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Temporomandibular Joint Disorders


The temporomandibular joints (TMJ) are the joints located on each side of your face, just in front of the ear, that connect your lower jaw to your skull. On each side of the face, the joint is the contact point between the temporal bone (the side and base of the skull) and the mandible (the lower jaw), and properly functioning, the pair of TMJ's allows all the actions we associate with moving the jaw, such as chewing, talking, yawning, kissing, swallowing, and so on.

The TMJ is, anatomically and functionally, a very complex joint, with rotating and sliding capabilities that allow the jaw to move up and down, open and close, side to side, and forwards and backwards. The lower jaw is also one of the few bones with two joints; its movement requires very coordinated parallel movements to function properly.

Like other joints, the TMJ involves the joint itself, the surrounding muscles, ligaments, and nerves. Temporomandibular Dysfunction (TMD) can be caused by problems with any of these components. It is estimated that TMD affects as many as 11 million Americans a year; interestingly, approximately 90% of those who seek treatment are women between the ages of 20 and 45. Most cases of TMD are temporary and resolve by themselves with time and local and supportive care; sometimes, however, TMD can cause chronic and debilitating symptoms.

There is a wide range of theories in the medical and dental community explaining the causes of TMD. Symptoms of TMD may be caused by trauma, such as a blow to the face. Diseases that affect joints, such as rheumatoid arthritis or systemic lupus, can also cause chronic problems at the TMJ, including degeneration of the joint. Habits, actions or jaw structures that cause excessive strain on the muscle or joint may also bring on symptoms of TMD. For example, bruxism (clenching or grinding of the teeth, usually during the night) puts very severe stress on the entire joint structure. Some oral specialists think a very bad bite (severe malocclusion) can cause TMD. Finally, psychological factors like excessive stress, while probably not responsible for TMD, can exacerbate the symptoms.

Symptoms

The symptoms of TMD are very diverse. The most common ones are:
  • jaw discomfort or soreness (often most prevalent in the morning or late afternoon)
  • clicking or popping of the jaw
  • locking of the jaw
  • limited mouth motions
  • sensitivity of the teeth without the presence of an oral health disease
  • swelling or tenderness of the face around the TMJ
  • clenching or grinding of the teeth
  • headaches located in the temples or back of the head
  • pain radiating behind the eyes, in the face, shoulder, neck, and/or back
  • earaches or ringing in the ears (not caused by an infection of the inner ear canal)
Diagnosis

TMD is a complex set of conditions with a very diverse set of symptoms, and the criteria for diagnosing TMD are not well-defined. Before being diagnosed with TMD, it is important to exclude other medical conditions that may have similar symptoms. Your doctor, dentist or oral surgeon will speak with you about your symptoms and conduct a detailed examination.

One very important point in diagnosing TMD and forming a treatment plan is determining whether symptoms are caused by a problem relating to the muscles supporting the joint (extra-capsular, or outside of the joint capsule), by structural problems such as a loose ligament or a displaced disc (intra-capsular, or inside of the joint capsule), or both. Several imaging techniques can be used to help diagnose TMD, and look for structural problems in the joint. X-rays may show problems with the bones in the joint, but do not visualize soft tissue. Computerized Tomography (CT) and Magentic Resonance Imagery (MRI) scans provide a very high level of detail of the bone tissue, as well as the surrounding soft tissue of the joint. Finally, arthroscopy, actually looking inside the joint with special very small fiber-optic telescopes, can be used.

Treatment

Because it is an umbrella term for a variety of disorders with a range of causes, there is no single treatment approach to TMD. Conservative treatment (ie. treatment involving reversible procedures) is generally the most appropriate starting point in treatment.

Combinations of self-care techniques or behavioral changes such as the following may provide relief for some patients:
  • Eating soft foods, cutting up food into small pieces, and avoiding hard, crunchy foods or foods that involve excessive chewing can minimize stress on the jaw muscles, allowing the injury or inflammation to heal.
  • Applying ice packs and moist heat packs can relieve pain.
  • Reducing or eliminating the clenching of the teeth (bruxism) can decrease the stress on the joint and tension of the muscle.
  • Relaxation techniques and stress management can help break patterns such as bruxism, can prevent exacerbating TMD symptoms, and can help deal with the pain often symptomatic of chronic TMJ.
Interventional treatments such as the following may also be prescribed:
  • Medication, such as non-steroidal anti-inflammatory drugs or muscle relaxants
  • Physical therapy
  • The use of a splint, a special bite appliance that is fitted to the upper or lower teeth. Some splints help to treat bruxism, others support the jaw taking pressure off of the joint and the muscles.
Most specialists agree that 90% of TMD sufferers will respond to conservative and non-surgical care. Surgery and other irreversible procedures should be considered after conservative measures have failed to relieve symptoms, or in those specialized situations structural damage to the joint.

If your dentist or oral surgeon believes that your symptoms are caused or worsened by a misalignment of your lower and upper jaws (a bad bite, or malocclusion), orthodontics, sometimes combined with jaw realignment surgery may be suggested.

Several surgical techniques are available to treat structural problems in the joint such as displacement or degeneration of the disc or degeneration of the bony part of the joint. Depending on your specific situation, these surgeries may be conducted in one of three ways. Arthrocentesis, or washing out of the joint, can be performed in the office using local anesthesia with intravenous sedation. Arthroscopic surgery, using tiny instruments and fiberoptics, is performed with general anesthesia, and is a less invasive surgery associated with less scarring and shorter recovery time. In some cases, open joint surgery may be more appropriate to better visualize the joint and enable greater bony and/or soft-tissue repair.

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