Posted 4/6/2022 by admin

Go Tmd

A young woman with a few particular esthetic concerns was to be the subject of discussion at a recent dental study club meeting. Prior to the meeting, she saw two oral surgeons, a prosthodontist, a periodontist, and an orthodontist. I wasn’t going to be part of the crew who examined her until the orthodontist noticed that her jaw joints made some rather spectacular noise when she opened and closed.

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“She had better have a TMJ exam also,” the orthodontist suggested. And so she arranged an exam at my office.

When I saw her, I discovered that she had serious TMJ pain. “Actually, the pain here,” she said, indicating her left TM joint area, “is so bad that sometimes I can barely get through my day.” It turned out that she had been taking 800 mg ibuprophen tablets most days for the past two years.

X-rays showed posterior displacement of both mandibular condyles and a short ramus on the left side (please refer to my article on canted frontal occlusal plane) Joint vibration analysis (JVA by Bioresearch) showed significant joint noise on both sides with a clear indication of total anterior disc displacement. Certainly this young lady had severely compromised jaw joints and needed splint or orthotic therapy to reposition the joints as a first priority.

Members of this study club are among the best general dentists and specialists in Southern California. I hold them in highest regard and work with many of them when their patients exhibit TMJ or occlusal concerns. And yet, there was still room for disagreement.

At the dental meeting, most of the discussion centered on perio surgery and either orthodontic or restorative approaches to resolve her esthetic desires. But I told the group that pain was my number one concern. I said that in my opinion, treatment to eliminate or at least greatly reduce her constant pain should be addressed before any other dental treatment was considered.

While the prosthodontist who had seen her agreed, the two oral surgeons and one other prosthodontist–who had not examined her– had a different view. “You know, these TMJ problems are self-limiting anyway,” one of them said.

“Yes. Eighty percent of the time, these problems go away by themselves,” one restorative dentist chimed in.

And if you enter Self-limiting aspect of TMD on your web browser, you will indeed find many articles that say TMD is self-limiting. Self-limiting is described in two different ways, depending on the author. In some articles the term means that the bones and soft tissues eventually adapt and remodel and the symptoms go away. In other articles, self-limiting is defined as symptoms staying the same and not getting worse. (If the latter is true, would that be good enough for you, Doctor? It wouldn’t be for me. Not in the case of the patient we were discussing.)

So, I turned to the research literature. It turns out that the idea that TMD is self-limiting is highly controversial. Studies that suggest this may very well be flawed. As two authors of a peer-reviewed study (GB Wexler and MW McKinney) put it, “…studies cited to show that TMDs are self-limiting have major methodological limitations.” Their own study of 274 patients found that patients receiving treatment showed excellent improvement while those who were not treated had no significant improvement over time (Journal of Craniomandibular Practice 1: 30-37, 1999).

Perhaps the best and most comprehensive study involved 53 volunteers who had TMJ pain symptoms but agreed NOT to be treated. All 53 were examined and had MRIs of the TM joints at the beginning of the study, a follow-up at one year, and another follow-up 15 years later at which time MRIs were repeated. Think TMD is self-limiting? In this group of 53 (again NONE were treated—just observed) NO ONE GOT BETTER. And for some–about 10%– MRI showed worse disc displacement with evidence of degenerating joints at 15 years. These volunteers also had worse pain symptoms.

Some of the subjects of the study stated that during the 15 years their pain seemed to lessen for a while. But it came back 100% of the time. Self-limiting TMD? I don’t think so. And now a well-designed study bears this out.

(Temporomandibular Joints…a prospective 15-year follow-up clinical and MRI study. Sale H Bryndahl F and Isberg A. Radiology 2013 Apr. 267 (1) 183-194.)

What I told the group that night was that my typical patient is a 40 to 50 year old female who states she’s had TMJ related problems for years. The narrative I hear at the intake interview usually goes like this, “Oh, I noticed clicking forever. I mean, since I was a teenager anyway. I usually had some pain when chewing and when I woke up in the morning. But never like this. Over the last year or two it’s just gotten worse and worse. That’s why I’m here now.”

So, my own experience, over the last thousand or so patients, says “TMDs self-limiting? I wouldn’t count on it.”

But let me just tell a little story that may shed some light on the subject. Over the Memorial Day holiday I did some hiking in the Eastern Sierra. On one hike I went to one of my favorite alpine lakes and a little more than half way there encountered snow 4 to 5 feet deep and I drudged through it in … snow shoes? Well, no. MICROspikes—one of my favorite products for ice and snow–? No again. I did the last part of the hike through deepening snow to an ice covered lake in my tennis shoes. And somewhere in those last miles that saw me sometimes scrambling over ice, and sometimes slipping in snow that was turning to slush under a warming sun, I painfully twisted my right knee. I stopped for lunch at the still frozen lake, then hobbled across the snow again and made it back to the car 6 miles and a couple of hours later.

Back in Mammoth Lakes, I got out of the car rather carefully, one gingerly step at a time. Left foot down to the pavement. Okay. Right foot down. Oh-oh. That right knee is not going to hold. Got to be careful not to fall. My right knee buckled rather dangerously. In my imagination I pictured a few months with a physical therapist or maybe even knee surgery.

But guess what? Every day got a little bit better. Six days later, I did a hike in the eastern part of San Diego County and the knee that was so painful and feeble the week before was back to 100% strength and function. Dodged a bullet again!

So knee injuries are Self-limiting, right? Of course! Sometimes. But only sometimes. And so are TMJ injuries. I think we as practitioners (and even potential patients) have to simply use judgment. Occasionally a patient will be referred to me for a TMJ exam and I’ll ask, “How long has this problem been going on?” And the answer will be two or three weeks. Perhaps after an incident with a hard French roll. Okay, I will do the exam. But if joint images are normal, and range of motion is reasonable and there’s minimal pain on various palpations I will often say, “Mrs. Jones, I’d recommend we do nothing for now. Let’s schedule you for a brief reevaluation in a month or six weeks. I think you’re going to gradually improve and you’ll be fine with no treatment. If I’m wrong, and you’re the same or worse, I’ll talk with you about treatment options.” And most of the time, I find that was a good call. The patient returns to good comfort and function.

I would be willing to bet that this is a common scenario: a temporary TMJ strain. Maybe these are the cases included in the studies that say that TMD is self-limiting. Okay. These temporary joint strains probably are self-limiting. I’ll buy that. But what about the young lady we talked about at the beginning? That’s a case of articular disc displacement and significant daily pain for the last two years. Doctor, if you’re betting on TMD symptoms getting better over time, just how long are you really willing to wait?

Medically Reviewed by:Ivan F. Stein, DDS

There are a number of treatment options available to correct TMJ disorder. Your particular treatment should be determined through consultation with a dental professional who is highly experienced in temporomandibular joint problems. Ideally, your dentist should have expertise in evaluating jaw-to-bite relationships and experience with proper treatment procedures such as occlusal equilibration and the use of intra-oral appliances.

Treatment Options: Conservative is Key

“Conservative” is the key word when it comes to TMD treatment. Most treatments are simple and can be done at home without the need for surgery. The most severe cases may require treatment with splints, mouth guards, or other traditional forms of TMD therapy like physical therapy.

Regardless of the treatment prescribed for you, it is important that you follow your dentist’s instructions. You should also keep up with routine dental visits so your dentist can regularly monitor your TMJ symptoms.

In addition, the TMJ Association advises patients to keep in mind that there is currently no evidence to suggest that TMD can be prevented. Therefore, caution is advised regarding any treatment(s) presented as providing this benefit.

Traditional Treatment Options

A careful examination of the joints and occlusion is a critical step before a specific treatment is selected. Some specialists have a computer to analyze your bite. Only a small percentage of TMD cases require surgical intervention. If an improper bite is the cause of the TMD, many bite corrections can be achieved with orthodontics, restorations, equilibration or appliance therapy.

Appliance Therapy (Splint or Mouth Guard)

Typically the first line of treatment provided by your dentist will be the use of a splint. The splint is worn to reduce stress on the jaw and to allow the muscles to function optimally and/or to cover the deflective interferences affecting the bite so that the lower jaw can be repositioned into the socket properly. If a splint helps relieve the pain, it is possible that your bite or parafunction was causing the problem.

Many types of splints and appliances may be fabricated by your dentist. The appliance that is best for you will be decided based upon clinical findings, symptoms, and diagnostic tests (X-rays, etc.). Such appliances may help improve your bite while it is in place, thus providing the ability for the lower jaw to fall properly into the temporomandibular joint socket.

Occlusal Equilibration

If your dentist determines that no structural disorder exists in the joint, but that there are deflective interferences on the teeth that are affecting the bite and causing an improper jaw closure, you may undergo occlusal equilibration or your dentist may elect to treat the bite with an appliance.

Many TMJ cases can be corrected with occlusal equilibration, particularly when performed by a dentist experienced in TMD. Occlusal equilibration involves selective reshaping of the biting surfaces of the teeth and is often the best choice for eliminating deflective interferences so that the jaw can close properly. Once the lower jaw is able to close properly into position within the temporomandibular socket, your pain may be relieved immediately. Pain relief is typically achieved when the muscles are able to function properly.

Treating Structural Disorders

If your dentist suspects a structural disorder within the joint itself, further studies may be necessary prior to treatment to ensure that a proper diagnosis is made. The panoramic X-ray is an excellent screening tool though other diagnostic tests may be required.

These include:

MRI (magnetic resonance imaging) may be used to help your dentist view the soft tissue area surrounding the disc joint.
CT (computed tomography) scan to evaluate the bony areas of the jaw and hinge joint.

Depending on what these images reveal, your dentist may recommend an intra-oral appliance, orthodontia, or maxillofacial surgery. You may be referred to an oral surgeon or oral and maxillofacial surgeon who will further evaluate and treat your condition.

Surgical Treatment

Typically, surgery is only considered after all other conservative treatment options have been attempted. It is important to know that surgery may not always resolve TMD issues.

All TMJ-related surgery is performed under general anesthesia.

Some of these procedures include:

Arthrocentesis: During this minor procedure, your surgeon cleanses the joint by inserting needles into the joint area and dispensing sterile fluid. In some cases, the surgeon inserts a scalpel-like instrument inside the joint to remove any tissue adhesions and reposition the disc in the joint hinge.
Arthroscopy: During this procedure, your surgeon makes an incision at the temple point in front of the ear to reach an endoscope into the surrounding area. The endoscope provides a visual guide so that your surgeon can remove any adhesions, treat inflammation, or reposition the disc.
Open Joint Surgery: This may be the only option that provides access to deteriorating bony structures, tumors, severe scarring, or chipped bone areas. Depending on the type of problem, your surgeon may use a scalpel to remove or re-sculpt the affected area.

Alternatively, open-joint surgery may be performed. This may be the only option that provides access to deteriorating bony structures, tumors, severe scarring or chipped bone areas. Depending on the type of problem, your surgeon may use a scalpel to remove or re-sculpt the affected area.

Treatment Costs

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TMJ treatment costs depend on several factors, including the expertise of the dentist, the location of the dentist, the type of dental insurance you have, and the facility fees for procedures. For example, if occlusal orthotics or a removable appliance is prescribed as part of your TMJ treatment, the cost could be roughly $800 to $3,500.

Depending on the type of medical and dental insurance you have, insurance companies may offer a reimbursement of the total procedure costs.

Alternative Treatments

Alternative medical treatment for TMD is considered less conservative and unnecessary if you initially receive proper diagnosis and treatment.

Alternative treatments include transcutaneous electrical nerve stimulation (TENS), ultrasound, trigger-point injections, and radio wave therapy. TENS and radio wave therapy send low levels of electrical or radio waves of energy to the affected area in order to stimulate blood flow to the joint and surrounding area. However, these options do not treat the causes of TMD and may only provide limited, temporary, symptomatic relief.

Botox

Once reserved for lessening the tell-tale signs of aging, such as annoying wrinkles and frown lines, Botox injections are being used more frequently in dental offices as “off label” treatments for more troublesome maladies such as TMD. Scientific studies have shown that patients who received the injections experienced significant improvements in pain, function, ability to open their mouth, and levels of tenderness to palpation.

Botox is injected into the temporalis, medial pterygoid (deep jaw muscle), and masseter muscles that together move the jaw. Botox blocks nerve signals that cause uncontrollable muscle movements, essentially relaxing the muscles.

Botox injections take only 10 to 15 minutes and remain effective for anywhere between 2 and 6 months. Therefore, like its cosmetic counterpart, Botox TMD treatments must be repeated every few months. If you have TMD and your dentist determines that you are a candidate for this treatment, how often you’ll need to receive Botox injections to relieve symptoms will depend on the severity of your condition.

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To achieve a successful outcome, it is important for your dentist to use the correct injection technique as well as follow the appropriate dosage guidelines.

Cost of Botox Treatment

The cost of the Botox treatment will vary based on where you live, where you receive treatment, and the severity of your condition (and therefore how many Botox injections are needed). Botox treatment is usually charged on a per-visit basis.

Most dental insurance companies do not cover Botox treatments because they are “off label,” optional treatments. Therefore, the costs associated with your treatment most likely will be out-of-pocket expenses. However, financing or payment plans may be available.

[updated May 13, 2019]

About the Reviewer

Ivan F. Stein, DDS, is a recognized innovator in neuromuscular and cosmetic dentistry. He has dedicated two decades of his career to researching and treating functional disorders of the jaw and mouth – including temporomandibular joint disorder (TMD) and excessive snoring caused by obstructive sleep apnea (OSA) – as well as full mouth reconstruction.

Dr. Stein earned his Doctor of Dental Surgery degree at prestigious Georgetown University Dental School. He has personally developed a number of successful oral appliances for use in neuromuscular dentistry, including Oravan OSA, an oral appliance for the treatment of obstructive sleep apnea. Dr. Stein was named a Top Dentist in NJ Monthly Magazine and has been invited to appear on ABC and CNBC to discuss dentistry as an art, as well as the safety of dental materials. He is in private practice at Northfield Dental Group, serving patients in and around West Orange, Short Hills and Livingston, New Jersey.