TMJ - Temporomandibular Joint Dental Treatments

Treatment of TMJ can take several forms because there may be a multitude of parts to the puzzle. Medicine has been asked for years to solve this puzzle, with little success. Therapies based on drugs, counseling, or surgery, while temporarily effective in some cases, have not provided the answer for the majority of chronic pain sufferers. Likewise, dentistry, primarily through grinding or reshaping the teeth, has not had a consistently high percentage of long-term success.

Treatment should be based upon an accurate diagnosis following a complete history and comprehensive examination of each patient. This stage is called Stage I. It is our firm belief that treatment must always follow diagnosis. Insertion of a dental appliance without accurate diagnosis does not provide an environment where we can predict results, let alone know what we are trying to treat. Therefore, along with the complete history and examination, we need radiographs of the jaw joint and possibly of the head and neck.

We may also incorporate computer-aided diagnostics. This can include computerized recording of jaw joint sounds to assist in determining the level of deterioration present in the jaw joints, computerized recording of jaw movement, and computerized recording of muscle activity. All of this information will be used to formulate a specific treatment plan for each patient's individual needs.

Once a treatment plan has been decided, Stage II, or therapy begins. The goal of therapy is again to unstress the jaw joint, provide therapy to reduce muscle spasm, and assist with improvement of body posture while repositioning the jaw so that it is related to the head in a more physiologically correct position. The improvement in the positional relationship of the jaw to the head is done in tandem with therapy to eliminate spasm and trigger areas in muscles as well as identify and correct perpetuating factors that may cause a return of symptoms.

This stage of therapy, which usually lasts three to six months, may take a team approach. Physicians, chiropractors, physical therapists, and psychologists may need to be consulted for their clinical expertise.

A dentist trained in these areas is, however, the key clinician by whom a chronic head and neck pain patient must be treated. Only a dentist is trained to work with the dental bite and the relationship of the jaw to the head. Further, teeth that are missing, worn down, or do not provide for a correct dental bite can make a malrelationship of the jaw to the head difficult to treat successfully without dental intervention.

If it is determined that a malalignment of the jaw exists, an intra-oral appliance called an orthotic (sometimes called a splint) is commonly prescribed. Normally, the orthotic is worn 24 hours a day. This device will help to unstress the jaw joint and relieve muscle spasms in both the head and neck.

If referral for treatment with other health care providers is deemed necessary, it will be done at this time so that they can take advantage of the unstressed jaw position allowed by the orthotic. We have found well-timed combination therapies by dental and other health care providers to be most effective.

Single modalities such as an orthotic are used as the first method to stop the cycle of pain. Patients may also experience significant results from the therapeutic use of TENS (transcutaneous electrical neural stimulation), ultrasound, vapocoolant spray and stretch, trigger point injection with local anesthetic, hot packs, exercise therapy, and posture training. Each level of therapy is added to the treatment regimen as needed.

Additional orthotics may be needed during Stage II therapy depending on the individual. Some patients may complete therapy by gradually reducing wear of the initial appliance. Eventually, they may need to wear the orthotic only during the night time. Other individuals may need further appliance therapy to have successful management of their pain. The goal of additional appliance therapy is to predict the most physiologically correct position for the jaw with the most orthopedically correct body posture attainable.

Once pain therapy is completed, the patient is ready for Stage III, or stabilization, during which we try to stabilize the physiologic jaw position realized in Stage II. One or a combination of the following dental procedures may be used to affect a relatively permanent holding of the desired jaw position: coronoplasty (slight reshaping of the enamel of the teeth to remove interferences), orthodontics, fixed prosthetics (crowns and/or bridges), removable dental prosthetics, or a combination of the above.

A final stage, maintenance, is often necessary because, as stated earlier, there is no cure but rather management of TMJ disorders. This stage is relatively simple and generally involves fabrication of an appliance to wear during sleep or when symptoms temporarily increase. Frequency of use of the appliance is dictated by the patient and their symptoms.

In summary, typical treatment for TMJ dysfunction usually follows this pattern:

1) initial screening and consultation;
2) complete history and evaluation including radiographs and computerized diagnostics if needed;
3) appliance therapy to reposition the jaw in a more comfortable and correct position in tandem with physical medicine if needed;
4) weekly, biweekly, and then monthly adjustments for three to six months;
5) when both the doctor and patient are satisfied with the progress of treatment, a more permanent positioning of the jaw is considered. In each case, that positioning should follow appliance therapy and will vary according to the patient's need for bite space and current oral conditions.

We desire all of our patients to be aware of the nature, scope, and prognosis of their treatment. Please note that there are two distinct stages of TMJ treatment: symptom relief and stabilization of the correction. The improvement rate of each patient will vary. Some may improve 80% or more, others less. Therefore, we cannot guarantee specific improvements of any one individual. Much of the success lies in the hands of the patient. Proper diet, muscle exercises and wearing of the appliances plays as significant a role in treatment as does the work of your doctor.

The care of the craniomandibular pain patient is changing. The emphasis on examination and diagnosis has expanded. Therapeutics have broadened to overlap all fields of health care. The multidisciplinary approach is encouraged to achieve more thorough lasting results. The understanding of the interrelationship between medicine and dentistry grows stronger each year. Consequently, there is renewed hope for those who suffer from the chronic pain of TMJ dysfunction.