need for physical therapy or massage. Consider stress
reduction therapy, including biofeedback.
More controversial treatments
When the basic treatments listed above prove unsuccessful, your dentist
may suggest one or more of the following:
- Transcutaneous electrical nerve stimulation (TENS)
– This therapy uses
low-level electrical currents to provide pain relief by relaxing the jaw joint
and facial muscles. This treatment can be done at the dentist’s office or at
home.Ultrasound – Ultrasound treatment is deep heat that is applied to the
TMJ to relieve soreness or improve mobility.Trigger-point injections – Pain medication or anesthesia is injected
into tender facial muscles called ‘trigger points" to relieve pain.Radio wave therapy – Radio waves create a low-level electrical
stimulation to the joint, which increases blood flow. The patient experiences
relief of pain in the joint.
Surgery
Surgery should only be considered after all other treatment options have
been tried and you are still experiencing severe, persistent pain. Because
surgery is irreversible, it is wise to get a second or even third opinion from
other dentists.
There are three types of surgery for TMD: arthrocentesis, arthroscopy, and
open-joint surgery. The type of surgery needed depends on the TMD problem.
– This is a minor procedure performed in the
office under general anesthesia. It is performed for sudden-onset, closed lock
cases (restricted jaw opening) in patients with no significant prior history of
TMJ problems. The surgery involves inserting needles inside the affected joint
and washing out the joint with sterile fluids. Occasionally, the procedure may
involve inserting a blunt instrument inside the joint. The instrument is used
in a sweeping motion to remove tissue adhesion bands and to dislodge a disc that
is stuck in front of the condyle (the part of your TMJ consisting of the
"ball" portion of the "ball and socket").Arthroscopy – Patients undergoing arthroscopic surgery are given
general anesthesia. The surgeon then makes a small incision in front of the ear
and inserts a small, thin instrument that contains a lens and light. This
instrument is hooked up to a video screen, allowing the surgeon to examine the TMJ and surrounding area. Depending on the cause of the TMD, the surgeon may
remove inflamed tissue or realign the disc or condyle.
Compared with open surgery, this surgery is less invasive, leaves less
scarring, and is associated with minimal complications and a shorter recovery
time. Depending on the cause of the TMD, arthroscopy may not be possible, and
open-joint surgery will need to be considered.
– Patients undergoing open-joint surgery also are
given a general anesthesia. Unlike arthroscopy, the entire area around the TMJ is opened so that the surgeon can get a full view and better access. There
are many types of open-joint surgeries. This approach may be taken
if:
- The bony structures that comprise the jaw joint are deteriorating.
- There are tumors in or around your TMJ.
- There is severe scarring or bone chips in the joint.
Compared with arthroscopy, open-joint surgery results in a longer healing
time, and there is a greater chance of scarring and nerve injury.
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