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Craniofacial Pain and TMJ/TMD Therapy

Do you experience headaches, ear clicking, popping, ringing or pressure, dizziness, jaw pain, jaw locking, limited opening or movement of the jaw, clenching, grinding, broken or worn teeth?

TMD is not one disorder, but a group of conditions, often painful, that occur when chewing muscles and jaw joints do not work together correctly. However, not all Craniofacial Pain (head/face pain) is related to TMJ problems, which is why an accurate diagnosis is critical. Inaccurate treatment can lead to more pain and problems.

You may be one of the 60 million North Americans affected by TemproMandibular Joint Dysfunction (TMD).

What and where are the TMJs?

The temporomandibular joints (TMJs) are located on each side of the face near the ears where the lower jawbone (mandible) joins the temporal bone of your skull. A joint is defined as a space where two or more bones come together to effect motion.

These are the only joints in the body that are required to operate simultaneously. In other words, you can’t just use one side or the other. They are a ball and socket joint. The “ball” is the topmost part of the lower jaw and the “socket” is part of the skull. The lower jaw is connected to your skull by muscles, and the blood supply and nerves are located at the back of each socket. For this system of joints and nerves to be healthy and painless, the ball needs to be located in the center of the socket.

What is TMD (Temporomandibular Dysfunction) and what causes it?

As previously stated, TMD is not one disorder, but a group of conditions, often painful, that occur when chewing muscles and jaw joints do not work together correctly. The most common cause of jaw related problems is a bad (misaligned) bite.

Initially, when we evaluate craniofacial pain, we will determine if the pain originates in the hard tissue (bone/joint) or soft tissue (muscle). Some patients have a muscular spasm (bite misalignment issue). Some patients have an internal derangement (joint issue). The ability to determine this difference is critical to effective treatment. If not treated accordingly, you could become much worse.

If you are diagnosed with an actual TMJ problem, it usually means that you have an internal derangement. This means that there are physical changes in the joint itself that are causing the pain. Sometimes pain is caused by the bite (the way the teeth come together). When the bite is off, it can cause the muscles in your face and neck to spasm. Trauma or accidents to the head or face can cause the condyle to be pushed back and up into the joint socket causing inflammation, muscle spasms and sometimes fractures or breaks.

That being said, TMD may also be caused by pain somewhere else in your body. For example, you may have pain in your hip causing you to subconsciously clench your teeth and disrupt the alignment of your teeth. This clenching results in jaw pain (TMD). Your jaw pain is now secondary pain. If your jaw pain is treated, there will be some level of relief, but if the primary cause (the hip) is not addressed, the jaw pain can, and probably will, return.

So What Does It Mean If My Bite Is Off?

Your teeth must meet over 2000 times a day/night over a 24 hour span. If your bite is unbalanced due to misaligned teeth, we also know that the jaw joints (Temporomandibular Joints) are out of alignment usually due to the lower jaw being pushed back (retrognathic position). As a result, the muscles are stretched and must work harder as they attempt to compensate for these misalignments. The blood supply and nerves are now feeling the pressure at the back of the socket, and this muscle tension becomes pain spreading around your ears to your head, neck, shoulders, and back. This pain causes your head to posture forward, away from the pain, putting more tension on all of these muscles.

The pressure on the nerves at the back of the socket triggers a reaction in the entire nervous system activating the body’s “Flight or Fight” (sympathetic) response. This is the body’s response to stress that prepares the body for action and is not meant to operate for long periods of time. However, for those people whose jaw is pushed into this back (retrognathic) position, they are in a constant state of “Flight or Fight”. Being in “high alert” for any extended period of time can be very tiring, and remaining in this state for long periods will cause other body systems to break down. Think of the body as a system of gears: when one gear breaks, it affects the entire system. This is how the misalignment of your teeth and TMJs can affect your entire body.

Treatment Options

Because there are so many subtle nuances to these disorders, there is no one solution. Each of these issues has different treatment protocols which are based on each patient’s particular needs. Some of these protocols involve other specialties. Not following the proper protocol can make you worse. This is why proper diagnosis is critical.

Restoring harmony to your TMJs and bite requires having clear knowledge of how your jaw functions and how to diagnose the primary cause of the pain. Since serious medical problems, such as vascular disease, cervical disc disorder, or brain tumors, can produce symptoms similar to those related to TMD, the initial step would be a diagnostic process that determines whether your symptoms are the result of TMD or some other cause. The doctor will make his diagnosis after completing a comprehensive exam of the TMJs, head, and neck. The exam is typically followed by one of the following protocols:

  • Acute Therapy– This protocol will often be used for accident situations.
  • Occlusal Equilibration (Bite Adjustment)– This protocol involves balancing the bite to distribute forces evenly and, as a result, stop muscle spasming.
  • Phase I – “Orthotic Therapy”- This protocol is all about stabilizing the joints, reducing inflammation, and addressing the primary source of the pain. Once the diagnostic analysis is complete, Phase I involves, but is not limited to, the use of orthotic appliances, physical therapy, natural supplements and medications, nutritional counseling, and various physical therapy modalities. As discussed earlier, misalignment often affects posture or neck and shoulder pain. In some cases it is necessary to be referred to other professionals, such as chiropractors, physical therapists, nutritionists, oral surgeons, medical doctors, neurologists, or ENT specialists in order to treat certain aspects of your TMD. This phase, called “Positioning Orthotic Therapy,” will be deemed complete when you have reached “maximum medical improvement” (MMI) for your TMD condition. At that time there will be discussion of how to gradually discontinue or “wean” your use of the orthotic appliance. If you had been seeing other professionals, it might be necessary to continue seeing them for any persistent symptoms. If you were not seeing another professional but are experiencing some persistent symptoms, there may be a need to begin additional treatment.
  • Phase II– If symptoms recur during or after the weaning process, an additional “finishing stage” of treatment called Phase II may be required. Treatment may involve bite adjustment, orthodontics, or a “long term” appliance. The application of these proper and appropriate treatment modalities will correctly align the bite, keeping the joints and teeth healthy and stable.

Final Thoughts…

Although most TMD conditions respond well to treatment, factors such as your general health, compliance with treatment directives, stress, posture, age, work habits, bite relationship, and the degree of existing tissue injury could affect the outcome and reduce the opportunity for total resolution of your symptoms. All of the subtle nuances associated with these disorders have to be taken into account to ensure proper and effective treatment. This is one of the main reasons Dr. Giordano and his staff spend so much time in continuing education each year. After all, exceeding expectations has always been and will always be our standard of care!