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                           ORTHODONTICS          TMJ & PAIN MANAGEMENT         COSMETIC CROWNS & DENTURES    SURGERY   TEETH WHITENING

ORTHODONTICS      TMJ & PAIN MANAGEMENT   COSMETIC CROWNS   DENTAL IMPLANT     TEETH WHITENING    SURGERY     PANORAMIC X-RAY 

TMJ DISORDERs:
The oral jitters you may have but has no awareness of...
by. Dr. Eden Ramos, DMD, RN

ABSTRACT:_During my early years of dental practice, I never knew the word abfraction, the importance of the word "disclusion" in horizontal or lateral and protrusive jaw movements, the interrelationship of the teeth to the masticatory muscles and the condyle-disc complexes and its vital correlations with the occurence of these symptoms such as - migraines, clicking jaw joints, ringing of the ear, popping sounds of the jaw joints, tooth mobility/flexure without known dental pathologyand tooth and dental fillings getting fractured and other TMD related problems. God is so God, He made opportunities by allowing me to meet this Hawiian-Japanese TMJ practitioner, name Dr. James Sagawa, who taught me, together with other 4 students, everything he knew about TMJs. and TMDs, which he's been into rooted practice for nearly 40 years. The rest of the knowledge and learning experiences that followed then and now is awesome. Patients who have been diagnosed TMDs but have no awareness of it are now being informed and their possible non-invasive treatment options and precautions/instructions they could opt for clinical management are laid down.  Nowadays, there are increasing number of cases of TMJ dysfunction that I have seen in my clinic with either one or more of the following classic signs and symptoms the like of migraines, neck or shoulder pain, ringing of the ears, clicking sounds of the jaw joints during opening or closing, masticatory muscle pain related to bruxism or clenching, and temporal headache, tooth sensitivity and abfractions. It maybe that these symptoms could be present in our patients before, but, since I never knew then of its relevance to teeth and occlusion, that I "missed one puzzle" to complete the entire picture. As one TMJ specialist, Dr. Jeffrey Okeson says, which is so true, "One can't diagnose anything he has not heard of." Having a knowledge about  human dental anatomy and functional occlusion, and being keen in diagnosing the presenting signs and symptoms that may co-exist if these structures deteriorate, more so  in relating these findings  to masticatory muscles  and jaw joints are ALL TOO  EQUALLY IMPORTANT as the treatment itself. 


      If the teeth are the direct cause of TMD's, then the dentists who are trained to do TMJ treatments and therapies have much to offer to their patients by relieving them from their “discomforting lives” of constant bugging pain attributed to TMD [Temporomandibular Joint Dysfunction].  It is an unfortunate reality though, that many of these patients who have TMJD concerns were not really aware of it themselves. They would come only for treatment when their tolerance to pain due to severe toothache, migraine and infliction of pain somewhere on the face, neck and head portion has gone beyond tolerance. Some patients have mentioned about visiting an EENT or neurologist for the ringing or itching of their ears, or nagging headache respectively, but no apparent pathologic finding was found to be relevant to their symptoms . With that sort of health dilemma, these patients will just have to endure this type of  ailment, with the hope that as the time would pass by --natural self-healing will take place..

     Knowing the patient's history by thorough interview, getting, fabricating diagnostic tool such as study casts, taking photos and x-rays are very helpful adjuncts in coming up with a sound treatment plans. Early detection spare the patient from further health discomfiture of teeth and its surrounding structures, breakdown of masticatory muscles and that of condyle-disc complex.


     The jaw joint is also known as the temporo-mandibular joint or TMJ. It can be felt by placing your fingers just in front of your ears, and opening and closing your mouth. The joint allows the mandible to open, close, and to move side to side and forward. It plays an important role in jaw functions such as talking, chewing and yawning. It is one of the most complex and frequently used joints in the body. The jaw joint consist of an almond- shaped bone which is housed inside the a bony recess of the temporal bone of the human skull called glenoid fossa. These pair of bones called condyle are normally capped by a movable dense fibrocartilage disc and are supported by ligamentous attachment on each side of the skull. Making all the mechanics of jaw movements such as opening and closing, right or left lateral horizontal, and protrusive or forward jaw movements smooth and friction free under normal anatomical jaw movements. Just imagine the disc as likened to water-filled balloon, the condyle can roll underneath it freely and smoothly. However, under certain stress and strains put upon these joints, a dysfunction at the condyle disc complex can cause derangement in the movement of the jaw. Abnormal occlusion of teeth either on the molar area or on front teeth can cause erratic jaw movements and constrained muscles of the musculoskeletal system. Posterior avoidance or Anterior Avoidance contact is caused by proprioceptor sensor of the teeth, muscles and joints. The mandible tries to avoid any parafunctional contact 

[interferences in occlusion] by assuming a “habitual position” where the masticatory muscles feel more  comfortable. The masticatory muscles assume the role of balancing the bite up to the maximum limit or tolerance it could hold on. However, whenever there is a discrepancy in ones bite and it becomes protracted, the jaw will overcompensate and shift every time you bite, chew, and speak. This shifting can place an immense amount of pressure on your teeth, jaw muscles, and jaw joints (TMJs), creating stress and strain effect that can manifest as teeth-grinding (bruxism), and TMJ disorder such as tell-tale clicking of the jaw and other musculoskeletal problems. These condition is what we call as TMD or temporomandibular dysfunction. TMD condition has multifactorial causes among which that we can implicate are:


  • Night grinding and daytime clenching of teeth
  • emotional and physical stress
  • tension in the jaw muscles due to trauma
  • injuries such as fractures and dislocations of the TMJ
  • osteoarthritis or rheumatoid arthritis
  • dental fillings that are poorly contoured or high
  • crowns or bridges that are not properly equilibrated
  •  poor orthodontic treatment results
  • Loss of one tooth or more that led to a change in tooth position


SYMPTOMS OF TMJ DISORDER

TMJ disorders in different people can cause different symptoms that may vary from mild discomfort to severe pain. For example, pain may be sharp, searing and intermittent, or dull and constant pain. Symptoms of TMJ disorder may include:


  • limited jaw opening
  • tooth sensitivity
  • difficulty in opening the mouth
  • a stuck or 'locked' jaw
  • popping sounds or jaw clicking noises ,
  • pain when chewing or yawning
  • pain when opening the jaw widely
  • pain in or around the ears and cheeks
  • temporal headaches and, occasionally, migraine-like              headaches and nausea
  • earaches, loss of hearing or ringing in the ears
  • face, neck, back and shoulder pain
  • a feeling of facial muscle spasms especially in the                  morning after sleep
  • faceting of on tooth surface [abfraction]
    • tooth abscess in the absence of caries, gingivitis or      periodontitis
    • tooth mobility
    • tooth/filling fracture
    • bone radiolucency on x-ray
    • clenching and grinding of teeth
    • death of a tooth [worst case scenario of prolong untreated case]
    • numbness of fingers

. WHAT CAUSES RINGING OF THE EARS ? [TINNITUS]

     There many studies and school of thoughts regarding tinnitus of the ears:_

1>Grinding of teeth (bruxism), degenerative changes in the joint (ankylosis), joint pain as well as itching of the ear are signs related to TMJ. The movements of the jaw or neck increases pressure on the hair cells in the inner ear which can cause ringing in the ears or tinnitus and vertigo; unusual symptoms not often thought to be related to neck pain [1 ]

2> Pain, stuffiness and ringing in the ears (tinnitus) may be part of TMJ Disorder syndrome. The same nerves that supply a group of chewing muscles also supply the middle ear muscles. The shape, position and size of the upper and lower teeth directly affect jaw posture, and have been known to cause ear pain, stuffiness and pressure changes on the middle ears.

3>Research has discovered that the nerve supply from the TMJ seems to have a connection with the parts of the brain that help with hearing and interpreting sound. [5]

    

      One of the visible signs that a patient is suffering from TMD dysfunction is wearing away of tooth structure at the cervical margin. This is due to constant occlusal loading caused by a parafunctional contacts between two opposing teeth. Abfraction is a wedge-shaped cervical lesion that results from repeated tooth flexure caused by occlusal loading. Other terms have also been suggested for this phenomenon, including noncarious cervical lesions and stress corrosion. Although these lesions have been recognized for years, their etiology has been debated. Numerous hypotheses were put forward over time to explain the cause of these lesions. The most common theory was that of toothbrush abrasion occurring independently or in conjunction with acid erosion. However, the sharp angles and frequent subgingival location of these cervical lesions cannot be adequately explained by any of the previous hypotheses. It was not until the early to mid-1980s that the concept of tensile stress as the etiology of these lesions came to the forefront. Sufficient experimental and clinical evidence has now been garnered to establish the primary etiology of these lesions as tensile stress of occlusal origin.


     As lateral [horizontal] occlusal forces are generated during mastication and parafunction, flexure of the tooth occurs at the cervical fulcrum. This flexure concentrates tensile stresses that disrupt the chemical bonds of the crystalline structure of enamel and dentin. Small molecules then enter the microfractures and prevent the reformation of the chemical bonds. Loss of tooth structure ultimately occurs in the regions of concentrated stresses. After the initiation of these lesions, tooth surface disintegration could lead to accelerated wearing down by mechanical forces, [ even when gently applied to the tooth as the quarrying effect made by toothbrush bristles.]


     An accurate diagnosis is important to ensure the right treatment undertakings.

Your TMJ dentist will formulate a diagnosis based on clinical findings during oral examination. Presence of signs and symptoms are noted such as pain, clicking sounds, deviation in jaw movements, tooth size and shape alterations, mobility, sensitivity, and etc. Past and present medical and dental history like tooth extraction [major and minor] including medications taken and oral theraphies underwent through including its duration. Traumatic jaw injuries experienced if ever had need to be completely evaluated.

Certain anti-depressants such as SSRI are also being attributed to the occurrence of TMD. The subjective complaint of the patient often has relevance to his/her suffering. A good TMJ dentist must have a skill in extracting previous history that may affect the course of the treatment plans for the patient.

    

       TMJ dysfunction is a multifactoral illness with different causative factors requiring respective treatment approach.

 [ Ex. >A._-Emotional stress:_ treatment: remove the person from the origin of stress and advise for behavioral awareness to lessen the stress.>B._High crowns/bridges and dental fillings:_Bite equilibration to adjust the raised occusion to normalcy,c._>Bruxism: occlusal splint or mouth guard fitting and D.._occupation-related problem ex. Telephone operator that uses their neck and shoulder to hold the telephone, wind pipe instrument blower that holds the mouthpiece by their teeth:_treatment: modify the mode of handling instruments.]. 

    

      Tactile method of examination can also be employed to check your teeth for mobility and increased sensitivity. Some cases proved too painful to touch due to increased pressure inside the pulp chamber. Some had experienced “pulpal hypertension” either due to macrotrauma or sudden application of force to the tooth or microtrauma due to constant but minute afflictions of occlusal forces applied to the tooth. If death of the pulp took place, and it is verified by x-ray and thermal test, then Root Canal Theraphy can be undertaken to spare the patient from bothersome pain.

Your dentist may recommend taking impressions for upper and lower plaster moulds of your teeth to analyze and check your bite while it is mounted on the adjustable articulator.  A well mounted upper and lower cast on the articulator is a good diagnostic tool to make a free hand early assessment of any parafunctional [non-functional] tooth contacts using thin aluminum colored-coated articulating foil. Dark markings are registered during lower articulated cast movements in opening/closing, lateral excursive and in protrusive. This approach gives the TMJ Dentist to make practice reduction on the lower and upper casts and to give him/her an idea as to where the supposed actual reduction on cusps and tooth inclines could be made before the real bite equilibration on the patient could be done. The Bite Equilibration is a meticulous procedure of removing occlusal interferences on the patient’s bite so the upper and lower teeth can come together evenly and this is also an attempt to redirect the distracted jaw joint in the most stable position. And according to Dr. Jeffrey Okeson, a TMJ guru, the most stable position is when the condyle is at the most superior anterior position in the glenoid fossa being capped by the disc and supported by healthy ligaments and muscles.

     

      Articulated casts could also reveal any abnormal tooth structure or details which maybe hard to detect during actual patient oral examination. [ex Cracks or fissure, faceting on enamel, misalignment of tooth position,caries etc.]  

     TMJ shots, Panoramic X-ray help determine the position TMJ in its articulation to the skull bone. The maxillary teeth and its proximity to the sinus can be determined. Close approximation of the root of the teeth along the floor of the sinus could be attributed to teeth sensitivity. This is also carefully examined. The panoramic also let the attending dentist examine the jaw bone for any radiolucencies and radiopacities that may be helpful in coming up with a diagnosis related to pain and discomfort. The TMJ shot is a magnified view of TMJ as it hinged on the glenoid fossa of the temporal bone. It features the jaw joints in open and closed position and allows the dentist to see whether the TMJ is in a stable position in the skull.

Cone Beam Tomography are also equally important diagnostic methods to determine any possibility of abnormalities in tooth anatomy and physiology.

There are still many form of diagnostic tools for TMJ examination, however, only these tools I have mentioned are helpful as a practical way of doing it.


TREATMENT OF TMJ DYSFUNCTION

     When pain relievers and anti-inflammatory medicines proved unrewarding for recurrences of pain many times over, Muscle Deprogram and Bite Equilibration are two methods of choice that are proven useful in returning the bite from habitual contact position to the functional and comfortable position called True Centric Occlusion. It is a long and tedious procedure of finding and grinding off parafunctional contacts on the surfaces of teeth utilizing occlusal markers and foils. Most favorable results are obtained when these two procedures are done together. Tactile sense helps detect flexing or “jerking” of teeth using thumb and index fingers. Although not every TMJD [ Temporomandibular Dysfunction] problem requires outright muscle deprogramming or bite equilibration. Sometimes reconstruction of worn out teeth, installing crowns or removable dentures, and installing CGF or canine guided function could be helpful for initial or temporary relief as “jaw positioner.” The CGF guides the jaw to come up with a stable temporomandibular joint position before the need for a GNATOLOGICAL OCCLUSAL SPLINT could be tried [this is in case of persistent pain and discomfort ]. An intact canine teeth help the jaw in its various phases of movements without causing harm to itself and its surrounding structures, muscles of mastication and to the TMJ. When the muscles get strained caused by heavy and constant occlusal loading, the former structures will suffer physiologic demise.

However, when the canine teeth are malposed or worn-out, a composite reconstruction can be readily done. In contrast with orthodontic treatment which could take longer to achieve results. The canine rise brought about by the said discreet procedure in correcting the bite produces posterior teeth disclusion [clearance] during functional horizontal jaw movements. The stronger the restoration and its attachment to the canines, the better its therapeutic effect to the teeth, masticatory muscles and jaw joint. These inter-related dento-facial anatomical structures are needed for orderly bite mechanics. One can not perform well without the other.


When all other conventional efforts failed, and patient still complained of pain and discomfort, a hard Gnathological Splint would be prescribed. It is equilibrated at a required intervals dictated by the TMJ dentist.

A surgical operation by Maxillofacial dentist will be recommended if the TMJD is so grave and severe and when all conventional treatments failed to address the problem.

We talk, we chew and swallow. One aspect or form of survival for Life that we do are inclusive and initially takes place inside our mouth and it has been serving us since birth. When our teeth erupt, both temporary and permanent, it has been subjected to use and misuse, care and neglect and assaulted by ingestion of acidic and alkaline, sweet and salty, hard and soft and other foods that compromise the health and integrity of our teeth and its surrounding structures. God has not given us 3rd set of teeth that we could rely on when we are aged. Our permanent teeth, in want of care can easily become exterminated due to ones neglect. Life is always made of CHOICES.. a choice to look well or a choice to look poorly, a choice to grow old with our teeth or a choice to go edentulous. Can’t we now, at least, take care of it before it is too late or before we become enlisted among those afflicted with TMDs? Every good and bad decision is a matter of choice. Every clicking noise in your jaw joint is a classical sign asking for treatment and remedies. That unhealthy sound is speaking and pleading for help.

References:


[1] 2011 journal BMC Ear Nose & Throat Disorders, Signs and symptoms of Temporomandibular Joint Disorders related to the degree of mouth opening and hearing loss,”

[2] Center for Sleep and TMJ Disorders of Fairfield, http://www.fairfieldsleeptmj.com/common-tmj-symptoms

[3-5] Kanehl Dental Group, http://kanehldental.com/blog/ear-related-symptoms-of-tmj

[6] Center for Sleep and TMJ Disorders of Fairfield, http://www.fairfieldsleeptmj.com/common-tmj-symptoms

[[PASTING TABLES IS NOT SUPPORTED]] [7] ABFRACTION, ABRASION, ATTRITION, AND EROSION – james W. Curtis Jr., DMD, Beverley A. Farley, DMD, Ronald E. Goldstein, DDS/ Online: http://www.scritub.com/limba/engleza/health/ABFRACTION-ABRASION-ATTRITION